Dementia
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2
Kendall L. Stewart, MD, MBA, DLFAPA
May 17, 2013
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
2Please
Why is this important?
• About 1.5-percent of people
over age 65 have dementia.
• And 16 to 25-percent of those
over 85 do.
• About 50 to 60-percent of
patients with dementia have
Alzheimer’s disease.1
• Patients with Alzheimer’s
disease occupy more than 50percent (or 2 million) nursing
home beds.
• Since our population is aging,
the number of these cases will
increase.
• The financial and emotional
tolls extracted are enormous.
1Risk
• After mastering the information
in this presentation, you will be
able to
– Identify the other diagnoses in
this category,
– Identify the diagnostic criteria
for dementia,
– Specify three disorders that
may produce dementia,
– Describe the evaluation of the
patient with dementia,
– Discuss a differential diagnosis,
– Write a typical treatment plan,
and
– Explain some of the typical
treatment challenges.
factors include being female, having a first-degree relative with the disorder and a history of head injury.
progresses gradually but steadily to death within 3 to 9 years of diagnosis.
2Alzheimer’s
What other disorders are included in
this category?
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Delirium
Dementia
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Amnestic Disorders
Other Cognitive Disorders
Alzheimer’s Early Onset
Alzheimer’s Late Onset
Vascular Dementia
Due to HIV
Due to Head Trauma
Due to Parkinson’s
Due to Huntington’s
Due to Pick’s
Due to Creutzfeldt-Jakob Disease
Due to a General Medical Condition Substance-Induced,
Persisting
– Not Otherwise Specified (NOS)
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How do these patients present?1,2
• This is a 70 year-old retired
barber.
• “I just can’t remember things
like I used to.”
• “He’s not himself.”
• “He doesn’t pay attention to his
appearance like he used to.”
• “He gets irritable and mad over
nothing.”
• “He’s real suspicious of other
people for no reason.”
• “He keeps asking me the same
question over and over.”
1Family
2View
• “He loses his keys and blames it
on me.”
• “He misunderstand things and
gets upset.”
• “He gets lost in the store.”
• “He gets more confused at
night.”
• “He remembers things from
years ago just fine, but he can’t
remember something that
happened this morning.”
• “Sometimes he doesn’t
recognize his grandkids.”
• “He’s getting worse.”
members living with the patient usually provide the best histories.
yourself as their consultant; they are the real experts.
What are the diagnostic criteria for
Alzheimer’s dementia?
•
Multiple cognitive deficits manifested
by both
– Memory impairment1,2
– One or more of
• Aphasia (language disturbance)
• Apraxia (impaired motor
activity)
• Agnosia (failure to recognize
objects)
• Disturbance in executive
functioning (planning,
organizing, sequencing,
abstracting)
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Cognitive impairments reflect
deterioration and cause impairment
Course is characterized by gradual
onset and continuing decline
1Good-natured
2“What’s
confabulation is fairly common.
my name?”
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Cognitive deficits not due to
– Other central nervous system
conditions that cause dementia
– Other systemic conditions that
cause dementia
– Substance-induced conditions
Deficits do not occur exclusively
during a delirium
The disturbance is not better
accounted for by another Mental
Disorder (Schizophrenia, Major
Depressive Disorder)
What are some of the many disorders
that produce dementia?1,2
Alzheimer’s disease
Vascular dementia
Drugs and toxins
Intracranial masses
Anoxia
Trauma
Normal-pressure
hydrocephalus
• Neurodegenerative
disorders
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– Parkinson’s disease
– Huntington’s disease
1Every
2My
• Infections
– Creutzfeldt-Jakob
– AIDS
• Nutritional disorders
– Thiamine deficiency
– Folate deficiency
• Metabolic disorders
– Dialysis dementia
– Hypothyroidism
• Chronic inflammatory
disorders
– Lupus
– Multiple sclerosis
psychiatrist memorizes such a list for Board exams.
hung-over examiner drilled me on these, then gave up and sent me out early.
Slide 1 of 2
How should you evaluate the patient
with dementia?
