week 13- dementia Flashcards
is memory loss need to be present in dementia
no affects many cognitive domains and not necessarily memory
6 key neurocognitive domains in dementia
- perceptual-motor function
- language
- executive function
- learning and memory
- complex attention
- social cognition
types of cognitive decline
-psuedodementia (depression or other psyhiatric disorder)
-delirium
-MCI
-dementia (AD, vascular, Lewy body, frontotemporal)
dementia definition in DSM 4
Dementia is often associated with memory loss, but definitions have evolved to think beyond memory impairment and describe a diverse group of disorders that affects multiple cognitive domains.
DSM-IV (1994) characterized dementia as a chronically progressive brain disease that impairs intellect and behaviour to the point where customary activities of daily living become compromised.1
dementia definition in DSM 5
replaced the term ‘dementia’ to major neurocognitive disorder characterized by:
- evidence of significant cognitive decline in one or more cognitive domains compared to a previous level of performance
- persistent and progressive decline over time
- cognitive deficits interfere with independence in everyday activities
- not associated with delirium or another psychiatric/mental disorder
prevalence of dementia
increasing/// 2022 was 600k Canadians
age of onset in dementia
Dementia typically begins after age 60, and the prevalence doubles approximately every 5 years thereafter; in persons aged 85 and older, around half have dementia.4
women or men in dementia more
More prevalent among women, likely due to longer life expectancy
most common form of dementia
Alzheimer disease is the most common cause of dementia (70-80% of all cases)
Other causes include:
* Vascular dementia (15%)
* Lewy body dementia (5%)
* Frontotemporal dementia (25% in patients with dementia >65 y/o)
* Mixed dementia (most common: Alzheimer disease with vascular dementia)
strongest risk factor for dementia
age
The lifetime risk of dementia is approximately 17%,
with the incidence doubling each decade after 60 years of age.5
things that increase risk of dementia
- family history of dementia
- apolipoprotein E4 genotype
- personal history of cardiovascular, cerebrovascular disease,
diabetes mellitus, hypertension, obesity (midlife) - history of significant head injury
- hearing loss
- vitamin D deficiency
- chronic sleep deprivation
- cigarette smoking
- lower education level
protective factors against dementia
- physical activity
- higher education level
- ongoing intellectual stimulation
- social engagement
dementia definition? what is affected?
Cognitive decline from a previous level of performance in one or more cognitive domains that interferes with independence in activities of daily living. ADL
most common symptom in dementia
memory impairment
symptoms in dementia- agnosia
Agnosia: inability to recognize and name familiar objects when visual perception is adequate.1
symptoms in dementia- aphasia
Aphasia: language disturbance which can be motor or sensory aphasia.
symptoms in dementia- apraxia
Apraxia: inability to perform a motor task despite intact motor function.
symptoms in dementia- executive dysfunction
Executive dysfunction: inability to think abstractly and to plan and carry out complex behaviors including initiating the steps necessary to do a task, monitoring progress, and stopping the task.
symptoms in dementia- neuro and social deficits
Neuropsychiatric and social deficits presenting as depression, apathy, anxiety, hallucinations, delusions, agitation, insomnia, sleep disturbances, compulsions, or disinhibition
examples in the complex attention cognitive domain effected by dementia
Normal, routine tasks take longer; difficulty in completing tasks when multiple stimuli are present; difficulty in maintaining information while completing task (e.g., completing mental math calculations, remembering a phone number to dial); work requires more overview/rechecking than before.
examples in the executive function cognitive domain effected by dementia
Difficulty in completing previously familiar multistep tasks, such as preparing a meal; no longer wanting to participate in activities of the home; difficulty in completing activities or tasks because of easy distractibility; social outings become more taxing and less enjoyable.
examples in the language cognitive domain effected by dementia
Difficulty finding the correct words; using general pronouns regularly instead of names; mispronunciation of words; problems with understanding verbal and written communication.
