Dementia in Clinical Practice
• Mary Ann Forciea
MD
• Clinical Prof of
Medicine
• Division of Geriatric
Medicine
• UPHS
•
Photo: Nat Geographic
Who has dementia?
• 78 yr old retired
librarian
• Lives alone,
children visit on
holidays
• Family concerned
about ‘clutter’ in
house, hygiene,
unpaid bills
• 68 yr old child care
worker
• Lives with her
husband, drives, in
charge of ‘house
money’
• “Forgot” a child in
classroom at end of
day
Who has dementia (2) ?
• 84 yr old urology
inpatient
• 70 yr old
homebound patient
– Post op day 1:
hostile
– Bedbound, mute
– Family caregivers
– Oral intake
decreasing
• Attempts to strike
nurse with cane
• Refusing blood
draw
• Pulled out catheter
Terms
• Dementia
– Chronic, progressive
– Impairment in >1 “domain of cognition”
• Memory, language use, executive
function(judgment), attention, coordination
• Mild cognitive impairment
– Impairment in 1 “domain of cognition”
– ? “pre-dementia”
• Delirium
– Short term
How do we know about Brain
Function?
• Cell structure
– Microscope (biopsy, cell culture)
– CT, MRI, PET scans
• Brain regions
– imaging
• “Domains” of cognition
– Imaging
– Psychological testing
Cell structure: Neurons
• Networks
• Grey matter/white
matter
Brain regions
• Regions have different
activities
Domains of cognition
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Memory
Calculation
Language
Orientation
Spatial construction
Executive function (judgment)
Mapping Memories
Natl Geographic
What is wrong in dementia?
Theories
Neurons: waste products, shape of cells,
signaling, genetic flaws
Regions: biochemistry, structure
Domains: communication
We don’t yet know.
Clinical observations
• All patients with dementias are not alike.
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Age of onset
Family history
Initial symptom
Most troublesome symptom
Rate of progression
Response to treatment
• Is dementia a symptom, not a disease?
Dementia
Subtypes
• Alzheimer’s Disease
• Fronto-temporal dementia (formerly Pick’s
Disease) – 15%
• Corticobasilar dementias
• Dementia with Lewy Bodies – 20%
– Distinguished from Parkinson’s Disease with
dementia
• Vascular disease
Alzheimer’s type dementia
• Gradual onset
• Global impairment in cognition
– Usually memory impairment predominant
• Increased risk in siblings
– Apo e allele risk
• Slow progression (5-7 years)
– Predictable course (global deterioration scores)
AD - pathology
• Imaging
• Neuropathology – quantity and location
– Senile plaques
• White matter
• Amyloid core
– Neurofibrillary tangles
• Tau protein abnormalities
– Initial concentrations highest in hippocampus
and temporal lobes
Plaques
Tangle
What clinical problems do patients with
Alzheimer’s Dementia Encounter?
• Diagnosis
• Symptom Management
• End of life care
Case 1 NC
• 64 yr old retired OR nurse
• Referred for evaluation of impaired memory
– Birthdates, telephone numbers
– Impaired job performance for 1-2 yrs prior
– Inability to ‘balance checkbook’
• Gradual decline over 5 years
• Died of pneumonia
Diagnosis
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Largely on history
Exclude other conditions
Role for biomarkers in near future
Staging
– Mental status testing (MMSE, MOCA, MiniCog)
– Functional status staging (FAST, GDR)
Biomarkers for Alzheimer’s
Dementia
• Apo lipo protein E subtypes
– Apo E-2, E-3, E-4
• 2 copies of E4 increases risk in some populations
• Spinal fluid ‘tau’ protein levels
• PET scans for amyloid
– People with unexplained MCI
– Patients with an unusual course
– Early onset dementia
Concerns about PET scans
• How specific is an abnormal test?
• May not be useful for staging
– (how advanced is the disease)
• Will abnormal scans result in
‘overdiagnosis’ employment or insurance
implications?
FAST
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The FAST scale has seven stages:
1 which is normal adult
2 which is normal older adult
3 which is early dementia
4 which is mild dementia
5 which is moderate dementia
6 which is moderately severe dementia
7 which is severe dementia
7a.speaking limited to 6 words or fewer in an average day
b. Speech ability limited to the use of a single intelligible
word in an average day
c. Ambulatory ability lost (cannot walk without personal
assistance).
d. Ability to sit up without assistance lost (e.g., the individual
will fall over if there are no lateral rests [arms] on the chair).
e. Loss of the ability to smile.
AD - treatment
• Improve all co-existing
conditions!
• Specific treatments
– Cholinesterase inhibitors
• Donepazil, rivastigmine
– Adrenergic stimulants
• Memantine
• Treatment of associated
symptoms
– Agitated behaviors
• Non pharmacologic,
environmental
• drugs
End of life issues
• Should be anticipated
– Advance Directives, conversations with proxies
• Goals of care
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Nutrition
Hospitalization
Caregiver burdens
Hospice involvement
Summary
• “Dementia” is a symptom
complex
• We are in the early stages
of understanding the
pathology, and
discovering effective
treatment
• Optimal care requires
advance planning,
caregiver involvement,
and a team of
professionals