Definitions
Who are
you
again?
Assessment
No ifs,
ands, or,
buts..
Treatment
Prevention
What is the definition of
dementia?
Acquired cognitive deficits sufficient to interfere with
social or occupational functioning in person
without depression or clouding of consciousness
Alzheimer’s disease
Mixed
Lewy body
Vascular dementia
Fronto-temporal
CJD
60%
20%
10%
5%
4%
<1%
What is vascular dementia?
patchy loss of neurons in areas of infarcts (multi-infarct, lacunar, periventricular)
cognitive changes depend on area of infarct
recall improves with cuing, more aware of memory problem
Diagnosis:
•dementia
•vascular component – by hx, px or imaging
•temporal relationship between
abrupt onset
stepwise decline
impaired executive function
gait disorder
emotional lability
clinical/neuroimaging evidence of cerebrovascular disease
What is fronto-temporal
dementia?
EtOH, COPD, Picks, CBGD, Huntingtons
memory relatively well-preserved
core diagnosis (in italics):
•insidious onset
•slow progression
•behavioural changes – loss of social awareness (disordered social
conduct), disinhibition, emotional blunting, mental rigidity, inflexibility,
hyperorality, perseveration, distractibility, loss of insight, declining
hygiene, character change
•language changes with reduction in verbal output
DAILY DOUBLE
Name 1 test that can be used to check frontal
lobe function
word list - name as many 4-legged animals as can in 1 min
trails - trail A (A-B-C-D..), trail B (A-1-B-2-C-3..)
similarities/differences - apple/orange, vinegar/salt
What is Lewy body dementia?
neuronal loss in limbic, substantia nigra, autonomic system
memory loss + motor changes + hallucinations early
like an AD + PD
2 of (probable DLB) or 1 (possible) of following:
.fluctuating sx, with variation in alertness and attention
.recurrent visual hallucinations, typically well-formed and detailed
.spontaneous extrapyramidal signs/motor features of Parkinsonism
Features supportive for diagnosis are:
repeated falls
hypersensitivity to neuroleptics
delusions
nonvisual hallucinations
syncope/transient LOC
drug-unresponsive depression
•REM sleep – acting out, vivid violent dreams
What is Alzheimer’s disease?
DSM IV criteria for AD
The development of multiple cognitive deficits that is manifested by BOTH of:
• memory deterioration
• >=1 of aphasia (language)
agnosia (objects)
apraxia (motor activities)
executive function impairment (planning, organising, sequencing)
 is a significant decline compared to previous fn
 causes significant impairment in social/occupational function
 gradual onset, continuing decline
NOT due to cerebrovascular dz, Huntington’s dz, Parkinson’s dz, systemic conditions know to cause dementia (hypothyroidism,
vit B12 deficiency, folic acid deficiency, neurosyphilis, HIV infection), substance-induced conditions, delirium, major depressive
disorder, schizophrenia
What is the course of
Alzheimer’s disease?
Early
memory impairment – recent>remote
Middle/Late
behavioural disturbances – agitation, aggression, combativeness,
shouting, disinhibition
psychotic sx – paranoia, delusions, hallucinations
wandering behaviour
gait, motor disturbances, incontinence
What are the most
important elements of the
HPI?
Memory deterioration
Aphasia
Apraxia
Agnosia
Executive function
Depression
Delusions
Hallucinations
Personality changes
Apathy
Agitation
- recent, remote
- probs understanding language, names of things, reading/writing
- inability to carry out goal-oriented motor functions e.g. getting
dressed in correct order
- inability to recognise people and objects
- ability to anticipate, select, initiate an action, plan and organise a
procedure e.g. financial planning
What are important
questions in PMH, FH, &
SH?
PMH
Systemic diseases, ca, neurological, psychiatric, thyroid disorders
HTN, a fib,
Head injury
EtOHism,
FH
Dementia, AD (2-4 x increased risk if 1st degree relative), Huntington's dz
SH
EtOH, smoking, substance abuse
Occupational exposures
Level of education
What medication hx is it
important to elicit?
•narcotics
•anticholinergics
•benzodiazepines
•psychotropics
•OTC, herbal
How can you assess
functional status?
ADL
“DEATH”
Dressing
Eating
Ambulating
Toileting
Hygiene
IADL “SHAFT”
Shopping
Housekeeping
Accounting
Food preparation
Transportation
FAQ (functional activities questionnaire)
bill paying
assembling records relating to business affairs
shopping alone
playing a game of skill
performing a task involving multiple steps (writing letter, stamping
envelope, placing in mailbox)
preparing a balanced meal
being aware of current events
understanding and discussing TV, book etc
remembering and keeping appointments
driving, arranging to take bus, walking to familar places
What is the prevalence of
comorbid depression?
prevalence in pts with AD is 6-20%
weight & sleep changes
sadness
crying
suicidal statements
excessive guilt
What parts of physical
exam are important in
dementia?
•VS incl postural
•vision
•hearing
•CNs
•motor, sensory function esp localising sx, Parkinsonism, stroke
•reflexes
What’s normal
anymore?
