Download Dementia

An Overview of Dementia
The Earliest Case
Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)
Case Presentation
• 76 yo black male ~6months of troubles
getting lost, difficulties managing
money/medications
• Son states he tend to repeat himself
• He is aware and concerned about his
memory
• MMSE 23/30
Case Presentation
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What labs are indicated?
Neuroimaging?
What is the most likely diagnosis?
What is the prognosis?
Myths About Dementia
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Dementia is an inevitable part of aging
Dementia is synonymous with
Alzheimer’s disease
Dementia cannot have an acute onset
Dementia is an untreatable disorder
Dementia cannot be accurately
diagnosed without autopsy
Myths About Dementia
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Dementia is a “global” disorder of
cognitive function
Dementia is only a memory problem
Dementia always impairs insight into
cognitive deficits
Dementia is only a cognitive & not a
behavioral disorder
Dementia in Primary Care
• Primary care physicians see large
numbers of patients with dementia
• Dementia can be accurately diagnosed
and managed in a primary care setting
• General medical health is closely
related to late life cognitive function
Barriers to Assessment of
Dementia
• Failure to recognize symptoms of
dementia
• Negative attitudes towards treatment
and therapeutic nihilism
• Limited time
• Lack of confidence in establishing a
particular diagnosis
Potential Benefits of
Establishing a Diagnosis
• Planning for the future
• Identify patients at high risk of
complications
• Early treatment may delay progression
• Refer to community based resources
Normal Cognitive Aging
• Decreased speed and efficiency of
learning
• Difficulty inhibiting irrelevant information
• Troubles with “working memory”
• No true language dysfunction
• No more rapid forgetting when
controlling for initial learning
Cognitive Review of Systems
• Troubles finding words, coming up with
names
• Difficulty understanding conversations
• Getting lost
• Troubles recognizing people or objects
• Repeating conversations
• Difficulty managing medications,
appointments, finances
• Personality changes, withdrawal, apathy
Clues to Presence of
Dementia
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Troubles managing medications
Difficulty providing detail in medical interview
Repetitive questions
New onset personality or mood changes
Family members expressing concerns over
memory or behavior
• Episodes of delirium after surgery or during
hospitalization
Definition of Dementia
• Acquired disorder of memory and at
least one other cognitive domain
(language, visuospatial function,
executive functions)
• Occurs in the setting of a clear
sensorium
• Affects occupational and social
functioning
Maryland Assisted Living
Study
• Dementia prevalence ~67% with AD
accounting for 50%
• Mean MMSE score of 14.5
• Family/caregivers failed to identify dementia
in ~20% of demented residents
• 28 % had not undergone a complete
evaluation
• Only 50% received treatment
J Am Geriar Soc 2004
Epidemiology of Dementia
• Over 100 illnesses cause dementia
• Majority of cases are Alzheimer’s disease
• Non-AD dementias account for ~50%
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Vascular dementia ~15%
Dementia with lewy bodies ~20%
Frontotemporal dementias ~5%
Other (NPH, syphillis, HIV, Parkinson’s disease
dementia, vasculitis, etc.)
Dementia Prevalence by Type
15 % Dementia
5 % FTD Lewy Bodies
5 % Other
20 % Vascular
Dementia
55 % Alzheimer’s disease
Delirium vs. Dementia
Delirium
Acute onset
Marked fluctuations
Poor attention
Changes in alertness
Marked circadian
disturbances
Dementia
Gradual
Less fluctuation
Generally attentive
Generally alert
Mild circadian
disturbance
Cortical vs. Subcortical
Dementia
Cortical
• Normal speed of
thought
• Aphasia
• Amnesia
• Visuospatial dysfunction
• Normal gait
• Paratonic rigidity
Subcortical
• Bradyphrenia
• No aphasia
• “Forgetful”, poor recall
• Visuospatial
dysfunction
• Impaired gait, posture
• Movement pathology
DSM-IV Diagnostic Criteria for AD
• Development of cognitive deficits manifested by
both
 impaired memory
 aphasia, apraxia, agnosia, disturbed
executive function
• Significantly impaired social, occupational
function
• Gradual onset, continuing decline
• Not due to CNS or other physical conditions
• Not due to an Axis I disorder (e.g.,
schizophrenia)
Risk Factors for AD
• Age
• Family history
• CV risk factors (hypertension, diabetes,
elevated homocysteine, cholesterol?)
