dementia uwks(rev)

7/21/2019 Dementia Uwks(Rev)

http://slidepdf.com/reader/full/dementia-uwksrev 1/86

DEMENTIA: Alzheimer’sDisease and Vascular

DementiaChristian Kamallan

Neurologist



“I am living ith

dementia! not d"ingith dementia#$

ALZHEIMER'S DISEASE



• Hippocampus: where short-term memories are converted to long-termmemories

• Thalamus: receives sensory and limbic information and sends tocerebral cortex

• Hypothalamus: monitors certain activities and controls body’s internalclock

• Limbic system: controls emotions and instinctive behavior (includes thehippocampus and parts of the cortex)

Inside the Human

Brain

Other rucial !arts

Slide 12



The Brain in Action

Hearing Words Speaking Words Seeing Words Thinking about Words

"ifferent mental activities take place in different parts of the

brain# !ositron emission tomography (!$%) scans canmeasure this activity# hemicals tagged with a tracer &light

up' activated regions shown in red and yellow#

Inside the Human Brain

Slide 13



Neurons

• %he brain has billions of

neurons each with an

axon and many

dendrites#

• %o stay healthy neurons

must communicate with

each other carry out

metabolism and repairthemselves#

• " disrupts all three of

these essential *obs#

Inside the

Human Brain

Slide 14



Plaques and Tangles The Hall!arks o" A#

%he brains of people with " have an abundance of twoabnormal structures:

An actual A# plaque An actual A# tangle

• beta-amyloid pla+ues which are dense deposits of

protein and cellular material that accumulate outside

and around nerve cells

• neurofibrillary tangles which are twisted fibers that build

up inside the nerve cell

AD and the Brain

Slide 1$



Cognitive ContinuumCognitive Continuum

NormalNormal

Mild CognitiveMild CognitiveImpairmentImpairment

DementiaDementia



&Man ools himsel!

He prays or a long lie"

yet he ears an old age!#

hinese !roverb



Dementia casesdouble every 20 years



$unction

Age

Deinite AD

%robable AD

Mild cognitive impairment



Mild cognitiveimpairment

Amnestic

Mild cognitiveimpairmentMultiple domainsslightly impaired

Mild cognitiveimpairment

&ingle non'memory domain

Al(heimer)s disease

Al(heimer)s disease

* normal aging

$rontotemporal dementiaLe+y body dementia

%rimary progressive aphasia

%ar,inson)s disease

Al(heimer)s disease



Mild CognitiveIm%airment&MCI'

Criteria:

•Memor" com%laint

•Normal general cognitive (unction•Normal activities o( dail" living

•Memor" im%aired (or age

•Not demented

-ID./

http://d/Lu-Inst%20DEMENTIA,%20Yogya%2026-27%20Apr'14/Video%20case/smith-en(MCI).mpg

http://d/Lu-Inst%20DEMENTIA,%20Yogya%2026-27%20Apr'14/Video%20case/smith-en(MCI).mpg



De)nition Dementia

•A decline o( intellectual (unction incom%arison ith %atient’s %reviouslevel o( (unction#

•*evere enough to cause im%airmento( social and %ro(essional activities

•+e,ected on decline on AD- and IAD-

•.suall" associates ith /ehavior changes#



Area involves indementia

!"#I$I

!#

%EHA&I!R

ADL

(#$I!#



01 To be earlier: potential beneits

• !btain a))ro)riate treatment earlier• Hel) t*e +amily to understand and acce)t

• inancial and le,al )lans -*ile com)etent

•Enable t*e )atient and +amily to ma.e li+estyle c*oices

• Induce better ad*erence and mana,ement o+ ot*er medical

conditions

• $a.e a))ro)riate ste)s to )revent in/ury drivin,1 -ea)ons

• "et ,reater access to *el) -it*in t*e *ealt*care system and

-it*in communities

from Cummings, 2011



Dia,nosis

%ASED !# LI#IAL 3(D"ME#$

$y)e o+ dementia can be de4nedenou,* certainty t*rou,*5

•linical )atterns o+ dementin,

illness•Doin, a))ro)riate dementia-or.6u)



Ste)s in Dementia 7or.6u)

• 0istor" ta1ing &ollateral source 2%atient'

