dementia in clinical practice mary ann forciea md clinical prof of medicine division of geriatric...
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Dementia in Clinical Practice
• Mary Ann Forciea MD
• Clinical Prof of Medicine
• Division of Geriatric Medicine
• UPHS• Photo: Nat Geographic
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Who has dementia?
• 78 yr old retired librarian
• Lives alone, children visit on holidays
• Family concerned about ‘clutter’ in house, hygiene, unpaid bills
• 68 yr old child care worker
• Lives with her husband, drives, in charge of ‘house money’
• “Forgot” a child in classroom at end of day
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Who has dementia (2) ?
• 84 yr old urology inpatient– Post op day 1:
hostile• Attempts to strike
nurse with cane
• Refusing blood draw
• Pulled out catheter
• 70 yr old homebound patient– Bedbound, mute– Family caregivers– Oral intake
decreasing
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Terms
• Dementia– Chronic, progressive– Impairment in >1 domain of cognition
• Mild cognitive impairment– Impairment in 1 domain of cognition– ? “pre-dementia”
• Delirium– Short term
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What do we know about Brain Function?
• Cell structure– Microscope (biopsy, cell culture)– PET scans
• Brain regions– imaging
• “Domains” of cognition– Imaging– Psychological testing
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Cell structure: Neurons
• Networks • Grey matter/white matter
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Brain regions
• Regions have different activities
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Domains of cognition
• Memory
• Calculation
• Language
• Orientation
• Spatial construction
• Executive function (judgment)
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Mapping MemoriesNatl Geographic
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What is wrong in dementia?
Theories
Neurons: waste products, shape of cells,
signaling, genetic flaws
Regions: biochemistry, structure
Domains: communication
We don’t yet know.
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Clinical observations
• All patients with dementias are not alike.– Age of onset– Family history– Initial symptom– Most troublesome symptom– Rate of progression– Response to treatment
• Is dementia a symptom, not a disease?
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DementiaSubtypes
• Alzheimer’s Disease• Fronto-temporal dementia (formerly Pick’s
Disease) – 15%• Corticobasilar dementias• Dementia with Lewy Bodies – 20%
– Distinguished from Parkinson’s Disease with dementia
• Vascular disease
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Alzheimer’s type dementia
• Gradual onset
• Global impairment in cognition– Usually memory impairment predominant
• Increased risk in siblings– Apo e allele risk
• Slow progression (5-7 years)– Predictable course (global deterioration scores)
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AD - pathology
• Imaging• Neuropathology – quantity and location
– Senile plaques• White matter• Amyloid core
– Neurofibrillary tangles• Tau protein abnormalities
– Initial concentrations highest in hippocampus and temporal lobes
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What clinical problems do patients with Alzheimer’s Dementia Encounter?
• Diagnosis
• Symptom Management
• End of life care
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Case 1 NC
• 64 yr old retired OR nurse• Referred for evaluation of impaired memory
– Birthdates, telephone numbers– Impaired job performance for 1-2 yrs prior– Inability to ‘balance checkbook’
• Gradual decline over 5 years• Died of pneumonia
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Diagnosis
• Largely on history• Exclude other conditions• Role for imaging in near future• Staging
– Mental status testing (MMSE, MOCA, Mini-Cog)
– Functional status staging (FAST, GDR)
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FAST
• The FAST scale has seven stages:
• 1 which is normal adult
• 2 which is normal older adult
• 3 which is early dementia
• 4 which is mild dementia
• 5 which is moderate dementia
• 6 which is moderately severe dementia
• 7 which is severe dementia
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AD - treatment
• Improve all co-existing conditions!
• Specific treatments– Cholinesterase inhibitors
• Donepazil, rivastigmine
– Adrenergic stimulants• Memantine
• Treatment of associated symptoms– Agitated behaviors
• Non pharmacologic, environmental
• drugs
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End of life issues
• Should be anticipated– Advance Directives, conversations with proxies
• Goals of care– Nutrition– Hospitalization– Caregiver burdens– Hospice involvement
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Summary
• “Dementia” is a symptom complex
• We are in the early stages of understanding the pathology, and discovering effective treatment
• Optimal care requires advance planning, caregiver involvement, and a team of professionals