DEMENTIA: EVALUATION AND TREATMENTAnna Borisovskaya, MD (with contributions by J. Frederick, MD and S. Thielke, MD)

2

Objectives: At the end of this talk you will be able to

Describe the epidemiology of dementiaBe able to define and diagnose dementia, as well as its different typesUnderstand the options for treatment of cognitive and neuropsychiatric symptoms of dementia

3

Epidemiology

• US population is “graying”• By 2030 there may be 70 million elderly in the

US (currently around 35 million)• Prevalence of dementia in 65+ year olds: 6-8%• Prevalence of dementia in 80+ year olds: 30%• Most common type of dementia is

Alzheimer’s: 5.2 million Americans have Alzheimer’s as of 2013

4

Terminology

• Deriving from Latin (demens – mad)• In psychiatry, used to be termed dementia,

now called major neurocognitive disorder• “Early onset” – before the age of 60, often

familial, more common for Frontotemporal dementia (FTD)

• “Late onset” – after the age of 60

5

Diagnosis:DSM-V Criteria for Major Neurocognitive Disorder

A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains*:

- Learning and memory- Complex attention- Language- Perceptual-motor- Executive function- Social cognition

6

DSM-V Criteria for Major Neurocognitive Disorder cont.

• B. The cognitive deficits interfere with independence in everyday activities. At a minimum, assistance should be required with complex instrumental activities of daily living, such as paying bills or managing medications

C. The cognitive deficits don’t occur exclusively in the context of a deliriumD. The cognitive deficits aren’t better explained by another mental disorder

7

DSM-V Criteria for Major Neurocognitive Disorder cont.

• * Evidence of decline is based on: concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function and a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or in its absence another quantified clinical assessment.

8

Subtypes

• “Early onset” – before the age of 60, often familial, more common for Frontotemporal dementia (FTD)– Strong genetic link– Tends to progress more rapidly

• “Late onset” – after the age of 60– Represents majority of cases

9

Common syndromes encountered in dementia

• Aphasia, Apraxia, Agnosia • Impaired executive function: difficulty with

planning, initiating, sequencing, monitoring, or stopping complex behaviors

• All of the above contribute to loss of instrumental activities of daily living

10

Aphasia

• Problems with language, comprehension• Initially characterized by fluent aphasia• Able to initiate and maintain conversations• Syntax and grammar intact but speech is

vague with nonspecific phrases like “the thing”

• Later language can be severely impaired with mutism, echolalia

11

Apraxia

• Inability to carry out motor activities previously able to do despite intact motor function

• Contributes to loss of ADLs

12

Agnosia

• The inability to recognize or identify objects despite intact sensory function– Typically occurs later in the course of illness– Can be visual or tactile

13

ADL and IADL

Activities of daily living (ADL)• Bathing• Dressing• Grooming• Toileting• Continence• Transferring

Instrumental activities of daily living (IADL)• Using a phone• Travel• Shopping• Preparing meals• Housework• Medication

management• Money management

14

• Cognitive decline AND associated neuropsychiatric symptoms lead to increasing dependence on others and often eventual institutionalization

15

Someone presents with cognitive problems…what do you do?

16

The work up

• Thorough history (medical, psychiatric, neurological)• Get collateral!! Are ADL/IADLs affected?• Physical and neurological exam• Cognitive testing (screening, then more detailed if

needed)• Labs and imaging (rule out reversible causes)• Consider neuropsychological testing or referral to

psychiatry or neurology• Determine the etiology/establish the diagnosis• Treat! (or refer)

17

Cognitive screening tests

• Mini-Mental Status Exam (MMSE) • Montreal Cognitive Assessment (MoCA) • Mini-Cog – combines clock drawing and three

item memory test. • Saint Louis University Mental Status (SLUMS)

18

Screening test: MMSE

• Useful to have at baseline• Can track changes over time• In Alzheimer’s, patients lose 3 points/year• Careful of false positives in those with little education• Careful of false negatives in those with high

premorbid intellectual functioning

19

Screening test: MoCA

• Comprehensive, not easy! • Catches those with higher premorbid

functioning levels. • Is free unlike MMSE • Mocatest.org

20

Screening test: SLUMS

• Better psychometric properties than MMSE, with scoring normed to educational level

• http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

21

Screening test: MINI-COG

1. Instruct the patient to listen carefully to and remember these 3 words: banana-sunrise-chair

2. Instruct the patient to draw the face of a clock, after the numbers are placed, ask them to draw the hands of the clock to read “one ten.”

