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– Post op day 1:

hostile• Attempts to strike

nurse with cane

• Refusing blood draw

• Pulled out catheter

• 70 yr old homebound patient– Bedbound, mute– Family caregivers– Oral intake

decreasing

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

• Memory

• Calculation

• Language

• Orientation

• Spatial construction

• Executive function (judgment)

Mapping MemoriesNatl 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.– Age of onset– Family history– Initial symptom– Most troublesome symptom– Rate of progression– Response to treatment

• Is dementia a symptom, not a disease?

DementiaSubtypes

• 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

• Largely on history• Exclude other conditions• Role for imaging in near future• Staging

– Mental status testing (MMSE, MOCA, Mini-Cog)

– Functional status staging (FAST, GDR)

FAST

• 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– 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