Case Discussion - Dementia Flashcards
Mild cognitive impairment
criteria
(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
MCI
Transformation to AD
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
Diagnosis of dementia
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
AD
Assessment tools
Good evidence for using…
1) Mini Mental Status Exam (MMSE, adjusted for age and education)
(2) Memory Impairment Screen
(3) Neuropsychological batteries
(4) Montreal Cognitive Assessment (MoCA)
AD
Assessment tools
Weaker evidence for using…
(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
Etiologies of dementia
list
AD Vascular dementia Dementia with lewy bodies Frontotemporal dementia Rapidly progressive dementia Hereditary
Dementia etiologies
Vascular dementia
(1) Multi-infarct
(2) Lacunar infarctions
(3) Single infarct (?)
(4) Binswanger’s disease
Dementia etiologies
Dementia with lewy bodies
Other dementia with Parkinsonism:
(a) Late Parkinson’s disease
(b) Progressive supranuclear palsy (PSP)
(c) Multiple system atrophy (MSA)
(d) Cortico-basal degeneration (CBD)
Dementia etiologies
Frontotemporal dementia
(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
Dementia etiologies
Rapidly progressive dementia
(1) Prion disease
(2) Limbic encephalitis
(3) Meningitis
(4) Hydrocephalus
Clinical features of DLB
Central feature is dementia that…
(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
Clinical features of DLB
Core features include
(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
Confounding conditions for dementia
Normal aging
Depression
Delirium
Psychosis
Subacute encephalopathies resembling dementia
list
Medication
Ethanol
Metabolic – calcium, thyroid, renal, hepatic, vitamin, electrolyte, respiratory, glucose
infectious – chronic meningitis, syphilis, HIV
Neoplastic – primary, metastatic, meningitic
Chronic subdural hematoma
Vasculitic
Routine evaluation of the demented patient
list
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
Non-routine evaluation of the demented patient
list
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
Dementia
When is lumbar puncture performed
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
Dementia
Tests of uncertain value
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
Pharmacologic tx of AD
(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)