3. Ask the patient to repeat the 3 previously stated words.

Clock Drawing Test--abnormal

23

Mini-Cog scoring

3 word recall

1-2 = potential cognitive deficit- look at clock

Normal clock= no cognitive

deficit

Abnormal clock= cognitive

deficit

0 of 3= cognitive deficit

3 of 3= no cognitive deficit

24

Labwork

• Chem 10• CBC• LFTs• TSH• B12, Folate• RPR, HIV• Others only if clinical

suspicion is high

25

Imaging

• CT HEAD NONCONTRAST is standard

• MRI if vascular dementia is suspected

• SPECT or PET – usually not in the initial workup, but may be helpful to aid in difficult diagnosis, r/o FTD

26

A few words about “reversible” dementias

• Drug toxicity• Metabolic disturbance• Normal pressure hydrocephalus• Mass lesion (tumor, subdural hematoma)• Infection (meningitis, syphilis)• Collagen-Vascular disease (SLE, Sacroid)• Endocrine disorder (thyroid, parathyroid)• Nutritional disease (B12, thiamine, folate)• Other (COPD, CHF, Liver disease, apnea…)

Only 9% are potentially reversibleOnly 0.6% actually reverse with treatment

27

Dementia syndromes

• Alzheimer’s disease• Vascular dementia• Lewy body dementia (LBD)• Parkinson’s disease dementia (PDD)• Fronto-temporal dementia (FTD)• Mixed pathology• Korsakoff’s

28

Alzheimer’s disease

• Insidious onset, gradual progression, incidence age-related

• Short term memory problems on presentation

• Most common dementing illness• Ultimate diagnosis based on pathology of

neurofibrillary tangles and senile plaques

29

Alzheimer’s disease:etiology

• Biochemically characterized by a deficiency of acetylcholine, with cortex, amygdala, hippocampus all affected

• Basal nucleus of Meynert depleted of acetylcholine-containing neurons

• In minority of cases there’s an autosomal dominant inheritance linked to chromosomes 1, 14, or 21 (early onset)

• Apolipoprotein E gene, coded on chromosome 19, when homozygous for allele E4, increases the risk for late onset Alzheimer’s

30

Course of Alzheimer’s Disease

Mild (MMSE 20-24) – primarily memory and visuospatial deficits, mild executive functioning impairmentModerate (MMSE 11-20) – more pronounced aphasia, apraxia, loss of IADLs, may need increased assistance with ADLs, often exhibiting neuropsychiatric symptomsSevere (MMSE 0-10) – severe language disturbances, pronounced neuropsych manifestations, neurological symptoms (rigidity, incontinence, dysphagia, gait disturbance)Death 8-12 years after the diagnosisInstitutionalization common with increasing neuropsychiatric sx, loss of ADLs, caregiver stress

31

Vascular dementia

10-20% of dementia cases in North America (10-15% cases of AD are actually mixed AD/vascular) NINDS-AIREN criteria used clinically, defined as presence of - Dementia- Cerebrovascular disease (focal signs on neuro exam and evidence

of CVD on imaging)- Relationship between the two, as in:a)Onset of dementia within 3 months since a recognized stroke and/orb)Abrupt deterioration in cognitive function or stepwise, fluctuating progression of cognitive deficits

32

Vascular dementia: cortical subtype

Symptoms are related to the areas affected/strategically placed infarcts:• Medial frontal: executive dysfunction, abulia, or

apathy. Bilateral medial frontal lobe infarction may cause akinetic mutism.

