24. Dementia

Question 1

Definition of Major Neurocognitive Disorder (Dementia)

Answer 1

1. Evidence of significant cognitive decline in one or more cognitive domains

• Learning/memory
• Language
• Executive function
• Complex attention
• Perceptual-motor
• Social cognition

2. Impairs function (AVD, AVQ)
3. Not better explained by other disorder

Question 2

Name DDx Memory Loss (5)

Answer 2

• Major Neurocognitive Disorder (previously Dementia)
• Mild Neurocognitive Disorder
• Delirium
• Depression
• Neurological - Seizures, stroke/TIA

Question 3

Name types of Major Neurocognitive Disorder (7)

Answer 3

• Alzheimer (most common 50%)
• Mixed Alzheimer and vascular (20%)
• Vascular (15%)
• Lewy Body (5%)
• Frontotemporal (1%)
• Parkinson disease with dementia
• Other: Progressive supranuclear palsy (vertical supranuclear gaze palsy and postural instability), Huntington disease

Question 4

Describe : Alzheimer (3)

Answer 4

• Gradual onset
• Normal CNS
• Initial and most prominent deficit = amnestic (associated with impairment in learning and recall of recently learned information)

Question 5

Describe : Vascular Dementia (5)

Answer 5

• Abrupt
• Stepwise
• Cardiovascular risks (HTN, DLP)
• Dysexecutive syndrome
• Focal neurological features

Question 6

Name core features : Lewy Body Dementia (5)

Answer 6

• Fluctuating cognition
• Detailed visual hallucinations
• REM sleep behaviour disorder
• Parkinsonism (bradykinesia, rest tremor, rigidity)
• Other suggestive: Severe neuroleptic sensitivity (irreversible parkinsonism, impaired consciousness), postural instability, falls, syncope, autonomic dysfunction, hypersomnia, hyposmia, delusions, apathy, anxiety, depression

Question 7

Describe : Frontotemporal Dementia (2)

Answer 7

• Behavioural problems (disinhibition, loss of social awareness)
• Language impairment

Question 8

Describe : Parkinson disease with dementia

Answer 8

• Impaired executive dysfunction and visuospatial function
• Differentiate from Lewy Body as parkinsonism is present >1y prior to dementia (whereas in DLB dementia occurs before or at the same time as the parkinsonian signs)

Question 9

Describe : Mild Neurocognitive Disorder (3)

Answer 9

• Decline reported by patient, informant or clinician with objective deficits in 1+ domains (typically memory)
• Preserved independence in function
• Follow q3-6 months, Alzheimer’s 15% per year (2/3 will eventually convert to Alzheimer’s)

Question 10

Describe : Delirium

Answer 10

• Sudden onset
• Decreased concentration
• May have visual/tactile hallucinations)
• Caused by : Infection, Drugs/Toxins (polypharmacy, opioids, cholinergic, benzodiazepine, alcohol), Endocrine (Thyroid, B12), Electrolytes (glucose, sodium)

Question 11

Describe Physical Exam of Dementia (4)

Answer 11

• Gait
• Neurological signs
• Extra pyramidal symptoms
• Parkinson (cogwheel rigidity, tremors)

Question 12

Describe Investigations for dementia

Answer 12

• Labs (low yield <1%)
• Consider EKG prior to treatment. Avoid AchEI if LBBB, 2nd/3rd degree block, sick sinus, HR<50
• Consider CT head
• Depression screen

Question 13

Name labs for dementia (6)

Answer 13

• CBC
• TSH
• Electrolytes (Glucose, Cr, Ca)
• B12
• Lipids
• Neurosyphilis screen only if high clinical suspicion

Question 14

Consider CT head in dementia when ? (7)

Answer 14

• < 60yo
• Abrupt, rapid decline
• Focal neurological symptoms (headache, seizure, hemiparesis, babinski reflex)
• Urinary incontinence, gait disorder (r/o normal pressurehydrocephalus)
• Previous malignancy, trauma
• Anticoagulants/Bleeding disorder or history of bleeding disorder
• If presence of cerebrovascular disease would change management

Question 15

Describe diagnosis : Dementia

Answer 15

• Investigate symptomatic
• Highly educated : Hopkins Verbal Learning test, Word List Acquisition test
• MMSE <24 suggests dementia/delirium (1 in 10 false positive)
• MoCA <26 (MCI 78%, AD 100%,1 in 4 false positive)
• Clinical Dementia Rating (Lengthy)
• Mini-Cog (Brief). Clock drawing task and uncued recall of three unrelated words