examples in the learning and memory cognitive domain effected by dementia
Forgetting to buy items or buying the same items multiple times at the store; repetition in conversations; difficulty in recalling recent events; relying on lists of tasks to complete; forgetting to pay bills.
examples in the perceptiual-motor cognitive domain effected by dementia
Difficulty in using familiar technology, tools, or kitchen appliances; getting lost in familiar environments.
examples in the social cognition cognitive domain effected by dementia
Apathy, increase in inappropriate behaviors, loss of empathy, impaired judgment.
symptoms differing in dementia depending on what area of the brain effected
- Short term memory loss: hippocampus
- Word finding difficulty: temporoparietal junction of the left hemisphere
- Problems with articulation, fluency, comprehension, or word meaning are anatomically distinct
and less common - Visuospatial dysfunction: right parietal lobe is one of the brain areas affected
- Executive dysfunction: varies and could include the frontal lobes or subcortical areas like the
basal ganglia or cerebral white matter. - Apathy or indifference (separate from depression): may have a similar anatomy as executive
dysfunction. - Apraxia, (loss of learned motor behaviors), may result from dysfunction of the frontal or parietal
lobes, especially the left parietal lobe.
physical exams to see neurological findings in dementia
- Eye movement abnormalities
- Parkinsonism or other motor abnormalities
- Focal neurological deficits
time course of dementia
Insidious onset and gradual progression of symptoms
if dementia develops quickly what is usually the cause
When dementia develops quickly (over a few weeks to a few months) suspect rapidly progressive dementia. This could be caused by fatal and potentially transmissible conditions, such as prion disease, or manageable causes, such as infections, toxins, neoplasms, and autoimmune and inflammatory diseases.
median survival for demtnai
The median survival time after diagnosis of dementia is 4.5 years, but this varies based on age at diagnosis, ranging from 10.7 years for patients diagnosed in their 60s to 3.8 years for patients diagnosed in their 90s
dementia symptoms
- Behavioral problems, depression, and psychotic symptoms are common in all types of dementia.
- Eventually, most individuals with dementia struggle to perform simple tasks without assistance
1st step if think patient has memory loss of dementia
brief initial screening (i.e. mini cog)
if positive then do MMSE, MOCA
if positive screen for depression, CBC, b12, MRI, viral testing , thyroid
obtain history in dementia
- Characterize the nature, magnitude, and course of cognitive changes
- Nature: cognitive domains affected.
- Magnitude: severity as it relates to current functional abilities - does the cognitive loss affect
activities of daily living (ADL) and/or instrumental ADL? - Course: insidious onset and a slow progression? rapid onset and fluctuating and stepwise
progression? - Past medical history: vascular disease risk factors (hypertension and diabetes), existing brain conditions (such as stroke, Parkinson’s Disease, head trauma),
- Medication review: medications that impair cognition (e.g. anticholinergics, sleep aids and anxiolytics, analgesics such as codeine containing agents)
what can impair cognition
medications
(e.g. anticholinergics, sleep aids and anxiolytics, analgesics such as codeine containing agents)
medical history important for dementia
Past medical history: vascular disease risk factors (hypertension and diabetes), existing brain conditions (such as stroke, Parkinson’s Disease, head trauma),
history taking in dementia
Family history of dementia, especially young-onset dementia in first-degree relatives (inherited form of dementia)
- Social history: alcohol or other substance use, smoking history, risk for social isolation?
- Safety concerns: driving ability, episodes of wandering, vulnerability to financial or physical abuse
physical exam in dementia
- Neurological exam: evaluate objective evidence of neurocognitive problems, focal neurologic signs, parkinsonism
- Gait analysis
cognitive tests in dementia
who does them
what can effect results
- Conducted to screen for cognitive impairment (if dementia is suspected) and quantify severity of impairment.
- Can be completed by the patient or a reliable informant.
