who are you again? definitionsassessment no ifs, ands, or, buts.. treatment prevention
TRANSCRIPT
Who are you again?
Definitions
Assessment
No ifs, ands, or, buts..
TreatmentPrevention
Acquired cognitive deficits sufficient to interfere with social or occupational functioning in person without depression or clouding of consciousness
What is the definition of dementia?
Alzheimer’s disease 60%Mixed 20%Lewy body 10%Vascular dementia 5%Fronto-temporal 4%CJD <1%
What is vascular dementia?
patchy loss of neurons in areas of infarcts (multi-infarct, lacunar, periventricular)
cognitive changes depend on area of infarctrecall improves with cuing, more aware of memory problem
Diagnosis:•dementia•vascular component – by hx, px or imaging•temporal relationship between
abrupt onsetstepwise declineimpaired executive functiongait disorderemotional lability
clinical/neuroimaging evidence of cerebrovascular disease
What is fronto-temporal dementia?
EtOH, COPD, Picks, CBGD, Huntingtons
memory relatively well-preserved
core diagnosis (in italics):
•insidious onset•slow progression•behavioural changes – loss of social awareness (disordered social conduct), disinhibition, emotional blunting, mental rigidity, inflexibility, hyperorality, perseveration, distractibility, loss of insight, declining hygiene, character change•language changes with reduction in verbal output
DAILY DOUBLEDAILY DOUBLEName 1 test that can be used to check frontal lobe function
word list - name as many 4-legged animals as can in 1 min
trails - trail A (A-B-C-D..), trail B (A-1-B-2-C-3..)
similarities/differences - apple/orange, vinegar/salt
What is Lewy body dementia?
neuronal loss in limbic, substantia nigra, autonomic system
memory loss + motor changes + hallucinations earlylike an AD + PD
2 of (probable DLB) or 1 (possible) of following:
.fluctuating sx, with variation in alertness and attention
.recurrent visual hallucinations, typically well-formed and detailed
.spontaneous extrapyramidal signs/motor features of Parkinsonism
Features supportive for diagnosis are:repeated fallshypersensitivity to neurolepticsdelusionsnonvisual hallucinationssyncope/transient LOCdrug-unresponsive depression•REM sleep – acting out, vivid violent dreams
What is Alzheimer’s disease?DSM IV criteria for AD
The development of multiple cognitive deficits that is manifested by BOTH of:• memory deterioration• >=1 of aphasia (language)
agnosia (objects)apraxia (motor activities)executive function impairment (planning, organising, sequencing)
is a significant decline compared to previous fn causes significant impairment in social/occupational function gradual onset, continuing decline
NOT due to cerebrovascular dz, Huntington’s dz, Parkinson’s dz, systemic conditions know to cause dementia (hypothyroidism, vit B12 deficiency, folic acid deficiency, neurosyphilis, HIV infection), substance-induced conditions, delirium, major depressive disorder, schizophrenia
What is the course of Alzheimer’s disease?
Early memory impairment – recent>remote
Middle/Late behavioural disturbances – agitation, aggression, combativeness, shouting, disinhibition
psychotic sx – paranoia, delusions, hallucinationswandering behaviourgait, motor disturbances, incontinence
What are the most important elements of
the HPI?Memory deterioration - recent, remoteAphasia - probs understanding language, names of things, reading/writingApraxia - inability to carry out goal-oriented motor functions e.g. getting
dressed in correct orderAgnosia - inability to recognise people and objectsExecutive function - ability to anticipate, select, initiate an action, plan and organise a
procedure e.g. financial planningDepressionDelusionsHallucinationsPersonality changesApathyAgitation
What are important questions in PMH, FH,
& SH?PMHSystemic diseases, ca, neurological, psychiatric, thyroid disordersHTN, a fib, Head injuryEtOHism,
FHDementia, AD (2-4 x increased risk if 1st degree relative), Huntington's dz
SHEtOH, smoking, substance abuseOccupational exposuresLevel of education
What medication hx is it important to elicit?
•narcotics•anticholinergics•benzodiazepines•psychotropics•OTC, herbal
How can you assess functional status?
IADL “SHAFT”ShoppingHousekeepingAccountingFood preparationTransportation
ADL “DEATH”DressingEatingAmbulatingToiletingHygiene
FAQ (functional activities questionnaire)bill payingassembling records relating to business affairsshopping aloneplaying a game of skillperforming a task involving multiple steps (writing letter, stamping envelope, placing in mailbox)preparing a balanced mealbeing aware of current eventsunderstanding and discussing TV, book etcremembering and keeping appointmentsdriving, arranging to take bus, walking to familar places
What is the prevalence of comorbid depression?
prevalence in pts with AD is 6-20%
weight & sleep changessadnesscryingsuicidal statementsexcessive guilt
What parts of physical exam are important in
dementia?
•VS incl postural•vision•hearing•CNs•motor, sensory function esp localising sx, Parkinsonism, stroke•reflexes
What’s normal anymore?