MMSE
‘NORMALS’
LIMITATIONS
CORRECT FOR EDUCATION, AGE
How is clock drawing
scored?
Give 1 point for each of the following:
all 12 correct numbers,
hands in correct position,
closed circle,
numbers in correct position
<4 needs further evaluation
FREEBIE!
How are DSM IV criteria
tested?
memory
hold
recent
remote
aphasia
language production
-verbal
- written
comprehension
- verbal
- written
pt repeats 6 or 7 digits forward, 3 or 4 digits backwards
pt recounts simple short story, 4-5 sentences
significant national/international events
name body parts or objects in room
writes 1 sentence describing what is wearing
simple command e.g. walk over to window
simple written request
apraxia
pt demonstrates e.g. how to use toothbrush
agnosia
coins
executive fn
give pt instructions to plan, initiate and sequence a task
Draw a
clock!
What bloodwork is
recommended by CMA
guidelines?
CBC, lytes, Ca2+
TSH, glucose
That’s it!!
Name 3 additional tests to
consider
Optional additional tests:
 lipids, BUN/creatinine
ESR, serum cortisol
ammonia, LFTs,
B12/folate, water soluble vitamins
drug levels, heavy metal levels
VDRL, HIV
blood gas
carotid dopplers
CXR, ECG, EEG, LP, mammography
Name 4 indications for CT
head in dementia
Indications for CT head:
age <60 y.o.
rapid decline (months)
short duration (<2 yrs)
recent head trauma
new localising sx (Babinski, hemiparesis)
unexplained neuro finding (HA, sz)
urinary incontinence + gait disturbance early on (NPH)
incontinence
anticoagulation, bleeding dz
cancer history
atypical presentation
gait disturbance
What are 2 nonpharmacological
therapies for dementia?
•verbal/physical prompts with positive reinforcement
•memory training
•read newspapers, watch educational shows on TV
•reminders about content of conversations
Who do we screen?
No evidence to recommend screening for cognitive impairment in
absence of sx
Memory complaints should be followed up
What is the
pharmacological
treatment of dementia?
donepezil (Aricept) AchE 2 point improvement MMSE after 3
rivastigmine (Exelon)
AchE + butyrcholinesterase inhib
galantamine (Reminyl)
AchE + nicotinic receptor inhib
Indicated for:
AD MMSE 10-26
Lewy body
mixed
Acetylcholinesterase
Inhibitors
Indication
Metabolism
Dose interval
Initial dose
Min titration interval
Lowest therapeutic
Target dose
Max dose
ODB coverage
Donepezil
AD
daily in AM
5 mg
4 weeks
5 mg daily
10 mg daily
10 mg
covered
Rivastigmine
Galantamine
AD, Lewy body AD, mixed
hepatic + renal hepatic + renal
BID
BID
1.5 mg
4 mg
4 weeks
4 weeks
3 mg BID
4 mg BID
4.5 – 6 mg BID 8 mg BID
6 mg BID
12 mg BID
LU – 354 (1st 3 mos)
LU – 355 (after 3 mos)
Give me 1 tip on starting
therapy...
Start low, go slow!
Reassess in 4 weeks to increase dose, reassess at 2 weeks if necessary to assess
tolerability
Warn pt of common side-effects: nausea, anorexia, diarrhoea, dizziness, agitation
Repeat MMSE at 3 mos – need improvement or stabilization. Expected decline in
MMSE on treatment is <3 points/year
Name 1 treatment for
behavioural problems
At some point during illness, 90% pts have behavioural problems.
Review possible triggers (illness, pain, mealtimes, loneliness)
Non-pharmacological treatment:
familiar routines
sensory stimulation – auditory, visual, tactile
low lighting levels, music, simulated nature sounds may be calming
exercise program with outdoor daily walking if possible (decreases wandering, agitation)
pet therapy
Pharmacological treatment:
low dose neuroleptic drugs (risperidone, olanzepine, quetiapine).e.g. risperidone 1mg daily shown to be
effective and well-tolerated
SSRI
trazodone (esp for sleep disturbances)
CAUTION with benzodiazepines – use only in low doses and PRN
AVOID neuroleptics with marked anticholinergic effects e.g. chlorpromazine
Name 2 interventions for
the prevention of
dementia
treat vascular risk factors:
antihypertensives, statins (hypercholesterolemia),
anticoagulants (a fib), smoking cessation, DM control,
antiplatelets, carotid endarterectomy (stroke prevention)
correction of metabolic disturbances
improved basic education
decrease head injury incidence
?post-menopausal HRT (case control, cohort studies)
?NSAIDs
ginkgo biloba – no evidence for or against
Vit E 2000 IU daily – no evidence for or against
When do you refer? Give
me 1 instance....
•early behavioural changes
•delusions
•fluctuating course
•early motor changes
•atypical pattern
•uncertainty about diagnosis after initial assessment and follow-up
•request by family/pt for another opinion
•presence of significant depression esp if refractory to tx
•treatment problems or failure
•need for additional help in management
•when genetic counselling is indicated
•when research studies into diagnosis and treatment are being carried out