• 3h"sical e4amination

• Mental status e4amination

• +elevant la/orator" and (ollo u%



ollateral Source

• .suall" the s%ouse or an adult child#

• ###5/servations /" the collateralsource correlate /etter ithdementia than sel(6re%ortedcom%laints hich correlate more ithde%ression#

• A/sence o( collateral source seriousl"com%romises dementia diagnosis



History $a.in,

Consists o(

•Neuro/ehavioral histor"

•7eneral medical histor"

•7eneral neurological histor"

•3s"chiatric histor"

• To4ic! nutritional 8drug

histor"

•9amilial histor"

dementia or not

3ossi/le underl"ingetiolog" orother conditionassociatesith dementia



#eurobe*avioral History$a.in,

As. t*e collateral source

*%eci)call" as1 a/out changes : &A;C'

, o,nitive +unction: memor" %ro/lems!

orientation! language! e4ecutive (unction!%ersonalit"8a%ath"

, *an,e o+ be*avior

, De,ree o+ inter+erence -it* ADL and IADL

En<uire a/out: , )rst s"m%toms

, time o( onset

, nature o( illness



Im)airment in Memory

*"m%toms:

•+e%etitive <uestions or conversations!

•Mis%lacing %ersonal /elongings!•9orgetting events or a%%ointments!

•7etting lost on a (amiliar route



Im)airment in Lan,ua,e

• Involve s%ea1ing! reading! riting

• Di=cult" thin1ing o( common ordshile s%ea1ing! hesitations> s%eech!s%elling and riting errors



Im)airment &isual s)atial 8abilities

*"m%toms:

•Ina/ilit" to recognize (aces orcommon o/?ects or to )nd o/?ects indirect vie des%ite good acuit"

•Ina/ilit" to o%erate sim%le im%lementsor orient clothing to the /od"#



Dyse9ecutive +unction

Im%aired reasoning and handling o(com%le4 tas1s! %oor ?udgment @s"m%toms

•%oor understanding o( sa(et" ris1s

•ina/ilit" to manage )nances

•%oor decision6ma1ing a/ilit"•ina/ilit" to %lan com%le4 or se<uentialactivities



*an,es in )ersonality :c*aracter

Im%aired motivation! initiative

*"m%toms:

•increasing a%ath" 2 loss o( drive•social ithdraal

•decreased interest in %revious

activities

%e*avioral and



%e*avioral and)syc*olo,ical sym)toms

o+ dementia %;SD%e*avioural observation

•3h"sical aggression! screaming! restlessness!agitation! andering! culturall" ina%%ro%riate

or se4ual a//erants /ehaviours

;syc*osocial intervie-

•Disinhi/ition! hoarding! cursing and

shadoing•An4iet"! de%ression! hallucination anddelusions#



;*ysical E9amination

• 7eneral %h"sical e4amination

• Neurological E4amination:

, Increased IC3

, 9ocal Neurological de)cit:

• 7ait! motor 2 sensor" de)cit

• A/normal muscle tone 2 movement

and %rimitive re,e4es



o,nitive Screenin, $est

• Considering o( %racticalit"

• A /rie( screening test (or cognitiveim%airment that can /e %er(ormed inB minutes or less is easierincor%orated into dail" %ractice thana com%rehensive /ut time consuming



%rie+ 8 !b/ectiveScreenin, $ests

;atient e9amination

•Cloc1 Draing Test &CDT'##############################

•*hort ;lessed Test &*;T'################################6B’•A//reviated Mental Test ## 6B’

•Mini Mental *tate E4amination &MM*E'#######B6’

•Montreal Cognitive Assessment &MoCA'###### FB6F’



;syc*ometric $estin,

• Are not /" themselves diagnostic#

• 0el% in diagnosis /" %roviding<ualitative assessment o( mental(unction and the %attern o(involvement#

• 0el% in longitudinal assessment o(deterioration or im%rovement ithtreatment



Laboratory Dia,nostic7or.6u)

