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Assessment and Treatment of Dementia
Juan Francisco Rodriguez, M.D.
Adult and Geriatric Psychiatrist
Outpatient Mental Health Clinic
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DSM-IV Criteria
A- memory impairment (impaired ability to learn new information or to recall previously learned information)One (or more) of the following cognitive
disturbances:
aphasia
apraxia
agnosia
disturbance of executive functioning
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DSM-IV Criteria (cont)
B- the cognitive deficits with significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C- the course is characterized by gradual onset and continuing cognitive decline
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DSM-IV Criteria (cont)
D- other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, parkinson’s disease, Huntington disease, subdural hematoma, NPH, brain tumor).
Systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B 12 or folic acid deficiency, neurosyphyllis, HIV infection, substance induced conditions
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DSM-IV Criteria (cont)
E- the deficits do not occur exclusively during the course of a delirium
F- the disturbance is not better accounted for by another axis 1 disorder
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Signs and Symptoms of Dementia
Personality changes
Difficulty coping with changes
Confusion
Repeating themselves (asking the same questions)
Difficulty reading quickly
Forgetfulness
Poor decision making
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Assessment of Dementia
Detailed history to identify dementia
Assessment of Mental Status MMSE IADL’SADL’S
Neuropsychological testing
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Assessment of Dementia
Blood testsBrain imaging (CT, MRI, PET, SPECT of the headEEGPittsburgh Compound Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementiaUCLA Compound
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Assessment of Dementia (cont)
Medical condition
Medications
Neurological conditions causing dementia
Treatable conditions
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Differential Diagnosis
Primary EtiologyAlzheimer’s dementiaPick’s diseaseFrontotemporal dementiaLewy body dementia
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Differential Diagnosis
Secondary EtiologyVascular dementia e.g. cva, tia Infections e.g. Hiv, syphyllis Inflammatory e.g. SLETraumatic e.g. head injury
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Differential Diagnosis
NeurodegenerativeHuntington’s ChoreaCJD (prion)Parkinson’s Disease induced dementiaMultiple SclerosisWilson’s Disease
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Vascular Dementias
Hypertension
Cerebrovascular disease
Hyperlipedemia
Elevation of homocysteine level
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Management Strategies
Carefully plan relocationTemporal and long term
Discuss with family health care by proxy or advanced directives, DNR
Discuss the use of psychotropic medications
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Management Strategies
Discuss ethical issues Discuss management of behavioraldisruption and functional deficits
Discuss psychosocial issues Management and discuss quality of the issues and progression of the illnessDiscuss management of Tx plan including medications
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Management of Dementia
Non pharmacological
Pharmacological
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Pharmacological Management
Cholinesterase inhibitors
NMDA (memantine)
AMOI (eldepryl)
Medications for disruptive behavior
Antidepressants for comorbid disorders
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Cholinesterase Inhibitors
Cognex (tacrine)
Rivastagmine (Exelon) Patch
Donepezil (Aricept)
Galantamine
Galantamine (Razadyne ER)
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Question
65 yo wf with hx of dementia develops frightening visual hallucinations. Pt was started on low dosage of risperidone, days after the patient develops severe bradykenesia, tremor, rigidity, and gait disturbance. Side effects/adverse reaction suggests which type of dementia?
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Question (cont)
a- Alzheimer’s Dementia
b- Frontotemporal Dementia
c- Diffuse Lewy Body Dementia
d- Progressive Supranuclear Palsy
e- Normal Pressure Hydrocephalus
f- Parkinson’s Induced Dementia
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Question
Which of the following are not considered as
part of the routine dementia work-up?
a- VDRL
b- Neurological exam
c- Chest xray
d- Vitamin B 12 level
e- CT or MRI of the head
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Question
• A 70 yo wm with history of AD was first prescribed Exelon patch x 2 years without good results, he then was changed to galantamine oral bid. Family complains that patient’s cognition continues to deteriorate. Which of the following is the most likely approach in treatment?
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Question (cont)
a- Re-start Exelon
b- Continue galantamine
c- Start Razadyine
d- Start Tacrine
e- Start Aricept 5mg po qhs x 30 days then 10mg po qhs
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Question
75 yo patient with history of AD with
behavioral disturbance, he scores 15/30 in the
mmse, he has occasional visual hallucinations,
illusions and delusions. Patient has been taking
Aricept 10mg po qhs, he suddenly develops
stomach upset, which his pcp thinks is related
to his cholinesterase inhibitor, what is the next
step in treatment?
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Question (cont)
a- Continue Aricept po qhs
b- Change Aricept to po qam
c- D/C Aricept
d- Start rivastagmine
e- Start galantamine
f- Start Namenda