Case Discussion - Dementia

Question 1

Mild cognitive impairment

criteria

Answer 1

(1) Memory complaint, preferably corroborated by an informant
(2) Objective memory impairment
(3) Normal general cognitive function
(4) Intact activities of daily living
(5) Not demented

Question 2

MCI

Transformation to AD

Answer 2

10-15% per year convert from MCI to AD; 40% over 3 yrs, 80% over 6 yrs

44% of MCI may return to normal a year later

Question 3

Diagnosis of dementia

Answer 3

Loss of multiple cognitive abilities in a person with a clear sensorium (no delerium)

DSMIV-R requires memory impairment plus impairment in one of:

(1) language
(2) judgement
(3) abstract thinking
(4) praxis
(5) constructional abilities
(6) visual recognition

Question 4

AD

Assessment tools

Good evidence for using…

Answer 4

1) Mini Mental Status Exam (MMSE, adjusted for age and education)
(2) Memory Impairment Screen
(3) Neuropsychological batteries
(4) Montreal Cognitive Assessment (MoCA)

Question 5

AD

Assessment tools

Weaker evidence for using…

Answer 5

(1) Kokmen Short Test of Mental Status
(2) 7-Minute Screen
(3) Blessed Dementia Rating Scale
(4) CDR
(5) IQCODE
(6) Clock Drawing Test
(7) Time and Change Test

Question 6

Etiologies of dementia

list

Answer 6

AD
Vascular dementia
Dementia with lewy bodies
Frontotemporal dementia
Rapidly progressive dementia
Hereditary

Question 7

Dementia etiologies

Vascular dementia

Answer 7

(1) Multi-infarct
(2) Lacunar infarctions
(3) Single infarct (?)
(4) Binswanger’s disease

Question 8

Dementia etiologies

Dementia with lewy bodies

Answer 8

Other dementia with Parkinsonism:

(a) Late Parkinson’s disease
(b) Progressive supranuclear palsy (PSP)
(c) Multiple system atrophy (MSA)
(d) Cortico-basal degeneration (CBD)

Question 9

Dementia etiologies

Frontotemporal dementia

Answer 9

(1) Pick’s disease
(2) Chromosome 17 dementia
(3) Frontal lobe dementia with motor neuron disease (4) Primary progressive aphasia with dementia
(5) Progressive subcortical gliosis
(6) Primary progressive apraxia

Question 10

Dementia etiologies

Rapidly progressive dementia

Answer 10

(1) Prion disease
(2) Limbic encephalitis
(3) Meningitis
(4) Hydrocephalus

Question 11

Clinical features of DLB

Central feature is dementia that…

Answer 11

(1) Becomes worse over time
(2) Includes problems with attention and executive function
(3) May or may not include memory loss in the early stages of the disease but does appear eventually

Question 12

Clinical features of DLB

Core features include

Answer 12

(1) Changes in attention and alertness that fluctuate dramatically in a short amount of time
(2) Frequent visual hallucinations that are complex, confusing, and very detailed
(3) Parkinsonism beginning within 1 year of dementia including tremor at rest, stiffness (rigidity), slowness of movements (bradykinesia), difficulties with balance (postural instability)
(4) Marked sensitivity to dopamine blocking medications (antipsychotics, antinausea drugs) which cause worsening of parkinsonism

Question 13

Confounding conditions for dementia

Answer 13

Normal aging

Depression

Delirium

Psychosis

Question 14

Subacute encephalopathies resembling dementia

list

Answer 14

Medication
Ethanol
Metabolic – calcium, thyroid, renal, hepatic, vitamin, electrolyte, respiratory, glucose
infectious – chronic meningitis, syphilis, HIV
Neoplastic – primary, metastatic, meningitic
Chronic subdural hematoma
Vasculitic

Question 15

Routine evaluation of the demented patient

list

Answer 15

To exclude metabolic cognitive impairment and depression:

i) Complete blood cell count
ii) Serum electrolytes
iii) Glucose
iv) BUN/creatinine
v) Serum B12 levels
vi) Liver function tests
vii) Thyroid function tests
viii) Depression screening

Question 16

Non-routine evaluation of the demented patient

list

Answer 16

i) Screening for syphilis (unless patient has a specific risk factor)
ii) PET
iii) Linear or volumetric MR or CT measurement strategies
iv) SPECT
v) Genetic testing for DLB or CJD
vi) APOE genotyping for AD
vii) EEG

Question 17

Dementia

When is lumbar puncture performed

Answer 17

Lumbar Puncture is performed only when there is a reasonable suspicion of an etiology which might be detected by CSF examination or opening pressure

i) Presence of metastatic cancer
ii) Suspicion of CNS infection
iii) Reactive serum syphilis serology
iv) Hydrocephalus
v) Age under 55
vi) Rapidly progressive or unusual dementia
vii) Immunosupression
viii) Suspicion of CNS vasculitis

Question 18

Dementia

Tests of uncertain value

Answer 18

Genetic markers for AD not listed above
CSF or other biomarkers for AD
Tau mutations in patients with FTD
AD gene mutations in patients with FTD

Question 19

Pharmacologic tx of AD

Answer 19

(1) Cholinesterase inhibitors should be considered for mild to moderate AD (Standard), although studies suggest a small average degree of benefit – Donepezil, rivastigmine, galantamine
(2) Memantine (Namenda) is a low-affinity N-methyl-D-aspartate (NMDA) receptor antagonist
(3) Vitamin E (1000 I.U. PO BID) should be considered to slow progression of AD (Guideline)
(4) Selegiline (5 mg PO BID) is supported by one study, but has a less favorable risk–benefit ratio (Practice Option)
(5) Other antioxidants, anti-inflammatories, and other putative disease- modifying agents have a risk of significant side effects in the absence of demonstrated benefits (Practice Option)
(6) Estrogen should not be prescribed to treat AD (Standard)