%asic5

•%

•%S1 liver and renal

+unction tests•$*yroid stimulatin,*ormone $SH

•Serum %<2

Ancillary5• EE"• S analysis

• Serolo,y +orsy)*ilis

• HI& testin,• Heavy metal

screen



NE.+5IMA7IN7

• *tructural M+I

, 0i%%ocam%us

, Entorhinal corte4

• 9unctional Imaging

, M+*

, (M+I

, 3ET8*3ECT



Dia,nosis o+ AD

DSM6I&= A;A1 <>>?5

•7radual onset 2 %rogressive decline in:

, Memor" G at least one o( the:

, H A &A%hasia! A%ra4ia! Agnosia '

, D"se4ecutive (unctioning

•Im%airment in social and %ro(essional

activities! can’t /e e4%lained /" an" otherneurological! %s"chiatric! s"stemic orsu/stance6induced or onl" occur in delirium#

i +



$ri,,ers o+ #on6ADDia,nosis

• 5nset JB "#o> sudden onset! cognition,uctuation! ra%id %rogression

• #eurolo,ic abnormalities earl" in coursee#g# involuntar" movement! (ocal de)cits!

gait distur/ance! ata4ia! seizures• %;SD earl" in course: visual hallucination!

disinhi/ition! mar1ed a%ath"! socialconduct

• #euro)syc*olo,ical )ro4le earl" incourse: %rominent a%hasia! mar1ed de)citin attention! e4ecutive (unction! visualagnosia

i@ i l



ommon Di@erentialDia,nosis

• D-; &Dementia -e" ;od"'

• 3DD &3ar1inson Disease Dementia'

• 9T-D &9ronto6Tem%oral -o/eDementia'

• VaD &Vascular Dementia'

• 5thers

D-; Clinical Diagnosis



D-; Clinical Diagnosis&Revised criteria III

2005)• Dementia ith %rominent de)cits inattention! e4ecutive (unction! andvisuos%atial a/ilit"#

• Core (eatures &to core (eatures:%ro/a/le D-;> one (or %ossi/le D-;': , 9luctuating cognition ith %ronounced

variations in attention and alertness

, +ecurrent o( ell (ormed and detailedvisual hallucinations

, *%ontaneous (eatures o( %ar1insonism

Clinical Diagnosis



Clinical Diagnosis&Revised criteria III

2005)•*uggestive (eatures , +EM slee% /ehavior disorder , *evere neurole%tic sensitivit" , -o do%amine trans%orter u%ta1e in /asal

ganglia demonstrated /" *3ECT or 3ETimaging

•3ro/a/le D-;: or more core (eatures Gor more suggestive (eatures•3ossi/le : i( or more suggestive(eatures

t t l



ronto6tem)oraldementia

Core diagnostic (eatures

•A Insidious onset and ,radual)ro,ression

•;# Earl" decline in social inter%ersonalconduct

•C# Earl" im%airment in regulation o(

%ersonal conduct•D# Earl" emotional /lunting

•E# Earl" loss o( insight

t t l




*u%%ortive diagnostic (eatures

A %e*avioral disorder ,# Decline in %ersonal h"giene and grooming

,F# Mental rigidit" and in,e4i/ilit"

,B Distractibility and im)ersistence

,? Hy)erorality and dietary c*an,es

,C ;erseverative and stereoty)edbe*avior

, (tiliation be*avior

t t l




;# *%eech and language# Altered s%eech out%ut

,a# A s%ontaneit" and econom" o( s%eech

,/# 3ress o( s%eech

F# *tereot"%" o( s%eech

H# Echolalia# 3erseveration

# Mutism

t t l



C# 3h"sical signs

•# 3rimitive re,e4es

•F# Incontinence•H# A1inesia! rigidit"! and tremor

•# -o and la/ile /lood %ressure


t t l



Dementia ith:

•;ehavioral distur/ances 2 aLectives"m%toms

•*%eech disorders

•3h"sical signs o( %rimitive re,e4es

•Incontinence•A1inesia and rigidit"




&ascular dementia

Dementia ith:

•Evident o( cere/rovascular disease

•A clear tem%oral relationshi% /eteendementia and cere/rovascular disease



VaD

Hac*ins.i Isc*aemic Score

•A /rie( clinical tool hel%(ul in the“/edside$ diLerentiation o( the

commonest dementia t"%es! Dementiao( Alzheimer’s T"%e &AD' and VascularDementia &VaD'

