14 - Dementia

Question 1

What is dementia?

Answer 1

• 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

Question 2

How common is Alzheimer’s disease?

Answer 2

6%‒8% of people ≥65 yr have Alzheimer dementia (AD)

Question 3

What are the risk factors for dementia?

Answer 3

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)

Question 4

What are the factors that protect you from dementia?

Answer 4

Definite: unknown

Possible
• NSAIDs
• Antioxidants
• Intellectual activity
• Physical activity
• Statin

Question 5

What is important to ask dementia patients during the history?

Answer 5

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

Question 6

What do we do in a lab workup for patients presenting with dementia?

Answer 6

• 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)

Question 7

What are possible differential diagnoses for a patient presenting with dementia?

** most helpful clinically **

Answer 7

***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

Question 8

What is the most common cause of dementia in the industrialized world?

Answer 8

Alzheimer’s disease

2nd = Lewy body dementia

Question 9

What should you examine in dementia patients?

Answer 9

• Neurologic status
• Mental status
• Functional status

Question 10

What type of testing should you do on your dementia patients?

Answer 10

• Quantified screens for cognition
➢ For example, Folstein’s MMSE, Mini-Cog,
SLUMS, MoCA
• Neuropsychologic testing

Question 11

When should you consider brain imaging in a patient?

Answer 11

• Onset occurs at age

Question 12

How do you diagnose dementia?

Answer 12

• 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.

Question 13

What is on your differential diagnosis in dementia patients?

Answer 13

• Normal aging
• Mild cognitive impairment
• Delirium
• Depression
• Alzheimer disease
• Vascular dementia
• Lewy body dementia
• Other (frontotemporal dementia, alcohol, Parkinson
disease, neurosyphilis)

Question 14

What would you see in normal aging?

Answer 14

• 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

Question 15

What is “mild cognitive impairment”

Answer 15

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

Question 16

How do you distinguish delirium from dementia?

Answer 16

• 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

Question 17

What symptoms often overlap with dementia?

Answer 17

Depression

Question 18

Discuss the overlap of dementia and depression

Answer 18

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

Question 19

Describe the disease characteristics of Alzheimer’s disease

Answer 19

• 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)

Question 20

Describe the disease characteristics of vascular dementia

Answer 20

• 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

Question 21

What is the second most common cause of dementia?

Answer 21

Lewy body disease

Related to Parkinson’s disease

Question 22

Describe the disease characteristics of Lewy Body dementia

Answer 22

• 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

Question 23

Describe the disease characteristics of frontotemporal dementia

Answer 23

• Onset: gradual, usually age

Question 24

How do you stage dementia?

Answer 24

He doesn’t use the “7 steps”

This is what he does:

• Mild
• Moderate
• Severe (need 24 hr/day monitoring)
• Vegetative

Question 25

What are the 5 goals for everyone with dementia?

Answer 25

• 1. To make sure the patient is safe and happy
• 2. To make a clear diagnosis
• 3. To initiate best interventions (medications)
• 4. To answer any questions from patient and loved ones
• 5. To help initiate plans for the future so that the patient will always be safe and happy

Question 26

What is the primary goal of treatment for dementia pateints?

Answer 26

To enhance quality of life and
maximize functional performance by
improving cognition, mood, and behavior

Question 27

How can you non-pharmacologically manage dementia patients?

Answer 27

• 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

Question 28

What can help with “brain wellness”?

Answer 28

• Socialization
• Physical Exercise
• Cognitive Training
• Stress reduction
• Mediterranean Diet
• Meditation

Question 29

How do you pharmacologically manage dementia patients?

Answer 29

• 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

Question 30

What do cholinesterase inhibitors do?

Answer 30

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

Question 31

What does memantine do?

Answer 31

• 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

Question 32

What is the one supplement that may be helpful for dementia patients

Answer 32

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

Question 33

Test question: What is the most common cause of dementia?

Answer 33

Alzheimer’s disease

Question 34

Test question: How is dementia diagnosed?

Answer 34

Good history, physical and lab work

Do NOT need to wait for brain biopsy or autopsy

Question 35

Test question: How do you treat dementia/Alzheimer’s disease?

Answer 35

A combination of drugs, emotional support and caregiver support can be very effective