approach to dementia
Post on 16-Aug-2015
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Case 167 yr old man hypertensive (on medication) non
diabetic brought by his son with c/o progressive memory/language problems in the form of naming difficulties , impairment of financial affairs / driving to shop / misplacing things for last 6 yrs
O/E – BP 130/80 CVS/Resp/GI – WNL Neurological – cognitive –MMSE 20/30 ; speech
– circumlocuitous with word finding pauses motor / sensory /reflexes - wnl
Case 263 yr old male p/w h/o abnormal gait , poor
judgement and improper planning with increased urinary urgency
o/e – BP 136/80 CVS/Resp/GI – wnl Neuorological – gait- ‘magnetic gait’ ;
motor / sensory – wnl ; • CSF – opening pressure 18 cm of H2O ;
others - wnl
Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function beyond what might be expected from normal ageing.1
Dementia is an overall decline in intellectual function, including difficulties with language, simple calculations, planning and judgment, and motor skills as well as loss of memory.2
1 . WHO 2. DSM IV
Vitamin deficienciesEndocrine and metabolicChronic infectionsTrauma and diffuse brain damageNeoplasticDrugs/toxinsPsychiatricDegenerativeMiscellanous
GOALS..Differentiate dementias from delirium /
acute confusional states
Specific diagnosis
Assess reversible or correctible aetiology / components
Formulate management
HISTORY..Temporal courseInitial manifestationsAssociated Medical / Neurological
conditionsHereditary factorsPersonal factors
EXAMINATION:GENERAL AND SYSTEMICGeneral survey – f/o endocrine disease ,
vitamin deficiencies etcSystemic
Cardio vascularNeurological
Cranial nervesMotor – abnormal movements , tone ,
hemiparesisSensory – post. column , peripheral neuropathy Gait
CLINICAL COGNITIVE ASSESSMENT TOOLSMemory
Working- digit span forwardVerbal recent – 3-5 words ; immediate / delayed
recallNon verbal recent – figure drawing by recallRemote – historical / autoboigraphical events
LanguageComprehension – y/n questions , multistep
tasksRepetitionFluency – multiple items within specified timeConfrontational namingReading / writing
VisuospatialLine bisectionClock drawingFigure copyingVisual target cancellationSimultaneous b/l stimulation
Complex attentionOrientationAbstract conceptualization
FUNCTIONAL STATUS ASSESSMENTAssessment of activities of daily living (ADL)
Basic ADLs (BADL)Instrumental ADLs (IADL)
Available scalesBristolKatzLawton
LABORATORY INVESTIGATIONSTo confirm specific aetiologiesAssessment of associated correctible co-
morbidities
AAN lays down 3 levels of testing• Routine evaluations• Specific parameters (not to be done routinely)• Tests without clear confirming or refuting
data
NEUROIMAGINGAAN ratifies routine use of only CT / MRIOther modalities available
PETSPECTFDG-PETAmyloid imaging
DEMENTIA VS DELIRIUM ?Onset and courseDurationConsciousness and orientationAttentionLanguageMemoryPsychiatricSundowning
ALZHEIMER’S DISEASEDescribed by Alois Alzheimer in 1907Cognitive domains: memory › language ›
visuo-spatialSporadic and familial formsImaging – medial cortical (hippocampal)
+posterior predominant cortical atrophyPathology – NFTs , NPs , early amyloid
oligomersGenes – APP , PS1/PS2 , Apoε4
VASCULAR DEMENTIAMulti infarct dementia
Stepwise progression of neurodeficits with previous discrete episodes
Focal neurodeficitsImaging shows multiple infarcts
Diffuse white matter diseasePathology of small penetrating arteriolesInsidious progressive › stepwisePsychomotor symptoms , motor symptoms
(with gait disturbances) and memory loss .
FRONTOTEMPORAL DEMENTIASEarly behavioral / language / motor
symptoms with executive function deficits and relative memory sparing
4 variants – semantic dementia , progressive non-fluent aphasia , behavioral variant , MND associated
Imaging – atrophy of frontal , insular , temporal cortex and BG
Pathology – Tau / TDP 43 / FUS
PROGRESSIVE SUPRANUCLEAR PALSYEarly behavioral / executive and motor
symptoms (characteristic falls)Motor - oculomotor , stance / gaitImaging – degeneration / atrophy of brain
stem , basal ganglia , limbic cortex and selected cortical areas
Pathology – NFTs (brainstem and cortex)
LEWY BODY DEMENTIASPDD and DLBDProminent parkinsonian features – precedes
dementia in PDD and follows dementia in DLBD
Prominent visual hallucinations , fluctuating alertness , falls and RBD
Susceptible to metabolic and infectious insults
Pathology – lewy body
NORMAL PRESSURE HYDROCEPHALUSCharacteristic triad of gait disturbance ›
dementia ›urinary problemsPathology – disturbances in CSF fow /
absorptionDiagnosed by radionuclide cisternography ,
diagnostic drainage
Goals • Treat correctable factors (etiological / associated
co morbid)• Supportive and comforting therapy to the patient Modalities• Pharmacotherapy – eg. correction of hormonal /
nutritional factors , anti-microbials/anti retrovirals , anti-cholinesterases (for AD) , anti –psychotics/SSRIs/sedatives
• Shunting (for NPH) , chemo-radiation for neoplasms• Cognitive therapies / activities• Nursing and supportive care
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