•A cut6oL score (or AD and O (orVaD has a sensitivit" o( PQR and as%eci)cit" o( PQR &Morone" QQO'

./01/2



./01/2

Item #o Descri)tion &alue

< A/ru%t onset F

2 *te%ise deterioration

B 9luctuating course F

? Nocturnal con(usion

C 3reservation o( %ersonalit"

De%ression F *omatic com%laints

G Emotional incontinence

> 0istor" o( h"%ertension

<0 0istor" o( stro1e F<< Associated atherosclerosis

<2 9ocal neurological s"m%toms F

<B 9ocal neurological signs F

Hachins,i Ischaemic &core

AD &s &aD



AD &s &aD

AD VaD

Neuro trans!itter de"ect He!od%na!ic de"ect&e!ale predo!inance 'ale predo!inance

(radual onset Abrupt onset

Stead% deterioration Step)ise deterioration*

"luctuating courseBP nor!al H%pertension

No histor% o" stroke Histor% o" stroke

(lobal decline in cogniti+e

"unction

&ocal neurological s%!pto!s

and signs

,nlikel% to respond to

treat!ent

'a% respond to a drug )hich

!odi"ies !icrocirculation and

enhance cerebral tissue

per"usion

A good teacher is a perpetual learner

;otentiall Re ersible



;otentially ReversibleDementia

# 0"%oth"roidismF# 3ernicious anemiaH# Chronic *u/dural 0ematoma

# CN* in(ections: T;! Cr"%tococcal! viral!0IV! s"%hilis

# TumorsJ# Normal %ressure h"droce%halusO# Drug into4icationP# 0eav" metal %oisoning



Features suggesting reversibilityFeatures suggesting reversibility

• *horter duration o( illness

• *u/cortical t"%e o( dementia

•Moderatel" severe distur/ance• Sounger age o( onset

• 3rominent gait distur/ance

• .rinar" d"s(unction• 9ocal neurological signs



A1in To Dementia

• Delirium

, Acute onset

, 9luctuating course , Autonomic distur/ances

, 3reci%itating (actors li1e in(ection!

meta/olic and drugs



MMSE

• *creening test to %rovide /rie(!o/?ective measure o( cognitive (unction

• Administered in B6 minutes! scoresrange (rom B to HB

• “.se(ul in <uantitativel" estimating theseverit" o( cognitive im%airment$

• “.se(ul in seriall" documentingcognitive change in serial $

Di@erent co,niti e domains



Di@erent co,nitive domainstested

In seven categories:•5rientation to time %oints•5rientation to %lace %oints

•+egistration o( three ords H %oints•Attention and calculation %oints•+ecall o( three ords H %oints•-anguage P %oints

•Visual construction %oint

Total HB %oints



MMSE

ut6o@ Score

•F6HB no cognitive im%airment•P6FH mild cognitive im%airment

•B6O severe cognitive im%airment



MMSE

"ood )oints o+ t*e MMSE

•Most idel" acce%ted screening test

•7ood internal consistenc"

•7ood test6retest relia/ilit"•0igh validit": good sensitivit" and good

•s%eci)cit"

•Correlates ell ith other screeningtests e#g# cloc1 draing test and *hort;lessed test



MMSE

Limitation

•Con(ounded /" age! education andculture



loc. Dra-in, $est D$

•A sensitive measure o(:

•Visuo6s%atial (unction andconstructional %ra4is#

•0igher ordered cognitive a/ilities li1ethe conce%t o( time

Can hel% diLerentiate /eteen aconstructional vs# conce%tual %ro/lem



?6;oint Scorin, Met*od

#olan KA1 Mo*s R1 <>>?

