Download - Final Dementia
OVERVIEW OVERVIEW OF OF
DEMENTIADEMENTIA
DR. ALIM AKHTAR BHUIYANDR. ALIM AKHTAR BHUIYANMBBS, DTM & H (U.K.), M.D. (U.S.A),MBBS, DTM & H (U.K.), M.D. (U.S.A),
POST- DOCTORAL FELLOWSHIP IN EPILEPSY (U.S.A)POST- DOCTORAL FELLOWSHIP IN EPILEPSY (U.S.A)US BOARD CERTIFIED IN NEUROLOGYUS BOARD CERTIFIED IN NEUROLOGY
CONSULTANT NEUROGOLIST,CONSULTANT NEUROGOLIST,APOLLO HOSPITALS, DHAKAAPOLLO HOSPITALS, DHAKA
Dementia-What it Dementia-What it means?means?
Dementia-What it Dementia-What it means?means?
Key points: Impairment of multiple domains of cognitive functions: Memory impairment - Must----- a. New material learning
b. Forget previous learningWith at least one of the following cognitive disturbance:
i. Aphasia-language disturbanceii. Apraxia- impaired ability to carry out motor activities despite
intact motor functioniii. Agnosia- failure to recognize/ identify familiar object despite
intact sensory functioniv. Disturbence in executive functions
Significant impairment of social & occupational functioning- decline from previous level
Gradual onset, continuing cognitive decline with alert & normal arousal.(DSM IV)
Scenario of DementiaScenario of DementiaScenario of DementiaScenario of DementiaGlobal Situation 10% of all above 70 yrs. has memory
impairment
Of them 50% have AD
Annual rate of progression to Dementia is 15% Doubling the incidence of Dementia above 65 yrs for every five yrs.
50% above the age of 85 yrs have dementia.
Lancet 361: 2003
Scenario of DementiaScenario of DementiaScenario of DementiaScenario of Dementia
Scenario of DementiaScenario of DementiaDeveloped countriesUSA
Incidence – 4.8% , moderate to severe memory impairment
Dementia – 187/100000/year
AD – 123/100000/year
3-4 million patients
Race – White – 85%
– Black – 09%
– Others – 06% Victor & Ropper 2002
Primary degenerative Primary degenerative dementiasdementias
Alzheimer’s diseaseFrontotemporal Dementia & Pick’s disease
Dementia with Lewy bodies
A.
B.
Dementia Dementia (Alzheimer’s (Alzheimer’s disease )disease )
Pathology (Gross) :Every part of cerebral cortex is
involved with relative sparing of occipital pole
Marked atrophy, widened sulciShrinkage of gyriThinning of cortical ribbonVentricular dilatation especially
temporal horn, atrophy of amygdala & hippocampus
AD: a progressive CNS AD: a progressive CNS disorderdisorder
with a characteristic with a characteristic pathologypathology
Brainatrophy
Senileplaques
Neurofibrillary tangles
Katzman, 1986; Cummings and Khachaturian, 1996
Pathology of Vascular Pathology of Vascular DementiaDementia
Approach to DementiaApproach to Dementia
Determine presence of Dementia-Decision is solely & essentially
clinicalDetermine primary degenerative/other
potential treatable causes of dementiaCo-morbid medical illness. Treatment of an
intervening illness may reverse a worsening of dementia
Key pointsKey points
• Obtain a meticulous history (temporal profile)
• Rate of intellectual decline• Impairment of social function• General health & relevant disorders-
stroke, head injury• Nutritional status• Drug history• Family history of dementia• Occupational exposures - toxins
Approach to DementiaApproach to Dementia
• Age-Younger: Secondary cases-Older: AD/other primary dementia
• History- Meticulous history-Patient-Independent informate-Spouse
1. Patient difficulties•Difficulties patient having•Family member notice
Approach to Dementia - Approach to Dementia - HistoryHistory
EvaluationEvaluation
EN MID CZD NPH AD
Approach to Dementia - Approach to Dementia - HistoryHistory
2. Time course & progression
Weeks Months Years
Encephalitis MID-Stroke for stroke CZD NPH AD
3. Function of the patient At work At home Performance of basic activities of daily life
4. Issue of safety Driving
- accident, traffic violation, lost in drivingDanger
- to patient/others
Approach to Dementia - Approach to Dementia - HistoryHistory
5. Etiologically directed historyVascular disease-Risk factors Infections/toxic/metabolic/traumaPsychiatric-depression, insomnia,agitation
6. Family historyDementiaOther diseases: Thyroid, Infections.
Approach to Dementia - Approach to Dementia - HistoryHistory
Clinical differentiation of Major Dementias
Disease Initial symptom
Mental status
Neuropsy-chiatry
Neurology Imaging
AD Memory loss Episodic memory loss
Initially normal
Initially normal
Entorhinal & hippocam-pal atrophy
Vascular
(VaD)
Often sudden, variable initial symptoms, focal lesions
Frontal/exec-utive cognitive slowing, can spare memory
Apathy, delusions, anxiety
Usually motor slowing, spasticity, can be normal
Cortical or subcortical infarctions etc.
