DEMENTIA

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					DEMENTIA



   Monica Warhaftig, D.O
Assistant Professor Geriatrics
   WHAT IS DEMENTIA?
• An acquired syndrome of decline in memory and
  other cognitive functions sufficient to affect daily
  life in an alert patient

• Progressive and disabling

• NOT an inherent aspect of aging

• Different from normal cognitive lapses


                                                     2
DSM-IV DIAGNOSTIC CRITERIA
          FOR AD
• Development of cognitive deficits manifested by
  both
     • impaired memory
     • aphasia, apraxia, agnosia, disturbed executive function
• Significantly impaired social, occupational function
• Gradual onset, continuing decline
• Not due to CNS or other physical conditions
  (e.g., PD, delirium)
• Not due to an Axis I disorder (e.g., schizophrenia)

                                                                 3
        NORMAL LAPSES
             vs
          DEMENTIA
• Forgetting a name    • Not recognizing
                         family member
• Leaving kettle on    • Forgetting to serve
                         meal just prepared
• Finding right word   • Substituting
                         inappropriate words
                       • Getting lost in own
• Forgetting date or     neighborhood
  day
                                               4
5
                         Mild Cognitive
                            Impairment
 “Mild Cognitive Impairment (MCI) is a state between
   normal cognition and dementia, characterized by
       deficits not explainable by age, educational
              background, or medical illness.”
 Kryscio RJ, Schmitt FA, et al. Risk factors for transitions from normal to mild cognitive impairment and
                                  dementia. Neurology 2006; 66: 828-32.


• MCI is common (5-25%)
• MCI carries an increased risk of dementia and of death
   – If the deficits exist primarily in memory and executive function, risk of
     progression to dementia is higher
         • 10-15% per yr rate of development of dementia and AD compared to 1-
           7% per yr for those without MCI

                                                                                                        6
7
DIFFERENTIAL DIAGNOSIS
     FOR DEMENTIA
•   Alzheimer’s disease
•   Vascular (multi-infarct) dementia
•   Dementia associated with Lewy bodies
•   Delirium
•   Depression
•   Other (alcohol, Parkinson's disease [PD],
    Pick’s disease, frontal lobe dementia,
    neurosyphilis)

                                                8
        ASSESSMENT:
      HISTORY/PHYSICAL
• Ask both the patient &   •   Neurologic status
  a reliable informant     •   Functional Status
• Current condition        •   Mental Status
• Medical history          •   ie. Folstein, MiniCog,
• Current medications      •   Neuropsych testing
• Patterns of alcohol
  use or abuse
• Living arrangements


                                                        9
 Evaluation of Dementia
• Standard laboratory studies
  – Complete blood count
     • Anemia, infection
  – Comprehensive metabolic panel
     • Glucose, electrolytes, renal or hepatic failure
  – Thyroid function tests


• Studies done in suspect cases
  – Estimated sedimentation rate
  – Serology for syphilis, HIV, lyme disease
  – Screen for heavy metals
                                                         10
    ASSESSMENT: BRAIN IMAGING
•   Use imaging when:
•   Onset occurs at age < 65 years
•   Symptoms have occurred for < 2 years
•   Neurologic signs are asymmetric
•   Clinical picture suggests normal-pressure
    hydrocephalus

•   Consider:
•   Noncontrast computed topography head scan
•   Magnetic resonance imaging
•   Positron emission tomography
                                                11
  Evaluation of Dementia
• Radiologic/Neuro-Imaging studies
• Carotid dopplers
• CT Scan, MRI of Brain
   – Linear/volumetric measurement is not recommended
• PET and SPECT imaging not recommended for
  routine use in the diagnosis of dementia
   – “Little evidence to support the routine use of PET in
     pts with suspected or established dementia” JAGs 51:
     2003 Clinical criteria accurate in 90%

*PET scan may help clarify Alzheimer’s vs. other types dementias in
  those already fully evaluated
*SPECT scan may help identify early dementia but studies are limited
                                                                       12
    Potential Reversible Causes
• Neoplasms             • Nutritional disorders
• Metabolic disorders   • Psychiatric disorders
• Trauma                • Normo-pressure
• Toxins                  Hydrocephalius
• Infections              (NPH)
• Autoimmune
  disorders
• Drugs


                                                  13
    Distinguishing Dementia
• Delirium versus Dementia
  – Acute onset
  – Cognitive fluctuations over hours or days
  – Impaired consciousness and attention
  – Altered sleep cycles
• Depression versus Dementia
  – Demonstrate  motivation during cognitive
    testing
  – Express cognitive complaints that exceed
    measured deficits
  – Maintain language and motor skills          14
  SPECIFIC
DEMENTIAS…