•Dras closed circle %oint

•3laces num/ers in correct %ositions %oint

•Includes all F correct num/ers %oint

•3laces hands in correct %osition %oint



CDT: E9am)les

3atients ere instructed to dra in thehands at tent" minutes a(ter eight

•9igure A: /" a normal elderl" control

•9igure ;6E: %atients ith dementia

Inter)retation5 linical



Inter)retation5 linical /ud,ment

• A lo score & H' indicates the need(or (urther evaluation to source outother evidences o( im%airment or

correlation ith other tests

The role o( medications in



The role o( medications inthe management o(

dementia# Cure disease

F# 3revent disease or dela" onset

H# *lo %rogression o( disease

# Treat %rimar" s"m%toms egmemor"

# Treat secondar" s"m%toms egde%ression! hallucinations

Medications to treat %rimar"



Medications to treat %rimar"s"m%toms

• cholinesterase inhi/itors:

, done%ezil

, rivastigmine

, galantamine

• memantine

Ch li i hi/i



Cholinesterase inhi/itors• these drugs sto% the /rea1don o(

acet"lcholine hich is an im%ortantneurotransmitter in memor" and cognition

• all sho modest im%rovement in cognition

and (unction! and /ehavioural s"m%toms• res%onse: 8H im%rove! 8H sta/ilise! 8H

have no res%onse

• do not %revent %rogression o( underl"ing

disease



Cholinesterase inhi/itors

• done%ezil &Arice%t'

, given once dail"! dosage o( mg to Bmg

• rivastigmine &E4elon' , given tice dail"! dosages o( Hmg to

Fmg

• galantamine &+emin"l'

, given once dail"! dosages o( Pmg toFmg &can also /e given tice dail"'

.se o( cholinesterase



.se o( cholinesteraseinhi/itors

• need s%ecialist diagnosis o( AlzheimersDisease! and a MM*E score o( B to F#

• need to sho an im%rovement on MM*E o(

F %oints to continue medication on 3;*• side eLects 6 nausea! vomiting! diarrhoea!

dizziness! headache! muscle cram%s

• use care(ull" i( gastric ulcer! heart disease!

chronic lung disease %resent

.se o( cholinesterase



.se o( cholinesteraseinhi/itors

• arn against unrealistic e4%ectations

• atch (or return o( insight leading tode%ression or an4iet"

• sto%%ing o( medication:

, unacce%ta/le side eLects

, lac1 o( res%onse to medication

, late stages o( the disease

Memantine &E/i4a'



Memantine &E/i4a'

• glutamate is a transmitter in the /rain that

is aLected /" Alzheimers Disease• memantine /loc1s the %athological eLects

o( a/normal glutamate release! and allos/etter (unction o( the im%aired /rain

• indicated (or moderate to severe AD

• trials sho sloing in cognitive and(unctional decline and decrease in agitation

in treated grou% com%ared to %lace/o



Memantine

• can use ith other AD medications• side eLects 6 headaches! dizziness

• do not use in 1idne" disease or seizure

disorders• dosage: start ith mg dail" and

increase toBmg tice dail"

• %rivate scri%t 6 not on the 3;*• costs a%%ro4 JB8month

Medications to treat



Medications to treatsecondar" s"m%toms

• man" %eo%le ith dementia develo%s"m%toms such as agitation! aggression!de%ression! delusions! hallucinations!

slee% distur/ance and andering

• antide%ressants:

, s%eci)c serotonin reu%ta1e inhi/itors

&citalo%ram! sertraline'

-ID./

Medications to treat

http://d/Lu-Inst%20DEMENTIA,%20Yogya%2026-27%20Apr'14/Video%20case/jones-en(BPSD).mpg

http://d/Lu-Inst%20DEMENTIA,%20Yogya%2026-27%20Apr'14/Video%20case/jones-en(BPSD).mpg



• anti%s"chotics:

, t"%ical anti%s"chotics &halo%eridol'

, at"%ical anti%s"chotics &ris%eridone'

, modest eLect on s"m%toms

, atch (or side6eLects

• mood sta/ilisers:

, anticonvulsants &car/emaze%ine'

Medications to treatsecondar" s"m%toms

auses



auses*everal com%eting h"%otheses:

*oliner,ic *y)ot*esis6Caused /" reduced s"nthesis o(acet"lcholine

6Destruction o( these neurons causesdisru%tions in distant neuronal netor1s&%erce%tion! memor"! ?udgment'

Amyloid *y)ot*esis6A/normal /rea1don> /uildu% o( am"loid

/eta de%osits6Damaged am"loid %roteins /uild to to4iclevels! causing call damage and death

$au *y)ot*esis6Caused /" tau %rotein a/normalities

69ormation o( neuro)/rillar" tangles

Ris. actors



Ris. actors

• 5/esit"• 0igh /lood %ressure• 0ead trauma• 0igh cholesterol• ;eing AmericanU

, 0igher rates in• a%anese6Americans than a%anese• A(rican6Americans than A(ricans

