1
AD- the extent of the problem
• AD represents over 50% of all dementia
cases
• AD prevalence doubles every 5 years after
60 years of age
• AD affects 15 million people worldwide
2
The diagnosis and
assessment of AD
• "Listen to the patient, they are telling you
the diagnosis."
• "It is possible to make a diagnosis of
Alzheimer's disease, just as we can make a
diagnosis of other major illnesses."
• "The challenge today is to obtain an early,
accurate and specific diagnosis of dementia
using an effective diagnostic process."
3
Mini Mental State Examination score
AD prognosis
Optimal case
25 ---------------------| Symptoms
20
|----------------------| Diagnosis
15
|-----------------------| Loss of functional independence
10
|--------------------------------| Behavioral problems
5
Nursing home placement
|-------------------------------------------|
0
Death |------------------------------------------
1
2
3
4
5
Years
6
7
8
9
Feidman and Gracon, 1996
4
Definition of the dementia
syndrome
DEMENTIA
• Multiple cognitive deficits
– memory loss
– aphasia
– apraxia
– agnosia
– disturbance in executive function
• These lead to functional decline
5
Causes of dementia
Reversible dementias
Irreversible dementias
• Common causes:
– Depression
– Delirium
– Drug toxicity
• Common causes:
– Alzheimer's disease
– Vascular dementia
• Other causes
– Lewy body disease
– Pick's disease (dementia
of the frontal lobe type)
– Parkinson's disease with
dementia
6
Differentiating AD from other
dementias
Cognitive impairment
Exclude other causes
(e.g. delirium and
depression, etc)
Dementia
Exclude other
dementias
Alzheimer's disease
7
Dementia or delirium
Dementia
Delirium
* Insidious onset with unknown date
* Slow, gradual, progressive decline
* Generally irreversible
* Disorientation late in illness
* Slight day-to-day variation
OR
* Less prominent physiological
changes
* Consciousness clouded
only in late stage
* Normal attention span
* Disturbed sleepwake cycle;
daynight
* Psychomotor changes late in illness
* Abrupt, precise onset, known date
* Acute illness, lasting days or
weeks
* Usually reversible
* Disorientation early in illness
* Variable, hour by hour
* Prominent physiological changes
* Fluctuating levels of consciousness
* Short attention span
* Disturbed sleepwake cycle;
hour-to-hour variation
* Marked early psychomotor
changes
Ham, 1997
8
Dementia or depression
Dementia
* Insidious onset
* No psychiatric history
* Conceals disability
* Near-miss answers
* Mood fluctuation day to day
* Stable cognitive loss
* Tries hard to perform but is
unconcerned by losses
* Short-term memory loss
* Memory loss occurs first
* Associated with a decline in
social function
Depression
* Abrupt onset
* History of depression
* Highlights disabilities
* ’Don't know' answers
* Diurnal variation in mood
OR * Fluctuating cognitive loss
* Tries less hard to perform
and gets distressed by losses
* Short- and long-term memory loss
* Depressed mood coincides with
memory loss
* Associated with anxiety
Ham, 1997, modified from Wells CE, 1979
9
AD risk and protective factors
Risk factors
Protective factors
* Age
* Family History of AD
(ApoE-4)
* Head trauma
* Low educational level
* Environmental factors
* Down’s syndrome
* Genetic (ApoE-2)
* High educational level
* Long-term antiinflammatory
drug use, e.g.
NSAIDS
* Long-term use of
estrogens (in women)
IPA AD Conference, 1996
10
Making a diagnosis of AD
Need for early
diagnosis
Consistent onset, clinical
presentation and disease progression
Practical
assessment
methods
New symptomatic
treatments
Patient and
caregiver support
IPA AD Conference, 1996
11
Clinical features of AD
Functional
impairment
* IADL
* ADL
Cognitive decline
Insidious onset
* Memory loss
* Aphasia
* Apraxia
* Agnosia
* Executive
function
difficulties
AD
Behavioral signs
* Mood swings
* Agitation
* Wandering
Age over 60 years
No gait difficulties
IPA AD Conference, 1996
12
Clinical features of AD
Mild stage of AD (MMSE 2130)
Cognition
* Recall/learning
* Word finding
* Problem
solving
* Judgement
* Calculation
IMPAIRMENT
Function
* Work
* Money/shopping
* Cooking
* Housekeeping
* Reading
* Writing
* Hobbies
Behavior
* Apathy
* Withdrawal
* Depression
* Irritability
Adapted from Galasko, 1997
13
Clinical features of AD
Moderate stage of AD (MMSE 1020)
Cognition
IMPAIRMENT
Function
* Recent memory
(remote memory
unaffected)
* Language (names,
paraphasias)
* Insight
* Orientation
* Visuospatial ability
* IADL loss
* Misplacing
objects
* Getting lost
* Difficulty
dressing
(sequence and
selection)
Behavior
* Delusions
* Depression
* Wandering
* Insomnia
* Agitation
* Social skills
unaffected
Adapted from Galasko, 1997
14
Clinical features of AD
Severe stage of AD (MMSE <10)
Cognition
IMPAIRMENT
Function
* Attention
* Basic ADLs
* Difficulty
Dressing
performing
Grooming
familiar activities
Bathing
(apraxis)
Eating
* Language
Continence
(phrases, mutism)
Walking
Motor slowing
Behavior
* Agitation
Verbal
Physical
* Insomnia
Adapted from Galasko, 1997
15
Diagnosing AD in primary care
case-finding
"How is your memory?"
Case-finding
Pattie and Gilleard, 1979
16
Diagnosing AD in primary care
clinical history, common presentations
* Forgetfulness
* Getting lost in familiar settings
* Difficulties with finance
* Deterioration of work or home
performance
* Inability to recognize, or a lack of interest
in, family members
* Difficulties driving or using the telephone
Clinical History
17
Diagnosing AD in primary care
clinical history, questioning
Ask the following questions:
* How did it start? Was it sudden or gradual?