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1A
A thorough history and physical1
Vital signs
Mental status examination
Mini-Mental State Examination (MMSE)
Consider using the faster mini-cog test.
Review of medications and drug levels
Blood and urine screens for alcohol, drugs and heavy
metals
Physiological workup
Chest radiograph
Electrocardiogram
Neurological workup
Neuropsychological testing if indicated2
careful evaluation is critical for ruling out treatable forms of dementia.
bright people are aware of cognitive challenge; a tenured professor was certain he had a
learning disability!
2Very
Slide 2 of 2
How should you evaluate the patient
with dementia?1,2
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1If
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Physiological workup (if
indicated)
Serum
electrolytes/glucose/Ca2+/Mg
Liver, renal function tests
Serum chemistry profile
Urinalysis
Complete blood count with
differential
Thyroid function tests
including TSH
RPR (serum screen)
FTA-ABS (if CNS disease is
suspected)
Serum B12
Folate levels
•
Urine corticosteroids
ESR
ANA, C3C4, anti-DS, DNA
Arterial blood gases
HIV screen
Urine porphobilinogens
Neurological workup (if
indicated)
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CT or MRI scan of the head
SPECT
Lumbar puncture
EEG
you are a consultant, you will need to obtain copies of previous exams and studies.
is a hassle, but do not take the patient’s word that appropriate studies were done; some
repetition may be needed.
2This
What are some of the psychiatric
differential diagnoses?
Delirium
Amnestic Disorder
Vascular Dementia
Dementia due to General
Medical Conditions
• Substance Intoxication
• Substance Withdrawal
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• Substance-Induced
Persisting Dementia
• Dementia NOS
• Mental Retardation
• Schizophrenia
• Major Depressive Disorder
• Malingering
• Factitious Disorder
• Normal aging
What is the treatment?
•
Psychosocial Therapies1
1While
– Make sure the diagnosis is
correct.
– Consider behavioral treatment of
problematic symptoms
– Stimulation-oriented therapies
have modest support from
clinical trials and embody a
common sense, humane
approach.
– Supportive counseling may help
patients and their families deal
with a sense of loss early in the
illness.
– Cognitive-orientated
interventions are unlikely to be
helpful; they are more likely to be
annoying.
•
Pharmacotherapy
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Treat underlying conditions appropriately.
Taper and discontinue offending
medications.
Use sedatives, antidepressants and
antipsychotics sparingly since they can
make matters much worse.
Consider cholinesterase inhibitors in
patients with mild to moderate cognitive
impairment
• Donepezil (Aricept) 5-10 mg/day
Vitamin E may slow the rate of progression
Selegiline may prevent further decline but
Vitamin E is safer and just as effective.
Ergot mesylates cannot be recommended.
Benzodiazepines, atypical antipsychotics,
mood stabilizers and antidepressants are
somewhat helpful with agitation and
combativeness.
in widespread use, few of these interventions are truly evidence-based.
What are some of the typical treatment
challenges?
These diagnoses are hard to hear;
always offer to arrange for another
opinion at any world-class center
of their choosing.1
Patients and families need to
confront the driving issue before
they have to.
It is much easier to obtain a power
of attorney than to try for
guardianship later.
Families typically put off nursing
home placement too long.
When patients are
institutionalized, specialized
Alzheimer’s units produce no
better outcomes.
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1A
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Walking the razor’s edge between
agitation and sedation is the
preferred path; this walk is easier
if the family understands the
challenge.
Nursing homes prefer sedation.
Chemical and physical restraint
should be minimized, but both—
properly administered and
supervised—still have their place.
Preparing families for what is to
come and how to cope with it is the
physician’s greatest gift to loved
ones.
Assisting daughters (particularly)
with identifying and dealing with
unreasonable guilt can be
liberating.2
daughter insisted that the neurologist had told them that her mother “most certainly did not have dementia.”
our culture, women tend to feel much more responsible—particularly when helpless—than men do.
2In
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry,
Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology,
April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at
Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition,
2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry,
2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second
Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth
Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work
and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
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