Who are you again?

Definitions

Assessment

No ifs, ands, or, buts..

TreatmentPrevention

Acquired cognitive deficits sufficient to interfere with social or occupational functioning in person without depression or clouding of consciousness

What is the definition of dementia?

Alzheimer’s disease 60%Mixed 20%Lewy body 10%Vascular dementia 5%Fronto-temporal 4%CJD <1%

What is vascular dementia?

patchy loss of neurons in areas of infarcts (multi-infarct, lacunar, periventricular)

cognitive changes depend on area of infarctrecall improves with cuing, more aware of memory problem

Diagnosis:•dementia•vascular component – by hx, px or imaging•temporal relationship between

abrupt onsetstepwise declineimpaired executive functiongait disorderemotional 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 DOUBLEDAILY DOUBLEName 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 earlylike 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 fallshypersensitivity to neurolepticsdelusionsnonvisual hallucinationssyncope/transient LOCdrug-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, hallucinationswandering behaviourgait, motor disturbances, incontinence

What are the most important elements of

the HPI?Memory deterioration - recent, remoteAphasia - probs understanding language, names of things, reading/writingApraxia - inability to carry out goal-oriented motor functions e.g. getting

dressed in correct orderAgnosia - inability to recognise people and objectsExecutive function - ability to anticipate, select, initiate an action, plan and organise a

procedure e.g. financial planningDepressionDelusionsHallucinationsPersonality changesApathyAgitation

What are important questions in PMH, FH,

& SH?PMHSystemic diseases, ca, neurological, psychiatric, thyroid disordersHTN, a fib, Head injuryEtOHism,

FHDementia, AD (2-4 x increased risk if 1st degree relative), Huntington's dz

SHEtOH, smoking, substance abuseOccupational exposuresLevel of education

What medication hx is it important to elicit?

•narcotics•anticholinergics•benzodiazepines•psychotropics•OTC, herbal

How can you assess functional status?

IADL “SHAFT”ShoppingHousekeepingAccountingFood preparationTransportation

ADL “DEATH”DressingEatingAmbulatingToiletingHygiene

FAQ (functional activities questionnaire)bill payingassembling records relating to business affairsshopping aloneplaying a game of skillperforming a task involving multiple steps (writing letter, stamping envelope, placing in mailbox)preparing a balanced mealbeing aware of current eventsunderstanding and discussing TV, book etcremembering and keeping appointmentsdriving, 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 changessadnesscryingsuicidal statementsexcessive 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

aphasia

apraxia

agnosia

executive fn

hold pt repeats 6 or 7 digits forward, 3 or 4 digits backwardsrecent pt recounts simple short story, 4-5 sentencesremote significant national/international events

language production -verbal name body parts or objects in room- written writes 1 sentence describing what is wearing

comprehension - verbal simple command e.g. walk over to window- written simple written request

pt demonstrates e.g. how to use toothbrush

coins

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/creatinineESR, serum cortisolammonia, LFTs, B12/folate, water soluble vitaminsdrug levels, heavy metal levelsVDRL, HIV

blood gascarotid dopplersCXR, 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 traumanew localising sx (Babinski, hemiparesis)unexplained neuro finding (HA, sz)urinary incontinence + gait disturbance early on (NPH)incontinenceanticoagulation, bleeding dzcancer historyatypical presentationgait disturbance

What are 2 non-pharmacological

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 mosrivastigmine (Exelon) AchE + butyrcholinesterase inhibgalantamine (Reminyl) AchE + nicotinic receptor inhib

Indicated for:AD MMSE 10-26Lewy bodymixed

Acetylcholinesterase Inhibitors

Donepezil Rivastigmine GalantamineIndication AD AD, Lewy body AD, mixedMetabolism hepatic + renal hepatic + renalDose interval daily in AM BID BIDInitial dose 5 mg 1.5 mg 4 mgMin titration interval 4 weeks 4 weeks 4 weeksLowest therapeutic 5 mg daily 3 mg BID 4 mg BIDTarget dose 10 mg daily 4.5 – 6 mg BID 8 mg BIDMax dose 10 mg 6 mg BID 12 mg BIDODB coverage covered 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 routinessensory stimulation – auditory, visual, tactilelow lighting levels, music, simulated nature sounds may be calmingexercise 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-toleratedSSRI 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

dementiatreat vascular risk factors: antihypertensives, statins (hypercholesterolemia),

anticoagulants (a fib), smoking cessation, DM control, antiplatelets, carotid endarterectomy (stroke prevention)

correction of metabolic disturbancesimproved basic educationdecrease head injury incidence

?post-menopausal HRT (case control, cohort studies)?NSAIDsginkgo biloba – no evidence for or againstVit E 2000 IU daily – no evidence for or against

When do you refer? Give me 1 instance....

•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

•early behavioural changes•delusions•fluctuating course•early motor changes