* How long has it been going on?
* Is the situation progressing? If so, how rapidly?
* Is it step-wise or continuous?
* Is it worsening, fluctuating or improving?
* What changes have you noticed?
* Has there been a change in personality?
* Has the patient suffered any delusions or hallucinations?
* Does the patient become agitated or wander?
Clinical History
18
Diagnosing AD in primary care
functional assessment
Score Score
Maximum Actual
Functional Activities Questionnaire (FAQ)
1. Dealing with financial matters, paying bills, writing checks
3
2. Keeping records of taxes, business affairs
3
3. Shopping for everyday necessities: groceries, clothes, etc
3
4. Hobbies or playing games
3
5. Making tea, turning the kettle on and off
3
6. Cooking a balanced meal
3
7. Perception of current events
3
8. Level of attention and understanding: books, television
3
9. Memory: remembering appointments and medications
3
10. Getting about: driving or taking public transport
3
Total 30
Functional Assessment
Pfeffer et al 1982
19
Diagnosing AD in primary care
cognitive assessments, MMSE
Cognitive area
Mini Mental State Examination: test outline and scoring
Score Score
Maximum Actual
Orientation
*What is the (date, day, month, year, season)?
* Where are you (clinic, town, country)?
5
5
Memory
*Name three objects. Ask the patient to repeat them
Attention
*Serial sevens. Alternatively ask the patient to spell world
backwards (dlrow)
Cognitive Assessment
Folstein et al 1975
3
5
20
Diagnosing AD in primary care
cognitive assessments, MMSE (continued)
Cognitive area
Mini Mental State Examination: test outline and scoring
Score Score
Maximum Actual
Recall
*Ask for the three objects mentioned above to be repeated
3
Language
*Name a pencil and watch
*Repeat, 'No ifs, ands or buts’
*A three stage command
*Read and obey CLOSE YOUR EYES
*Write a sentence
*Copy a double pentagon
Cognitive Assessment
2
1
3
1
1
1
Total 30
Folstein et al 1975
Diagnosing AD in primary care
cognitive assessment
The Clock Draw Test
Time: 5.00
Score: 7 (normal)
Time: .10.30
Score: 3 (demented)
Time: 'no real time'
Score: 2 (demented)
Time: 1/4 past 25
Score: 3 (demented)
Cognitive Assessment
Thalmann et al 1996.
21
22
Diagnosing AD in primary care
physical examination
* Life-threatening conditions, e.g. mass lesions, vascular
lesions and infections
* Blood pressure and pulse
* Vision and hearing assessments
* Cardiac and respiratory function
* Mobility and balance
* Sensory and motor system examination (tone, reflexes,
gait and coordination) and depressive symptoms (sleep
and weight)
Physical examination
23
Diagnosing AD in primary care
laboratory tests
All patients
Most patients
* Complete blood count
* Thyroid function
* Vitamin B12 and folate
* Syphilis serology
* BUN and creatinine
* Calcium
* Glucose
* Electrolytes
* Urinalysis
* Liver function tests
* ECG
* Chest X-ray
Laboratory tests
24
Diagnosing AD in primary care
neuroimaging, computed (axial)
tomography (CT)
Various CT scan reports in AD
* Normal examination for the patient's age
* Generalized cerebral atrophy
* Small vessel changes, areas of
leucoencephalopathy
* No signs of subdural hematoma (if head
trauma suspected)
* Absence of specific areas of cerebral
infarctions or evidence of stroke
Neuroimaging
25
Primary care management of AD
specialist referral
* Inconclusive diagnosis
* Atypical presentation
* Behavioral/psychiatric symptoms
* Second opinion
* Family dispute
* Caregiver support
26
The role of the primary care
physician in mild to moderate AD
* Define all contributory factors and other illnesses
* Discuss the diagnosis, and differentiate other
types of dementia
* Withdraw non-essential drugs that may interfere
with cognition
* Treat or manage concomitant illness
(e.g. depression, hearing loss)
Gauthier, Burns and Pettit, 1997
The role of the primary care
physician in mild to moderate AD
27
(continued)
* Discuss the use of symptomatic therapies
* Monitor functional ability e.g. driving, safety
* Referral to specialist if appropriate
* Advise on will-making and advance directives
* Refer to local AD association for support
* Managing caregivers
Gauthier, Burns and Pettit, 1997
28
The role of the primary care
physician in severe AD
* Help caregivers discover and optimize the
patient's preserved function
* Monitor and treat complications
* Facilitate caregiver support (respite and day
care programs)
* Be aware of caregiver burden and stress
* Plan institutionalization, if needed
* Assist with end-of-life decisions
Gauthier, Burns and Pettit, 1997
Diagnosing AD in primary care
29
A systematic approach summary
CASE-FINDING
Symptoms
YES
suggesting
cognitive
impairment
CLINICAL ASSESSMENT
*Clinical history
*Physical examination
*Laboratory tests
*Functional assessment
*Cognitive assessment
Functional decline and cognitive
impairment
DIFFERENTIAL DIAGNOSIS
*Exclude
AD diagnosis
delirium
depression
other causes of dementia
*Evaluate evidence for
AD (neuroimaging)
MANAGEMENT OF AD
*Follow-up
*Patient and caregiver
counseling
*Management and symptomatic
treatment
*Specialist referral if indicated
30
Primary care management of AD
follow-up
* Cognitive ability
* Functional ability
* Behavior
* General health
* Routine health checks
31
Caregiver support in primary care
* Caring for patients
* Self-help
* Support services
* Medico-legal help
* Caregiver well being