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A neurology primer Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906) 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 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 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 Failure to recognize symptoms of dementia Negative attitudes towards treatment and therapeutic nihilism Limited time Lack of confidence in establishing a particular diagnosis Planning for the future Identify patients at high risk of complications Early treatment may delay progression Refer to community based resources 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 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 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 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 Over 100 illnesses cause dementia Majority of cases are Alzheimer’s disease Non-AD dementias account for ~50% ◦ ◦ ◦ ◦ Vascular dementia ~15% Dementia with lewy bodies ~20% Frontotemporal dementias ~5% Other (NPH, syphillis, HIV, Parkinson’s disease dementia, vasculitis, etc.) 5 % FTD 5 % Other 15 % Dementia Lewy Bodies 20 % Vascular Dementia 55 % Alzheimer’s disease 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 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 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) Age Family history CV risk factors (hypertension, diabetes, elevated homocysteine, cholesterol?) Late onset depression Delirium Fewer years of education Head injury NSAIDs Statins Antihypertensives Antioxidants Exercise 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 Mini Mental Status Exam Clock-drawing tests Blessed-dementia rating scale Mini-cog 7-minute screen Attention Language Memory Visuospatial/perceptual functions Executive functions Praxis Calculations Look for extrapyramidal dysfunction Asymmetric findings Pyramidal tract findings and pathologic reflexes Gait dysfunction Coordination Sensation Erythrocyte sedimentation rate RPR Lumbar puncture HIV Serial neuroimaging Functional neuroimaging (PET, SPECT) Full neuropsychological testing Poor short term memory Difficulty learning and retaining new information Mild word-finding difficulties Naming problems Problems with organization, and complex planning 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) 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) Slow or delay progression Correct exacerbating factors/conditions Treat and prevent concomitant CVD Treat behavioral and psychiatric problems Treat functional problems Acetylcholinesterase inhibitors ◦ Donepezil (Aricept) ◦ Rivastigmine (Exelon) ◦ Galantamine (Reminyl) N-methyl-D-aspartate inhibitors ◦ Memantine (Namenda) ◦ May be used in conjunction with CHEIs 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 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 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. 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 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