14 - Dementia Flashcards
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
How common is Alzheimer’s disease?
6%‒8% of people ≥65 yr have Alzheimer dementia (AD)
What are the risk factors for dementia?
Definite • Age • Family history • APOE4 allele (gene for AD) • Down syndrome
Possible • Head trauma • Fewer years of formal education • Late-onset major depressive disorder • Cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, obesity)
What are the factors that protect you from dementia?
Definite: unknown
Possible • NSAIDs • Antioxidants • Intellectual activity • Physical activity • Statin
What is important to ask dementia patients during the history?
Ask both the patient and a reliable informant
about the patient’s:
• Date of onset of current condition and nature
of symptoms
• Medical history
• Current medications & medication history
• Patterns of alcohol use or abuse
• Living arrangements
What do we do in a lab workup for patients presenting with dementia?
• Comprehensive h and p
• lab work: cbc, lytes, bun, creatinine,
calcium, rpr, B12, folate, ALT, AST, free T4,
TSH
• CNS visualization
• Neuropsych testing (mini-mental exam in the office, more testing with a specialist)
What are possible differential diagnoses for a patient presenting with dementia?
** most helpful clinically **
***DEMENTIAS*** • Drugs • Emotional (psychiatric) disorders • Metabolic disorders • Endocrine problems • Nutritional and Neurologic disease • Trauma and Tumor • Infection, ischemia, inflammation • Anemia, arrythmia • Social, Sensory, Spiritual isolation
You can use this for both delirium and dementia
What is the most common cause of dementia in the industrialized world?
Alzheimer’s disease
2nd = Lewy body dementia
What should you examine in dementia patients?
- Neurologic status
- Mental status
- Functional status
What type of testing should you do on your dementia patients?
• Quantified screens for cognition
➢ For example, Folstein’s MMSE, Mini-Cog,
SLUMS, MoCA
• Neuropsychologic testing
When should you consider brain imaging in a patient?
• Onset occurs at age
How do you diagnose dementia?
• It is important to note that we can make the
diagnosis with this approach accurately
greater than 90% of the time.
• The vast majority of diagnoses in patients
with dementia are made up of five clinical
syndromes:
• AD, Diffuse Lewy Body Disease,
Frontotemporal Dementia, Vascular
Dementia, and Normal Pressue
Hydrocephalus.
What is on your differential diagnosis in dementia patients?
• Normal aging • Mild cognitive impairment • Delirium • Depression • Alzheimer disease • Vascular dementia • Lewy body dementia • Other (frontotemporal dementia, alcohol, Parkinson disease, neurosyphilis)
What would you see in normal aging?
• No consistent, progressive deviations on testing
of memory
• Some decline in processing and recall of new
information: slower, harder
• Reminders work—visual tips, notes
• Absence of significant effects on ADLs or IADLs
due to cognition
What is “mild cognitive impairment”
He said its the same thing as early dementia, not a separate diagnosis
He tends to treat this aggressively
Subjective complaint of decline in at least one cognitive
domain: noticeable and measurable
How do you distinguish delirium from dementia?
• Delirium and dementia often occur together in older
hospitalized patients
• The distinguishing signs of delirium are:
➢ Acute onset
➢ Cognitive fluctuations over hours or days
➢ Impaired consciousness and attention
➢ Altered sleep cycles
➢ Search for underlying dementia once delirium cleared
What symptoms often overlap with dementia?
