APPROACH TODEMENTIA

ABDULLAH MD. HASAN2ND YR PGT

DEPTT. OF MEDICINE

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

Coronal T1 MRI

FDG PET

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

CTAxial T2 MRI

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

DEMENTIA : CRITERIADSM-IV-TR 1

DSM-V 2

American Psychiatric Association1. 20002. May 2013

DEMENTIA : CAUSESAlzheimer’s disease

Vascular

Parkinson’s disease

Drugs and toxins

Vitamin deficienciesEndocrine and metabolicChronic infectionsTrauma and diffuse brain damageNeoplasticDrugs/toxinsPsychiatricDegenerativeMiscellanous

A GENERAL APPROACH TOWARDS DIAGNOSIS..

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

COGNITIVE ASSESSMENTCognitive assessment scales

MMSEMoCARUDASIQCODEGPCOG

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

NEUROPSYCHIATRIC ASSESSMENTMoodPersonality changesVegetative statusPerceptionsThought content

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

OVERVIEW OF DISEASE ENTITIES

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

MANAGEMENT..

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

THANK YOU...