An Overview of Dementia

1. An Overview of Dementia A neurology primer

2. The Earliest Case Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)

4. Myths About Dementia • Dementia is an inevitable part of aging • Dementia is synonymous with Alzheimer’s disease • Dementia cannot have an acute onset • Dementia is an untreatable disorder • Dementia cannot be accurately diagnosed without autopsy

5. Myths About Dementia • Dementia is a “global” disorder of cognitive function • Dementia is only a memory problem • Dementia always impairs insight into cognitive deficits • Dementia is only a cognitive & not a behavioral disorder

6. Dementia in Primary Care • Primary care physicians see large numbers of patients with dementia • Dementia can be accurately diagnosed and managed in a primary care setting • General medical health is closely related to late life cognitive function

7. Barriers to Assessment of Dementia • Failure to recognize symptoms of dementia • Negative attitudes towards treatment and therapeutic nihilism • Limited time • Lack of confidence in establishing a particular diagnosis

8. Potential Benefits of Establishing a Diagnosis • Planning for the future • Identify patients at high risk of complications • Early treatment may delay progression • Refer to community based resources

9. Normal Cognitive Aging • Decreased speed and efficiency of learning • Difficulty inhibiting irrelevant information • Troubles with “working memory” • No true language dysfunction • No more rapid forgetting when controlling for initial learning

10. Cognitive Review of Systems • Troubles finding words, coming up with names • Difficulty understanding conversations • Getting lost • Troubles recognizing people or objects • Repeating conversations • Difficulty managing medications, appointments, finances • Personality changes, withdrawal, apathy

11. Clues to Presence of Dementia • Troubles managing medications • Difficulty providing detail in medical interview • Repetitive questions • New onset personality or mood changes • Family members expressing concerns over memory or behavior • Episodes of delirium after surgery or during hospitalization

12. Definition of Dementia • Acquired disorder of memory and at least one other cognitive domain (language, visuospatial function, executive functions) • Occurs in the setting of a clear sensorium • Affects occupational and social functioning

13. Epidemiology of Dementia • Over 100 illnesses cause dementia • Majority of cases are Alzheimer’s disease • Non-AD dementias account for ~50% • Vascular dementia ~15% • Dementia with lewy bodies ~20% • Frontotemporal dementias ~5% • Other (NPH, syphillis, HIV, Parkinson’s disease dementia, vasculitis, etc.)

14. Dementia Prevalence by Type

15. Delirium vs. Dementia Dementia Gradual Less fluctuation Generally attentive Generally alert Mild circadian disturbance Delirium Acute onset Marked fluctuations Poor attention Changes in alertness Marked circadian disturbances

16. Cortical vs. Subcortical Dementia Subcortical • Bradyphrenia • No aphasia • “Forgetful”, poor recall • Visuospatial dysfunction • Impaired gait, posture • Movement pathology Cortical • Normal speed of thought • Aphasia • Amnesia • Visuospatial dysfunction • Normal gait • Paratonic rigidity

17. 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 • Not due to an Axis I disorder (e.g., schizophrenia)

18. Risk Factors for AD • Age • Family history • CV risk factors (hypertension, diabetes, elevated homocysteine, cholesterol?) • Late onset depression • Delirium • Fewer years of education • Head injury

19. Possible Protective Factors • NSAIDs • Statins • Antihypertensives • Antioxidants • Exercise

20. Routine Evaluation of Dementia • Complete blood count • Thyroid function test (TSH) • Vitamin B-12 level/folate • Complete metabolic panel (BUN/Cr, glucose, calcium, LAEs, electrolytes) • Neuroimaging should be done at least once • Non-contrast CT • MRI brain without contrast

21. Brief Mental Status Examination • Mini Mental Status Exam • Clock-drawing tests • Blessed-dementia rating scale • Mini-cog • 7-minute screen

22. Comprehensive Mental Status Examination • Attention • Language • Memory • Visuospatial/perceptual functions • Executive functions • Praxis • Calculations

23. Key Physical Exam Points • Look for extrapyramidal dysfunction • Asymmetric findings • Pyramidal tract findings and pathologic reflexes • Gait dysfunction • Coordination • Sensation

24. Not Routinely Recommended • Erythrocyte sedimentation rate • RPR • Lumbar puncture • HIV • Serial neuroimaging • Functional neuroimaging (PET, SPECT) • Full neuropsychological testing

25. Mild AD 2001 to 2004

27. Early AD • Poor short term memory • Difficulty learning and retaining new information • Mild word-finding difficulties • Naming problems • Problems with organization, and complex planning

28. Moderate AD • Worsening memory problems • Remote memory becomes involved • More obvious language problems • Visuospatial and topographical orientation • Getting lost, unable to find way back home • Behavioral changes (delusions, aggression, irritability, anxiety)

29. Severe AD • Aphasia (unable to comprehend language other than simple commands) • Agnosia (difficulty recognizing objects, people, etc.) • Apraxia (inability to perform skilled movements despite intact motor/sensory skills)

30. Strategy for Treating AD • Slow or delay progression • Correct exacerbating factors/conditions • Treat and prevent concomitant CVD • Treat behavioral and psychiatric problems • Treat functional problems

31. Current Treatments • Acetylcholinesterase inhibitors • Donepezil (Aricept) • Rivastigmine (Exelon) • Galantamine (Reminyl) • N-methyl-D-aspartate inhibitors • Memantine (Namenda) • May be used in conjunction with CHEIs

32. Acetylcholinesterase Inhibitors • Approved for mild-moderate AD • Aricept just approved for severe AD • Start as early as possible • Continue as long as possible • Use maximum dose tolerated • Failure to respond to one does not preclude response to another

33. Acetylcholinesterase inhibitors • Most AD patients decline by 3-4 points on MMSE per year • Treatment generally may delay progression by ~ 6 months • Behavior and function may improve in addition to cognition

34. Reinforce Expectations of PersistentTreatment • ChEI treatment is the standard of care for mild to moderate AD • Improvement, stabilization, or slowed decline represent treatment success • Evaluate treatment response in the context of progressive decline • Inform patient and caregiver that stabilization is desirable • Use follow-up visits to reinforce realistic expectations • Aricept has proven benefits on cognitive, functional, and behavioral symptoms ChEI = cholinesterase inhibitor.

35. How to Improve AD Management • Detect and diagnose early • Provide early and persistent treatment • Evaluate treatment response in the face of progressive decline • Manage physician, patient, and caregiver expectations of disease course and treatment response

36. Summary • Dementia is a major public health problem • Dementia is under recognized in all settings • Dementia is a disorder of cognition, behavior and function • Effective treatments exist that may improve or help preserve all 3 domains