Depression
Discuss the overlap of dementia and depression
The symptoms of depression and dementia often
overlap:
• Impaired concentration
• Lack of motivation, loss of interest, apathy
• Psychomotor retardation
• Sleep disturbance
• Patients with primary depression are generally
unlike those with dementia in that they:
➢ Demonstrate ↓ motivation during cognitive testing
➢ Express cognitive complaints that exceed
measured deficits
➢ Maintain language and motor skills
• ~50% presenting with reversible dementia and
depression progress to dementia within 5 yr
Describe the disease characteristics of Alzheimer’s disease
• Onset: gradual
• Cognitive symptoms: memory impairment core feature
with difficulty learning new information
• Motor symptoms: rare early, apraxia later
• Progression: gradual, over 8–10 yr on average
• Lab tests: normal
• Imaging: possible global atrophy***, small hippocampal
volumes (cannot form new memories)
Describe the disease characteristics of vascular dementia
• Onset: may be sudden (like a stroke)/stepwise
• Cognitive symptoms: depend on anatomy of ischemia,
but dysexecutive syndrome common
• Motor symptoms: correlates with ischemia
• Progression: stepwise with further ischemia
• Lab tests: normal
• Imaging: cortical or subcortical changes on MRI
Rarely PURE vascualr dementia, a lot of times they have many strokes (stepwise decline) and this contributes to dementia, but there is also Alzheimer’s disease present contributing to the Alzheimer’s disease
What is the second most common cause of dementia?
Lewy body disease
Related to Parkinson’s disease
Describe the disease characteristics of Lewy Body dementia
• Onset: gradual
• Cognitive symptoms: memory, visuospatial,
hallucinations***, fluctuations
• Motor symptoms: parkinsonism (shuffling gate, no facial expression)
• Progression: gradual, but usually faster than AD
• Lab tests: normal
• Imaging: possible global atrophy
Usually have some really good days and some really bad days
Describe the disease characteristics of frontotemporal dementia
• Onset: gradual, usually age
How do you stage dementia?
He doesn’t use the “7 steps”
This is what he does:
- Mild
- Moderate
- Severe (need 24 hr/day monitoring)
- Vegetative
What are the 5 goals for everyone with dementia?
- To make sure the patient is safe and happy
- To make a clear diagnosis
- To initiate best interventions (medications)
- To answer any questions from patient and loved ones
- To help initiate plans for the future so that the patient will always be safe and happy
What is the primary goal of treatment for dementia pateints?
To enhance quality of life and
maximize functional performance by
improving cognition, mood, and behavior
How can you non-pharmacologically manage dementia patients?
• Cognitive rehabilitation
• Supportive individual and group therapy
• Physical and mental activity
• Regular appointments every 3–6 months
• Family and caregiver education and support
• Attention to safety
➢ Need for supervision, wandering, driving etc.
• Environmental modification
➢ Orientation and memory measures such as clocks,
calendars, to-do list, visual clues, simple and
compassionate communication style
What can help with “brain wellness”?
- Socialization
- Physical Exercise
- Cognitive Training
- Stress reduction
- Mediterranean Diet
- Meditation
How do you pharmacologically manage dementia patients?
• Treatment should be individualized • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine *** • Memantine *** • Other cognitive enhancers • Antidepressants • Psychoactive medications
Everyone gets on one of the cholinesterase inhibitors AND memantine
This is especially for Alzheimer’s, but if you have any dementia, these are very safe and can be helpful for any type of dementia
What do cholinesterase inhibitors do?
Slow breakdown of acetylcholine
• Clinical trials demonstrate modest delay in cognitive
decline compared with placebo in AD
• GI side effects common
➢ Mitigated by slow titration curve
➢ Maximum dosing of donepezil 23 mg/day creates significant
side effects without evidence of improving global function
• No evidence of difference in efficacy among drugs
What does memantine do?
• Neuroprotective effect is to reduce glutamate-mediated
excitotoxicity
• Modest benefit on cognition, ADLs, and behavior in AD
• Limited effect on cognition and no evidence to support
widespread use in vascular dementia
• FDA-approved for moderate to severe AD
• Common adverse events: constipation, dizziness,
headache
What is the one supplement that may be helpful for dementia patients
Ginkgo biloba
They are not controlled in the US so you never know how much or if there is any active Ginko biloba in the supplement you buy
Test question: What is the most common cause of dementia?
Alzheimer’s disease
Test question: How is dementia diagnosed?
Good history, physical and lab work
Do NOT need to wait for brain biopsy or autopsy
Test question: How do you treat dementia/Alzheimer’s disease?
A combination of drugs, emotional support and caregiver support can be very effective