Question 16

Describe LIFESTYLE tx of dementia

Answer 16

• Refer to Alzheimer society
• Discuss will, power of attorney, personal directives
• Safety issues (driving, stove, smoke detector, microwave)
• Occupational Therapy
• Hearing and vision screen
• Social work / Homecare services
• Healthy diet, smoking cessation
• Exercise program
• Eliminate medication (narcotics, anticholinergics, benzodiazepines);
• Alternative therapy : Aromatherapy, Multisensory stimulation, Music/dance therapy, Animal‑assisted therapy, Massage/touch therapy, Outdoor activities

Question 17

What’s tx for mild cognitive disorder ?

Answer 17

No pharmaco

Question 18

Acetylcholinesterase inhibitors may be considered when ?

Answer 18

Acetylcholinesterase inhibitors may be considered only in mild to moderate Alzheimer’s Disease (lower quality evidence in Lewy bodies, vascular, Parkinson), where :
* Healthcare professional has expertise in diagnosing and treating Alzheimer’s Disease
* Adequate support and supervision
* Adequate adherence and monitoring of adverse effects, which generally requires the availability of a carer
* Baseline structured cognitive and functional assessment
* Follow up should be carried out on regular basis at least every 3 months : Taper slowly before stopping, May restart if decline shortly after stopping
* May reduce all-cause mortality in patient with dementia

Question 19

Name examples AchEI (3)

Answer 19

• Galantamine
• Donepezil
• Rivastigmine

Question 20

Describe pharmacotx in Alzheimer’s

Answer 20

• AchEI - Consider in mild to moderate (eg. MMSE 10-26)
• Titrate q4 weeks
• Discontinue when risks outweigh benefits (taper, and monitor 1-3 months, if declines can restart)
• NMDA receptor antagonists (Memantine) in severe AD

Question 21

Name adverse effects : AchEI

Answer 21

• GI (nausea, diarrhea, vomiting)
• Bradycardia, hypotension, dizziness, syncope
• Insomnia / sleep disturbances
• QT prolongation and torsades de pointes (EKG prior to treatment as above)

Question 22

Describe tx : Frontotemporal dementia (2)

Answer 22

• SSRI (paroxetine) or trazodone
• No evidence for AchEI

Question 23

Describe tx : Vascular dementia

Answer 23

• Manage HTN, DM, smoking
• No evidence for AchEI

Question 24

Describe tx : Lewy Bodies

Answer 24

• Can consider AchEI (eg. Rivastigmine (Exelon) 1.5-6mg BID)
• Avoid antipsychotics
• Risk of NMS

Question 25

Describe tx : Parkinson’s/Cerebrovascular disease

Answer 25

Can consider AchEI

Question 26

Describe investigation : Behavioral and psychological symptoms of dementia (BPSD)

Answer 26

r/o medication side effects or interactions, treatable medical conditions such as sepsis or depression

Question 27

Describe tx : Severe agitation/Violent behaviour in Behavioral and psychological symptoms of dementia

Answer 27

Correct underlying

• Physical (pain, constipation, infection)
• Environmental (set routines, sound/lights, position, daytime activity)
• Psychiatric conditions (depression)
• Review medications

Intervention

• Relaxation, social contact, sensory (eg. music/aromatherapy)
• Increased services/care

Consider newer antipsychotics (less EPS), eg. Risperidone, Olanzapine, Seroquel
* Caution as increased risk of death, CVA, EPS, falls, somnolence, weight gain, diabetes

Question 28

When to consider referral in dementia ?

Answer 28

• Rapid progression
• Young
• Frontotemporal, Lewy Body, Parkinson’s Dementia

Question 29

Name risks of unsafe driving (4)

Answer 29

• Multiple motor vehicle accidents in past 5 years
• Self-restricted driving or Family/caregiver concerns
• Aggressive or impulsive behaviour
• MMSE 24 or less

Question 30

Describe how to evaluate risk in driving assessment

Answer 30

• Clinical Dementia Rating scale of 1 or more suggests unsafe driver. The Clinical Dementia Rating score equals the memory score unless the patient scores more or less than the memory score in three of the secondary categories.
• On-road assessment by occupational therapy