• Late onset depression
• Delirium
• Fewer years of education
• Head injury
Possible Protective Factors
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NSAIDs
Statins
Antihypertensives
Antioxidants
Exercise
Routine Evaluation of
Dementia
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Complete blood count
Thyroid function test (TSH)
Vitamin B-12 level/folate
Complete metabolic panel (BUN/Cr, glucose,
calcium, LAEs, electrolytes)
• Neuroimaging should be done at least once
– Non-contrast CT
– MRI brain without contrast
Brief Mental Status
Examination
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MMSE
Clock-drawing tests
Blessed-dementia rating scale
Mini-cog
7-minute screen
Comprehensive Mental Status
Examination
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Attention
Language
Memory
Visuospatial/perceptual functions
Executive functions
Praxis
Calculations
Key Physical Exam Points
• Look for extrapyramidal dysfunction
• Asymmetric findings
• Pyramidal tract findings and pathologic
reflexes
• Gait dysfunction
• Coordination
• Sensation
Not Routinely Recommended
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Erythrocyte sedimentation rate
RPR
Lumbar puncture
HIV
Serial neuroimaging
Functional neuroimaging (PET, SPECT)
Full neuropsychological testing
Mild AD 2001 to 2004
Early AD
• Poor short term memory
• Difficulty learning and retaining new
information
• Mild word-finding difficulties
• Naming problems
• Problems with organization, and
complex planning
Moderate AD
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Worsening memory problems
Remote memory becomes involved
More obvious language problems
Visuospatial and topographical orientation
Getting lost, unable to find way back home
Behavioral changes (delusions, aggression,
irritability, anxiety)
Severe AD
• Aphasia (unable to comprehend
language other than simple commands)
• Agnosia (difficulty recognizing objects,
people, etc.)
• Apraxia (inability to perform skilled
movements despite intact
motor/sensory skills)
Strategy for Treating AD
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Slow or delay progression
Correct exacerbating factors/conditions
Treat and prevent concomitant CVD
Treat behavioral and psychiatric
problems
• Treat functional problems
Current Treatments
• Acetylcholinesterase inhibitors
– Donepezil (Aricept)
– Rivastigmine (Exelon)
– Galantamine (Reminyl)
• N-methyl-D-aspartate inhibitors
– Memantine (Namenda)
– May be used in conjunction with CHEIs
Acetylcholinesterase Inhibitors
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Approved for mild-moderate AD
Aricept just approved for severe AD
Start as early as possible
Continue as long as possible
Use maximum dose tolerated
Failure to respond to one does not
preclude response to another
Acetylcholinesterase inhibitors
• Most AD patients decline by 3-4 points
on MMSE per year
• Treatment generally may delay
progression by ~ 6 months
• Behavior and function may improve in
addition to cognition
Reinforce Expectations of
Persistent Treatment
• ChEI treatment is the standard of care for mild to
moderate AD
• Improvement, stabilization, or slowed decline
represent treatment success
– Evaluate treatment response in the context of progressive
decline
– Inform patient and caregiver that stabilization is desirable
– Use follow-up visits to reinforce realistic expectations
• Aricept has proven benefits on cognitive, functional,
and behavioral symptoms
ChEI = cholinesterase inhibitor.
How to Improve AD
Management
• Detect and diagnose early
• Provide early and persistent treatment
• Evaluate treatment response in the face
of progressive decline
• Manage physician, patient, and
caregiver expectations of disease
course and treatment response
Summary
• Dementia is a major public health
problem
• Dementia is under recognized in all
settings
• Dementia is a disorder of cognition,
behavior and function
• Effective treatments exist that may
improve or help preserve all 3 domains