FTD Apathy, reduced judgment,/insight/speech/ language, hyperorality
Frontal/ executive, language,spare drawing
Apathy, euphoria, depression
Vertical gaze palsy,axial rigidity, dystonia
Frontal & or temporal lobe atrophy
Investigations in Dementia (contd.) A. Routine:
1. Thyroid function test: eg. Hypothyroidism2. Serum Vit. B12 Assay- Pernicious Anaemia3. Complete blood count (may give a clue):
Vitamin deficiency states Organ failure Endocrinopathies neoplastic conditions Toxic causes. eg, Basophilic Stippling of RBC
in lead poisoning Vacuolated lymphocytes in Niemann-Pick
disease4. Electrolytes:Eg. Increased K+ in CRF, Addison’s Disease
Investigations in Dementia (contd.) B. Optional Focused Tests:
1. Chest Skiagram:- Cardiomegaly- Stroke, Hypothyroidism, Anaemia,
Alcoholism, Etc. Ca- Bronchus Pulmonary Tuberculosis Vasculitis- SLE, Wegener’s Granulomatosis Sarcoidosis
2. CSF Study: CNS INFECTIONS. Eg. HIV, Neurosyphilis Decreased Aß42- Amyloid & increased tau protein in AD-
Not diagnostic
General principles of management
Aim of management : to achieve optimal daily function relieve distress provide practical help for patients & care givers
Attention must be paid to the : maintenance of personal hygiene safety nutrition take care of incontinence of bowel & bladder;
minor physical upset such as dehydration, constipation, bronchitis, urinary infection
Management of Dementia• Supportive treatment
– Non-pharmacological– Pharmacological
• Treatment of complications &
co-morbidities
• Symptomatic treatment
Supportive treatmentNon-pharmacological
• Advice, support and a sensible explanation are important for the caregiver
• Reduce excessive stimulation
• Divide tasks into small, simple steps; allow ample time
• Eliminate caffeine and alcohol
• Take their concern seriously
Drugs to avoid in Dementia
Antipsychotics : - Chlorpromazine - Clozapine - Olanzapine - Promazine - Thioridazine
Antidepressant : - TCA, - MAOls, - ParoxetineAnticholinergics : - Benzhexol
- Benztropine- Hyoscine
- Orphenadrine- Procyclidine
Note: Anticholinergic drugs may reduce the effects of anticholinesterase in all domains of efficacy: memory, activity, behaviour all may be worsened.
Supportive treatmentPharmacological (cont’d)
Commonly used drugs are-• Antidepressants: in general tricyclics and other
anticolinergic treatments are best avoided, if possible. SSRIs are better tolerated
• Neuroleptics: modest efficacy in improving behaviour, in-suspicious, hallucination -
sleeplessness and agitated behaviour
• Anxiolytics: in non aggressive agitation and insomnia; benzodiazepins- preferably short acting.
Treatment of complications and comorbidities
• Hypertension
• Diabetes mellitus
• IHD
• Heart failure
• Arthritis
• Infections
Like Dementia other diseases rise with advancing age
Symptomatic treatment of AD
The mainstay of symptomatic treatment of AD, so far, is the cholinergic treatment strategies and most widely used, till now, are the CholinEsterase (ChE) inhibitors.
Specific Treatment
Summary of AChE Inhibitors in Dementia
Drug Mode of action Efficiency in
Global Cognitive Functional Tolerability
Rivastigmine AChE inhibitor + + + ++ 1
Donepizil ,, + + + ++1
Galantamine ,, + + + ++1
Tacrine ,, + + ?
++ : good
? : evidence absent/equivocal
+ : moderate
1 : Tolerability depends on dose & speed of
- : Poor titration
For neurodegenerative dementias:
• No curative treatment is available till now
• Specific symptomatic treatment by ChE inhibitors remains the mainstay of treatment
• Amongst the ChE inhibitors, Rivastigmine is the most preferred one because of it’s-
• effectiveness in wide range of dementias• relatively less S/E profile• available in our country
*But it’s use may be limited for it’s relatively higher cost
NEW CLASS OF DRUGS USED FOR THE SYMPTOMATIC TREATMENT OF DEMENTIAS
NMDA Receptor Antagonist : MEMANTINE
•An uncompetitive moderate affinity N-methyl-D-aspartate receptor antagonist
•Recently approved in Europe and the USA for the treatment of moderate to severe AD. Also available in Mexico and in several South American countries
• Clinical data on memantine show benefit in cognitive and psychomotor functioning, benefit in activities of daily living, reduction of care dependence & excellent tolerability in AD
•Also helpful in mild to moderate vascular dementia; improves cognition consistently across different cognitive scales, with at least no deterioration in global functioning and behaviour
•Devoid of concerning side effects at daily dose of 20mg
CONCLUSION
Management of dementia should be multidirectional
It is important to identify the type and stage of dementia
Supportive care and treatment of comorbidity are important and common for all types
Treatable cause needs to be sought and sorted accordingly
Neurodegenerative dementias need symptomatic treatment with ChE inhivitors
Rivastigmine is possibly the best choice of ChE inhibitor so far and covers wider range for mild to moderate cases; donepezile is a suitable and cheeper alternative
Memantine is being tried for moderate to severe cases
Other treatment options are on the way
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