             15
         Alzheimer’s Dementia
• Dementia NOT caused by other medical/mood or
  CNS disorder
  – Definitive diagnosis is on brain biopsy/autopsy
     •   Neurofibrillary tangles and senile plaques
     •   Reduced cerebral production of choline acetyl transferase
     •   Decreased Acetylcholine synthesis
     •   Marked cholinergic deficit
  – DSM-IV criteria
     • Cognitive deficits including impaired memory, executive function
       and aphasia/apraxia/agnosia
     • Gradual onset, continuing decline; impaired social/occupational
       function

                                                                     16
    SYMPTOMS & SIGNS OF AD
• Memory impairment
• Gradual onset, progressive cognitive decline
• Behavior and mood changes
• Difficulty learning, retaining new information
• Aphasia, apraxia, disorientation, visuospatial
  dysfunction
• Impaired executive function, judgment
• Delusions, hallucinations, aggression,
  wandering
                                                   17
Structural Changes in MRI:
   Alzheimer's Disease




                             18
PET scan in Alzheimer’s disease
                                  19
        PROGRESSION OF AD
Mild Impairment             Moderate
• Disorientation for date   • Disorientation for date and
                              place
• Naming difficulties       • Comprehension difficulties
• Recent recall problems    • Impaired new learning,
                              calculating skills
• Mild difficulty copying
                            • Getting lost in familiar areas,
   figures                    wandering
• Decreased insight         • Not cooking, shopping, banking
• Social withdrawal         • Delusions, hallucinations
• Irritability              • Agitation, restlessness, anxiety,
                              aggression
• Mood change               • Depression
• Problems managing         • Problems with dressing and
   finances                   grooming
                            • Aphasia and apraxia



                                                             20
       PROGRESSION OF AD

Severe Impairment
• Nearly unintelligible verbal output
• Remote memory gone
• Unable to copy or write
• Unable to feed*
• No longer grooming or dressing
• Incontinent
• Unable to Walk
                                        21
Other Dementias……..




                      22
DSM-IV DIAGNOSTIC CRITERIA
 FOR VASCULAR DEMENTIA
• Development of cognitive deficits
  manifested by both
     • impaired memory
     • aphasia, apraxia, agnosia, disturbed executive
       function
• Significantly impaired social, occupational
  function
• Focal neurologic symptoms & signs or
  evidence of cerebrovascular disease
• Stepwise Deterioration (after each event)
                                                        23
    DEMENTIA ASSOCIATED
           WITH
       LEWY BODIES
•   Dementia
•   Visual hallucinations
•   Parkinsonian signs
•   Alterations of alertness or attention




                                            24
       DLB-Other Features
• Neuroleptic Sensitivity (ie Olanzapine)
• Falls
• Early incontinence




                                            25
       OTHER DEMENTIAS
• Alcoholic Dementia
  – Direct effects of alcohol, Secondary effects of
    alcohol,Wernicke-korsakoff syndrome
• Toxic Metal and Gas Exposure
  – Common exposures: lead, mercury, manganese,
    arsenic, carbon monoxide & carbon disulfide
• Vitamin Deficiencies
  – Vitamins B12, folate, niacin, and thiamine
  – More severe B12 deficiency: subacute combined
    degeneration

                                                      26
    Organic causes of dementia
•   Organ Failure (liver, kidneys)
•   Endocrine (hypothyroidism, diabetes)
•   Inflammatory (Lupus)
•   Neurodegenerative causes (multiple
    sclerosis & Huntington’s Chorea)




                                           27
             Normal-Pressure
               Hydrocephalus
• May appear similar to Alzheimer’s…..
• Early treatment may reverse cognitive
  changes before they become permanent
• Triad of symptoms: gait instability, urinary
  incontinence and dementia
  – Wide-based, shuffling gait with poor coordination
  – Incontinence follows gait change, includes urgency
  – Slow thinking/response, decreased spontaneity
• Enlarged ventricles on MRI
  – But no evidence of atrophy: Alzheimer’s shows large
    ventricles due to brain atrophy


                                                          28
    Parkinson Dementia

• Age Onset: 50 to 80; survival 8-15 yrs
• Dementia occurs later in the disease, mild to
  mod.
• Slowness of thought
• Neuropsychiatric symptoms common
• Dysphagia, dysphonia



                                                  29
  Frontotemporal Dementia
• Diagnostic criteria similar to Alzheimer’s
                        BUT
• Onset typically younger (less than 65 years)
• Predominant changes/disturbances in behavior
  – Personality change is a hallmark
  – Changes occur early and progress
• Non-fluent, expressive aphasia common
  – Words remain but are presented in nonsensical format
• Frontal and/or temporal atrophy on MRI
• Early absence of neurologic signs, neurologic
  signs occur with progression                         30
Structural
Changes in
MRI:

Fronto-
temporal
dementias

            31
 Parkinson Plus Dementias
• Dementia occurs early
Additional physical symptoms
• More frontal lobe features
• Earlier onset, more rapid course
• Frontal lobe features
• Poor response to levodopa
• Rapidly accelerates