• Left parietal: aphasia, apraxia, or agnosia.• Right parietal: hemineglect (anosognosia,

asomatognosia), confusion, agitation, visuospatial and constructional difficulty.

• Medial temporal: anterograde amnesia.

33

Vascular dementia: subcortical subtype

Lacunar infarcts and chronic ischemia affect white matter pathways and deep cerebral nuclei:• Focal motor signs• Early presence of gait disturbance • History of unsteadiness and frequent, unprovoked falls• Early urinary frequency, urgency, and other urinary symptoms not

explained by urologic disease• Pseudobulbar palsy• Personality and mood changes, abulia, apathy, depression,

emotional incontinence• Cognitive disorder characterized by relatively mild memory deficit,

psychomotor retardation, and abnormal executive function

34

Dementia with Lewy Bodies

• 4-33% of dementia cases are LBD (when autopsy is performed, greater frequency is found)

• Cortical Lewy bodies are the hallmark• Tough to diagnose, especially in mixed casesDiagnosis paramount due to particular treatment considerations!

35

Diagnosis of LBD

• Dementia• Presence of fluctuation in cognition/alertness,

Parkinsonism, and visual hallucinations• Suggestive features are REM sleep disorder, severe

sensitivity to neuroleptics, and low dopamine transporter uptake in basal ganglia on SPECT or PET

• Falls, syncope, autonomic dysfunction, depression, delusions are common but not diagnostic in and of themselves

37

Parkinson’s disease dementia (PDD)

• 31-41% of patients with Parkinson’s have dementia

• Cholinergic dysfunction theorized to be involved in genesis

• Characterized by executive dysfunction, visuospatial impairments, verbal memory problems, visual hallucinations

38

Frontotemporal dementia

• Also known as Pick’s disease though that is just a subtype (or behavioral variant)

• Another type is progressive aphasia• Usually of earlier onset (40-60 years of age)• Memory impairment not that common at the

onset of the disease• Brain imaging characterized either by frank FT

atrophy or by decreased metabolism in FT lobes on functional imaging

39

“Walnut brain”“Walnut brain”Notice the profound loss of matter in the frontal lobes, to a slightly lesser degree in the temporal lobes, in comparison with relatively preserved parietal and occipital lobes

40

Behavioral variant FTD (BvFTD)

Core diagnostic featuresA. Insidious onset and

gradual progressionB. Early decline in social

interpersonal conductC. Early impairment in

regulation of personal conduct

D. Early emotional bluntingE. Early loss of insight

Supportive diagnostic featuresA. Behavioral disorder – decline in

hygiene, mental rigidity, distractibility, hyperorality, perseverative behavior, utilization behavior

B. Change in speech and language – altered speech output, stereotypy of speech, echolalia, perseveration, mutism

C. Physical signs – primitive reflexes, incontinence, akinesia, rigidity, tremor, low/labile BP

D. Investigations – impairment of frontal lobe neuropsych tests, normal EEG, predominant frontal and/or anterior temporal abnormality on brain imaging

41

Treatment

1. Address cognitive dysfunction2. Address neuropsychiatric symptoms3. Address the needs of the caregiver and the

dyad of patient/caregiver4. Consider the environment/living situation

42

Treatment: Cognitive dysfunction

• Acetylcholinesterase inhibitors (see next slide) – use in all stages of AD, earlier is better (but not in mild cognitive impairment)

• Memantine – for moderate to severe stages of the disease• Do not use AchE inhibitors in FTD, do try them in other

types of dementia• Consider cognitive interventions (stimulation,

rehabilitation, training)• Physical exercise• Mediterranean diet has the best evidence

43

Treatment: Cognitive Enhancers

Medication Dosing Guidelines NotesDonepezil Initial dose 5 mg at bedtime

Titrate to 10 mg once daily at 4-6 weeksFor moderate to severe dementia, may titrate to 23 mg at 3 months

The only AchE inhibitor FDA approved for treatment of moderate to severe dementia

Galantamine Initial dose 4 mg twice a dayTitrate to 8 mg twice a day at 4 weeksTitrate to 12 mg twice a day at 4 weeks

Extended release capsules to provide once a day dosing are also available.Dosing adjustment recommended in renal and hepatic impairment.