• De%ression• -oer rates in highl" educated

, ;ene)cial conse<uences o( learningand memor"

;ossible ;rotective



;ossible ;rotectiveactors

• EducationThe ability of the brain to change suggests tosome that staying mentally active as you agemay help to maintain healthy brain synapses. A 2002 study reported an association betweenfrequent participation in cognitivelystimulating activities (such as reading, doing

crossword puzzles, visiting museums and areduced ris! for Alzheimer"s.• E9ercise

#owers ris! of high blood pressure and other ris!factors associated with Alzheimer$s

• Alco*ol onsum)tion

%en who consume one to three drin!s of alcohol per day cut their ris! of developing the diseaseby nearly half. Among women, however, the ris!was reduced by only &'. The type of alcohol hadno eect on the results. )ut further study isneeded. *n the meantime, e+perts do notrecommend drin!ing alcohol to fend o Alzheimer"s disease.

AD 2esearch: Managing &ymptoms



3etween 41 to 516 of people with " eventually develop

behavioral symptoms including sleeplessness wanderingand pacing aggression agitation anger depression and

hallucinations and delusions# $xperts suggest these general

coping strategies for managing difficult behaviors:

AD 2esearch: Managing &ymptoms

• 7tay calm and be understanding#

• 3e patient and flexible# "on’t argue or try to convince#• cknowledge re+uests and respond to them#• %ry not to take behaviors personally# 8emember: it’s

the disease talking not your loved one#

$xperts encourage caregivers to try non-medical copingstrategies first# 9owever medical treatment is often available if

the behavior has become too difficult to handle# 8esearchers

continue to look at both non-medical and medical ways to help

caregivers#

Management o Al(heimer)s Disease



Management o Al(heimer s Disease

Manage

cognitive

symptoms

Manage B%&D

&upport

patient3amily

Increased

4uality o

lie or

patient andamily

%h l i / ti AD



%harmacologic /ptions or AD

• ognitive enhancers W . classes

• holinesterase inhibitors (h$s)

• ;<"-receptor antagonist W "o not cure the disease or reverse cognitive

impairment

W an improve cognition and functional ability

W 8educe the rate of decline 5-. months (h$s)

W "elay in nursing home placement was 4-.

months (h$s)

Behavioral and %sychological



y g

&ymptoms o Dementia 5B%&D1

• pathy• "epressive symptoms

• nxiety

• gitation/irritability/aggression

• !sychotic symptoms

W "elusions

W 9allucinations

• "isinhibition

• $uphoria

• =oss of appetite

• 7leep disturbances

• 7tereotyped

behaviors (eg

pacing wanderingrummaging picking

%ampi et al#Clinical Geriatrics.

.1>5:?-?@#

Managing B%&D



g g

• dentify triggers W Observe symptom timing and fre+uency

W =ook for environmental triggers eg noise lighting

W nvestigate potentially treatable causes eg pain

• <ake ad*ustments

W ddress medical causes

W dapt environment

W dapt caregiving• <odify as needed

Managing B%&D



g g

Nonpharmacological Interventions

• Ase the &0 8s'Brepeat reassure redirect• 7implify the environment task routine

• nticipate unmet needs

• llow ade+uate rest between stimulating

events

• Ase cues

• $ncourage physical activity

• Other interventions



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• $=<;%$ EE$;$ E8O< %9$ "$%



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Conclusion

• Early diagnosis enables prompt and effectivemanagement, yields better quality of life for

patients and caregiver

• Neuroimaging especially MRI scan is widelyused in clinical setting now

• !iomar"er especially C#F study $as been

included in researc$ diagnostic criteria, butnot yet recommended for general clinical use,furt$er validation is eagerly awaited



• %$e core of all assessment in dementia care iscareful enquiry and attentive listening, and

• %$ere is no substitute for a clinical interview by a trained clinician

• !y doing appropriate wor"&up and recogni'ingt$e clinical pattern, most of t$e cause of

dementia especially (l'$eimer)s diseasedementia can be determined on enoug$certainty

Conclusion

dementia uwks(rev)

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