an overview of dementia. the earliest case hospital for mentally ill & epileptics (frankfurt...
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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
• What labs are indicated?
• Neuroimaging?
• What is the most likely diagnosis?
• What is the prognosis?
Myths About Dementia
• 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
• 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
• 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
J Am Geriar Soc 2004
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
Epidemiology of Dementia
• 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
55 % Alzheimer’s disease
20 % VascularDementia
15 % DementiaLewy Bodies
Dementia Prevalence by Type
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
• NSAIDs
• Statins
• Antihypertensives
• Antioxidants
• Exercise
Routine Evaluation of Dementia
• 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
• MMSE
• Clock-drawing tests
• Blessed-dementia rating scale
• Mini-cog
• 7-minute screen
Comprehensive Mental Status Examination
• 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
• 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
• 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
• 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
• 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