Dementia - Ifergane

Question 1

What are the clinical features and diagnostic criteria of dementia?

Answer 1

Impaired social or occupational function
Impaired memory, plus one or more area of the following cognitive functions:
Abstract/problem solving
Judgment
Language
Personality
Clear consciousness

Slow onset
Depressive symptoms after loss of cognitive function (but can precede diagnosis; ex: of AD by >2y)
Often deny cognitive loss

Question 2

How is subcortical dementia distinguished from cortical dementia?

What are examples of each?

Answer 2

Subcortical less severe than cortical

Slower speed of cognition

Frontal memory impairment aided by cues vs. dysphagia, dyspraxia and agnosia

Apathetic/depressive vs. less depression

Dysarthritic/extrapyramidal motor abnormalities vs. gegenhalten if any

Prominent changes in striatum and thalamus vs. cortical association areas

Progressive supranuclear palsy vs. Alzheimer’s disease

Question 3

What is the prevalence of Alzheimer’s Disease?

What are risk factors for AD?

What underles the clinical symptomatology?

Answer 3

Prevalence: 10% over age 65, 47% over age 84

Family history of Alzheimer's disease.
 APO genotype (epislon4): for late onset familial and sporadic forms, those who inherit one or more alleles are at greater risk.
 Aging and estrogen deficiency.

Cholinergic deficit:
Progressive loss of cholinergic neurons–>
Progressive decrease in available acetylcholine (ACh) –>
Impairment in activities of daily living (ADL), behaviour and cognition

Question 4

What are the diagnostic criteria of Alzheimer’s Disease?

Answer 4

Abnormal clinical exam and mini mental status exam
Deficits in 2 or more areas of cognition
Progressive worsening
No disturbance of consciousness
Absence of systemic or other brain disease to account for symptoms

Must be gradual, insidious and chronic

Question 5

What is the therapy for Alzheimer’s Disease

Answer 5

Central cholinesterase inhibitors
NMDA Antagonist

Question 6

What is delirium?

How is it distinguished from dementia?

What are some common causes?

Answer 6

Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
A change in cognition or the development of a perceptual disturbance .
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect:
amitryptiline and other drugs and toxins
Infections
Metabolic derangements
Brain disorders
Systemic organ failure
Physical disorders

Occassionally pneumonia delirium can be first presentation of dementia if there is not enough reserve and the patient is close to the cusp of dementia

Distinguish from psychogenic causes by encephalopathy in EEG

Question 7

What are some causes of subacute dementias?

What are other Dimentia syndromes?

Answer 7

Subdural hematoma.
Normal pressure hydrocephalus.
Treatable cancer- Para neoplastic syndrome
Metabolic causes (TSH,Thirotropin, thiamine-no harm but essential, B12, alcohol)
Inflammatory
Infectious (VDRL, HIV)
Medications (BZD, TCA, opioids…)

Alzheimer disease (50-60%)
Diffuse lewy body disease (10-20%)
Multi infarct –vascular dementia(10-20%)
Fronto temporal dementia - Pick’s disease. (rare-younger onset than Alzheimers, causes lack of inhibition)

Question 8

What distinguishes depression/anxiety and dementia?

Answer 8

Depression:
Younger patients
Patient complains about memory loss.
Patients often present by themselves.
May have signs of psychomotor slowing or look anxious.
Produce a poor effort on testing.

Dementia:
Older patients
Brought to physicians by their families
Normal social grace
Try hard but respond with incorrect answers.

Can be both!

Question 9

What is mild cognitive impairment?

Answer 9

Presence of memory difficulty and objective memory impairment.
Preserved ability to function in daily life.
Patients with MCI are at increased risk of dementia- no way to prevent degeneration except crossword puzzles and other stimulation.

Question 10

What are the pathological elecments that increase with time in Alzheimer’s disease?

Which decrease?

Answer 10

Increasing amyloid plaques and neurofibrillary tangles

Increased CSF tau and phosphorylated tau

Dependence on assistance in daily activities

Decreased FGD-PET parietal metabolism

Decreased SCF beta-amyloid peptide

Decreased Hippocampal size on MRI

Decreased neuropsychological test performance

ApoE4 worsens prognosis

ApoE3 is protective

Question 11

What is the order of progression of Alzheimer’s Disease

Answer 11

1. Loss of memory of recent events.
2. Deficits in other cognitive domains may appear with or after the development of memory impairment.
3. Language function and visuospatial skills tend to be affected relatively early.
4. Deficits in executive function and behavioral symptoms often manifest later in the disease course.

Average 3-3.5 point decline on MMSE each year

Average survival after diagnosis 3-8 years

Patients generally succumb to terminal-stage complications that relate to advanced debilitation, such as dehydration, malnutrition, and infection.

Question 12

What are diagnostic tests for Alzheimer’s disease?

Answer 12

Physical and neurological examination
Mini-Mental state
Clock drawing
Neuropsychologic testing
B12 , TSH +”routine laboratory”
Imaging (CT/MRI?)
E.E.G
L.P
Amyloid PET tracers (11C-labeled Pittsburgh compound)
Histopathologic examination

70-80% accurate

Only sure diagnosis is pathology post mortem

Question 13

What are preventative measures to take for dementia?

Answer 13

Reduce stress

Increase exercise

Increase mental stimulation

Antiinflammatories (not proven)

Statins

If have mild cognitive impairment (MCI) can pay for ACh inhibitors out of pocket