- Factors that can affect results include the patient’s educational level, age and language.
which cognitive test covers all 6 domains of dementia
cambridge cognitive examination
whats more important when diagnosing dementia; sensitivity of specificity
specificity
- When diagnosing dementia, valuing the specificity of the test over sensitivity can help avoid misdiagnosis and unnecessary tests.
early diagnosis of dementia via high sensitivity or specificity
- However, early diagnosis of dementia is important for effective interventions and education, and in some cases tests with high sensitivity to avoid mislabeling dementia as normal aging is preferable.
high LR+ in dementia
positive test indicates high probability of dementia
best LR- in dementia
less likely to mislabel a patient with dementia as experiencing normal aging.
USPSTF on current evidences of screening for cognitive impairment in adults
current evidence is insufficient to assess the benefits vs. harms of screening for cognitive impairment in older adults.
If dementia is suspected, physicians can use brief screening tests such as
Mini-Cog or General Practitioner Assessment of Cognition
If the results are abnormal, further evaluation is warranted using more in-depth screening tools such as the Montreal Cognitive Assessment, Saint Louis University Mental Status Examination, or Mini-Mental State Examination
3 brief initial screening tests for cognitive impairment
- mini-cog
- general practitioner assessment of cognition (GPCOG)
- ascertain dementia 8-item informant questionnaire
highest sensitivity for brief initial screening test
mini-cog (less specificity)
mini cog includes
A brief cognitive assessment that involves repeating three unrelated words, performing a clock drawing test, and recalling the three words
General Practitioner Assessment of Cognition (GPCOG) includes
Validated in the primary care setting that includes a patient screen and an informant component. It evaluates recall, time orientation, clock drawing, and information components.
Ascertain Dementia 8-Item Informant Questionnaire includes
Informant-based test that screens for major and minor neurocognitive disorders. It can also be administered to the patient but is less sensitive in that format.
if the brief screening test is positive or negative do what next
- Positive brief screening test→further cognitive test to quantify degree of impairment.
- If findings are normal on the cognitive test, consider referring for neuropsychiatric evaluation
especially if cognitive impairment is strongly suspected.
what tests to do after positive brief screening test for dementia
MMSE, MoCA, SLUM
MMSE
good specificity and sensitivity
alternative to MMSE
Montreal Cognitive Assessment (MoCA) and Saint Louis University Mental Status Examination (SLUM)
MMSE is bad because
copyrighted
what is pseudodementia
- Psychiatric disease can lead to impaired cognition (pseudodementia).
- Clinical presentation: poor focus and concentration may primary complaint
- The symptoms should improve with appropriate psychiatric treatment.
geriatric depression scale
5-item validated screening tool for depression in older patients
dementia and depression
Untreated mood disorders may increase the risk of developing age-related dementia, and psychiatric symptoms can worsen cognitive impairment in patients with dementia.
- It is important to not overlook the possibility of depression when screening for and treating dementia
lab tests for dementia
- Standard laboratory evaluation for patients with cognitive impairment (AAFP)5: CBC, comprehensive metabolic panel, TSH, and B12
- Other tests to consider based on specific concerns: HIV testing, rapid plasma regain (RPR) testing (neurosyphilis), inflammatory markers (vasculitis), CSF analysis (lumbar puncture) in patients with rapidly progressive symptoms to rule out prion disease or other infections.
best neuroimaging fro dementia
MRI without contrast, but CT scan if MRI contraindicated
routine neuroimaging in suspected dementia ebcause
to rule out intracranial abnormalities and may be helpful in determining dementia subtype.
is genetic testing recommended in routine testing for dementia
- Genetic testing for apolipoprotein E4 allele is not recommended as part of the routine evaluation for cognitive impairment. (doest change manamgent and freaks patient out)
- Referral for genetic testing should be considered in patients with positive family history (Alzheimer disease at a young age in an autosomal dominant pattern)