Rivastigmine Initial dose 1.5 mg twice daily for 2 weeksIncrease in increments of 1.5 mg twice daily every 2 weeks if well toleratedMaximum dose 12 mg a day

Dosing adjustment recommended in renal and hepatic impairment.Use caution when treating low body weight patients.The only AchE inhibitor FDA approved for treatment of cognitive impairment in Parkinson’s disease

Rivastigmine patch Initial dose 4.6 mg/24 hrs topical once daily for 4 weeksTitrate to 9.5 mg/24 hrs topical once dailyFor severe dementia, may titrate to 13.3 mg/24 hrs topical once daily after 4 weeks at prior dose

Dosing adjustment recommended in hepatic but not in renal impairment.Use caution when treating low body weight patients.Dose adjustment may be needed in high body weight patients.

Memantine Initial dose 5 mg daily, at one week increase to 5 mg twice a day, in another week increase to 5 mg in the morning and 10 mg in the evening, and in another week increase to target dose of 10 mg twice a day

FDA approved for use in moderate to severe ADDose adjustment recommended in severe renal and hepatic impairment.

Caution: side effects ahead. AchE inhibitors cause bradycardia, diarrhea, nausea. Gradual dose adjustments recommended.Memantine is relatively free of these side effects. Adjust doses in renal/hepatic impairment.

44

Neuropsychiatric symptoms• Agitation• Aggression• Depression• Anxiety• Psychosis

These symptoms are distressing and disruptive for the patients and their caregivers. Agitation and aggression are the reasons why patients end up hospitalized/institutionalized. Caregiver support and psychoeducation may prevent such outcomes.

45

Treatment of neuropsychiatric symptoms

Nonpharmacological approaches should be tried first!• And even before that, psychiatric/medical causes of

agitation must be ruled out• Identify precipitating/contributing factors to

agitation/anxiety• Teach caregivers how to do the same and provide

them with support• Address the unmet needs of the patient• Allow the patient to remain as independent as

possible when helping them with ADLs

46

Pharmacologic options

• Use medications when nonpharmacological methods failed, or succeeded only partially, or when high risk/violence exist

47

Options for treatment of agitation

• Acetylcholinesterase inhibitors and memantine – not great when effect needed urgently

• Atypical antipsychotics (not FDA approved, increase risk of mortality – black box warning, modest efficacy)

• Antidepressants – citalopram (consider QTc prolongation)• Carbamazepine – evidence not great (consider numerous

side effects and drug interactions)• Propranolol, prazosin – very limited evidence base, though

promising for prazosin (consider falls)• Benzodiazepines – emergent use only

48

Treatment of depression, psychosis

• Antidepressants for depression in dementia are somewhat controversial. There is little evidence for their use in anxiety in dementia.

• For severe depression/suicidality, consider hospitalization, consider ECT

• Treatment of hallucinations/delusions is not always needed – but when it is, start antipsychotics (atypical) slowly and titrate gradually

• Use quetiapine preferentially in LBD and PDD

49

Other treatment options for neuropsychiatric sx

• Recommend psychotherapy, exercise, pleasurable activities, support groups, memory aids

• Minimize changes in caregivers/environment• Music therapy is gaining strength as evidence

based intervention for treatment of anxiety

50

Take home points

• It is paramount to diagnose dementia!• Always obtain collateral from caregivers, and provide them

with education and support• Evaluation of cognitive function is key• Earlier treatment preserves functioning• Correct diagnosis prevents poor outcomes – as in giving

haloperidol to patients with DLB• Neuropsych sx are common and are best addressed with

nonpharmacological strategies• Use cognitive enhancing medications whenever possible• Use medications for agitation/neuropsych sx when unavoidable