                                     32
     Multisystem Atrophy
• Onset 55; survival 6-7 years
• Autonomic dysfunction (incontinence,
  impotence, orthostasis)
• Ataxia, dysarthria, contractures, dystonia
• Mild to moderate dementia
• Less tremor



                                               33
Progressive Supranuclear Palsy:
   Dudley Moore (1935-2002)
                • Initially presents
                  similar to Parkinsons
                  (earlier age)
                • Difficulty with vision
                • Falls
                • Unable to look down
                • Dysarthria/dysphagia
                • Lifespan 6 years


                                       34
 Progressive Supranuclear
           Palsy
• Onset: late 50 to mid 60, survival 10 years
• Mental slowness, frontal lobe dysfunction,
  pseudobulbar symptoms
• “surprised look”
• Dysarthria, dysphagia
• Often misdiagnosed:late onset of eye sx,
  missed gait and posture instability

                                            35
MANAGEMENT……….




                 36
SYMPTOM MANAGEMENT
• Sundowning
• Psychoses (delusions, hallucinations)
• Sleep disturbances
• Aggression, agitation



                                          37
 REDUCING SUNDOWNING
• Provide orientation clues
• Give adequate daytime stimulation
• Evaluate for delirium
• Establish bedtime routine and ritual
• Provide consistent caregivers
• Remove stimulating environmental factors
• Discourage drinking stimulants or smoking

                                             38
     NONPHARMACOLOGIC
•   Cognitive enhancement
•   Individual and group therapy
•   Regular appointments
•   Communication with family, caregivers
•   Environmental modification
•   Attention to safety



                                            39
          PHARMACOLOGIC
• Cholinesterase                 • excessive nmda:
  inhibitors:                    •   excitotoxicity and neurotransmittter
                                     damage
 Inhibit cholinesterase at the
   synaptic cleft
                                 • Memantine is neuroprotective
                                     & disease modifying;
• Offer a small improvement :
  cognition and activities of    •   for moderate to severe
  daily living                       dementia

• Examples:                      •   alone or in combination
• donepezil, rivastigmine,
  galantamine                    • Other cognitive enhancers:
                                   estrogen, NSAIDs, ginkgo,
• Memantine: (Namenda):            vit. E
  N-Methyl-D-Aspartate
• Antagonist: A receptor
  activated by glutamate: decr
  nmda                                                                  40
IMPROVEMENT w/ NAMENDA




                     41
 TREATING PSYCHOSIS IN
       DEMENTIA
Antipsychotic medications (side effects):
• Higher potency: haloperidol (extrapyramidal
  symptoms)
• Lower potency: thioridazine (anticholinergic
  effects, sedation, hypotension, constipation,
  urine retention)
• Atypical antipsychotics: clozapine,
  risperidone, olanzapine
Beware new prescribing information on some of
                                             42
 the atypical antipsychotics!
 ANTIPSYCHOTICS USED IN
       DEMENTIA
Drug                 Starting Dose        Peak Effective
                                             Dose
Clozapine        12.5-25 mg twice daily    100 mg daily
Haloperidol         0.25 at bedtime        3-5 mg daily
Olanzapine      1.25-2.5 mg at bedtime      5 mg daily
Risperidone     0.25-0.5 mg at bedtime    1-1.5 mg daily

   Note: Start low, go slow.

                                                          43
          MANAGING SLEEP
           DISTURBANCES
• Improve sleep hygiene (e.g, consistent bedtime,
  comfortable setting)
• Provide daytime activity, prevent daytime sleeping
• Use bright-light therapy
• Treat associated depression, delusions
• If the above do not succeed, consider:
     • trazodone 25-150 mg
     • nefazodone 100-500 mg
     • zolpidem 5-10 mg
• Avoid benzodiazepines or antihistamines
                                                    44
    MANAGING AGITATION
• Behavioral interventions: distraction,
  supervision, routine, structure
• Behavior modification using rewards
• Pharmacologic interventions:
  antipsychotics, antidepressants, mood
  stabilizers, buspirone, -blockers
• Avoid physical restraints

                                           45
RESOURCES
FOR MANAGEMENT

• Specialist referral   • Attorney
  to:                   • Day Care, Respite
     • geriatric          Care
       psychiatrist     • Alzheimer’s
     • Neuropsychol       Association
       ogist            • Meals on Wheels
     • Social worker
• Physical therapist
                                              46
             QUIZ – T/F
• Alzheimers is strictly a memory disorder
• Dementia with Lewy Bodies often
  manifests with hallucinations
• A Multisystem atrophy is a dementia of the
  frontal lobe pseudobulbar involvement,
  eye changes, gait disturbance
• Dementia in Parkinsons is nonexistant


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