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
• Mild cognitive impairment
– Impairment in 1 domain of cognition
– ? “pre-dementia”
• Delirium
– Short term
What do we know about Brain
Function?
• Cell structure
– Microscope (biopsy, cell culture)
– 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
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 imaging in near future
Staging
– Mental status testing (MMSE, MOCA, MiniCog)
– Functional status staging (FAST, GDR)
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
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