MMSE‘NORMALS’
LIMITATIONS
CORRECT FOR EDUCATION, AGE
How is clock drawing scored?
Give 1 point for each of the following:
all 12 correct numbers, hands in correct position,
closed circle, numbers in correct position
<4 needs further evaluation
FREEBIE!
How are DSM IV criteria tested?
memory
aphasia
apraxia
agnosia
executive fn
hold pt repeats 6 or 7 digits forward, 3 or 4 digits backwardsrecent pt recounts simple short story, 4-5 sentencesremote significant national/international events
language production -verbal name body parts or objects in room- written writes 1 sentence describing what is wearing
comprehension - verbal simple command e.g. walk over to window- written simple written request
pt demonstrates e.g. how to use toothbrush
coins
give pt instructions to plan, initiate and sequence a task
Draw a clock!
What bloodwork is recommended by CMA
guidelines?
CBC, lytes, Ca2+
TSH, glucose
That’s it!!
Name 3 additional tests to consider
Optional additional tests: lipids, BUN/creatinineESR, serum cortisolammonia, LFTs, B12/folate, water soluble vitaminsdrug levels, heavy metal levelsVDRL, HIV
blood gascarotid dopplersCXR, ECG, EEG, LP, mammography
Name 4 indications for CT head in dementia
Indications for CT head:age <60 y.o.rapid decline (months)short duration (<2 yrs)recent head traumanew localising sx (Babinski, hemiparesis)unexplained neuro finding (HA, sz)urinary incontinence + gait disturbance early on (NPH)incontinenceanticoagulation, bleeding dzcancer historyatypical presentationgait disturbance
What are 2 non-pharmacological
therapies for dementia?
•verbal/physical prompts with positive reinforcement•memory training•read newspapers, watch educational shows on TV•reminders about content of conversations
Who do we screen?
No evidence to recommend screening for cognitive impairment in absence of sx
Memory complaints should be followed up
What is the pharmacological
treatment of dementia?
donepezil (Aricept) AchE 2 point improvement MMSE after 3 mosrivastigmine (Exelon) AchE + butyrcholinesterase inhibgalantamine (Reminyl) AchE + nicotinic receptor inhib
Indicated for:AD MMSE 10-26Lewy bodymixed
Acetylcholinesterase Inhibitors
Donepezil Rivastigmine GalantamineIndication AD AD, Lewy body AD, mixedMetabolism hepatic + renal hepatic + renalDose interval daily in AM BID BIDInitial dose 5 mg 1.5 mg 4 mgMin titration interval 4 weeks 4 weeks 4 weeksLowest therapeutic 5 mg daily 3 mg BID 4 mg BIDTarget dose 10 mg daily 4.5 – 6 mg BID 8 mg BIDMax dose 10 mg 6 mg BID 12 mg BIDODB coverage covered LU – 354 (1st 3 mos)
LU – 355 (after 3 mos)
Give me 1 tip on starting therapy...
Start low, go slow!
Reassess in 4 weeks to increase dose, reassess at 2 weeks if necessary to assess tolerability
Warn pt of common side-effects: nausea, anorexia, diarrhoea, dizziness, agitation
Repeat MMSE at 3 mos – need improvement or stabilization. Expected decline in MMSE on treatment is <3 points/year
Name 1 treatment for behavioural problems
At some point during illness, 90% pts have behavioural problems.
Review possible triggers (illness, pain, mealtimes, loneliness)
Non-pharmacological treatment:familiar routinessensory stimulation – auditory, visual, tactilelow lighting levels, music, simulated nature sounds may be calmingexercise program with outdoor daily walking if possible (decreases wandering, agitation)pet therapy
Pharmacological treatment:low dose neuroleptic drugs (risperidone, olanzepine, quetiapine).e.g. risperidone 1mg daily shown to be
effective and well-toleratedSSRI trazodone (esp for sleep disturbances)
CAUTION with benzodiazepines – use only in low doses and PRN
AVOID neuroleptics with marked anticholinergic effects e.g. chlorpromazine
Name 2 interventions for the prevention of
dementiatreat vascular risk factors: antihypertensives, statins (hypercholesterolemia),
anticoagulants (a fib), smoking cessation, DM control, antiplatelets, carotid endarterectomy (stroke prevention)
correction of metabolic disturbancesimproved basic educationdecrease head injury incidence
?post-menopausal HRT (case control, cohort studies)?NSAIDsginkgo biloba – no evidence for or againstVit E 2000 IU daily – no evidence for or against
When do you refer? Give me 1 instance....
•atypical pattern•uncertainty about diagnosis after initial assessment and follow-up•request by family/pt for another opinion•presence of significant depression esp if refractory to tx•treatment problems or failure•need for additional help in management •when genetic counselling is indicated•when research studies into diagnosis and treatment are being carried out
•early behavioural changes•delusions•fluctuating course•early motor changes