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Approach to dementia
The document discusses the approach to dementia. It begins with definitions of dementia and mild cognitive impairment. There is impairment in neuropsychological abilities, behavior, activities of daily living, and quality of life in dementia patients. A thorough history, physical and neurological examination is essential to determine the type and cause of dementia. Investigations including blood tests, imaging and cognitive assessment scales help arrive at a confirmed diagnosis and identify any reversible causes. The most common types of dementia like Alzheimer's, vascular dementia, frontotemporal dementia and Lewy body dementia present with varying initial symptoms, mental status, neuropsychiatric and neurological features.
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Approach to dementia
- 1. Approach to Dementia Dr.Aminur Rahman FCPS (Med), MD(Neuro) ,FINR (Switzerland), FACP (USA) Fellow Interventional Neuroradiology (Thailand) Assistant Professor Department of Neurology Sir Salimullah Medical College
- 2. Dementia Definition: • Dementia isdefined as an acquired deterioration in cognitive abilities that impairs the successful performance of activities of daily living (ADL).
- 3. Mildcognitive impairment (MCI) •MCI is a state intermediate between normal cognition and dementia, with essentially preserved functional abilities.
- 4. Domain of impairment A.Neuropsychological B. Behavioural C. Activities of daily living (ADL) D. Quality of life (QOL)
- 5. Neuropsychological problems- 80% 1.General intelligence (verbal & nonverbal) 2. Memory (verbal and visual) 3. Language 4. Orientation 5. Visuospatial perception 6. Frontal lobe (executive) function
- 6. Behavioral disturbances 1. Agitation 2.Personality changes 3. Abnormal eating behaviours 4. Wandering 5. Affective disorders/mood disorders 6. Incontinence 7. Anxiety, phobias, fears 8. Delusions 9. Restlessness 11. Demanding/critical behaviour 12. hallucinations 13. Illusions 14. Shouting/screaming 15. Rage/violence 16. Disinhibition 17. Sleep-wake disturbances 18. Sexual behabiours 19. Compulsive/ritualistic behaviours
- 7. ADL A. Baseline self-careabilities 1. Eating, drinking 2. Toileting, washing 3. Walking 4. Dressing B. Complex everyday activities 1. Shopping 2. Food preparation 3. House keeping 4. Finances 5. responsibilities
- 8. In Dementia, thereis- • Neuropsychological problems • Behavioural disturbances • Impaired ADL Leading to- • Reduced QOL
- 9. Approach to Dementia A.Determine presence of Dementia -Decision is solely & essentially clinical B. Determine primary degenerative/other potential treatable causes of dementia C. Co-morbid medical illness. Treatment of an intervening illness may reverse a worsening of dementia Key points:
- 10. A. History ofPresent illness :Obtain a meticulous history (with temporal profile) A. Rate of intellectual decline B. Impairment of social function C. General health & relevant disorders-stroke, head injury B. History of past illness C. Nutritional status D. Drug history E. Personal history F. Family history of dementia G. Occupational history - toxins Approach to Dementia- History
- 11. A. History ofpresent illness: I. Age -Younger: Secondary cases -Older: AD/other primary dementia II. Sex: – More women are affected by dementia than men. – Worldwide, women with dementia outnumber men 2 to 1. Approach to Dementia - History (Contd.) Evaluation:
- 12. Approach to Dementia- History (Contd.) III. Meticulous history from -Patient -Independent informate -Spouse 1. Patient difficulties: • Difficulties patient having • Family member notice
- 13. EN MID CZDNPH, AD Approach to Dementia - History (Contd.) 2. Time course & progression Weeks Months Years
- 14. Approach to Dementia- History (Contd.) a) Onset: i) Early onset e.g.. CADASIL Deficiency states Postencephalitic SSPE Wilson’s Disease Leukodystrophy ii) Late onset e.g.. Alzheimer’s disease (AD)
- 15. Approach to Dementia- History (Contd.) b) Duration: i) Long duration – AD ii) Short duration – Chronic subdural haematoma, Creutzfeldt-Jakob disease (CJD) c) Temporal progression: i) Slowly progressive – AD ii) Relentlessly progressive – CJD, Huntington’s disease, other infections
- 16. 3. Function ofthe patient a) At work b) At home c) Performance of basic activities of daily life 4. Issue of safety Driving - accident, traffic violation, lost in driving Danger - to patient/others Approach to Dementia- History (Contd.)
- 17. 5. Etiologically directedhistory: a) Vascular disease-Risk factors b) Infections/toxic/metabolic/trauma c) Psychiatric-depression, insomnia, agitation Approach to Dementia- History (Contd.)
- 18. Approach to Dementia– History (Contd.) B. Past illness: Gastric surgery – vit. B12 deficiency Chancre – Neurosyphilis C. Nutritional status : – Malnutrition has been associated with more severe symptoms of dementia D. Drugs – sedatives, tranquilizers E. Personal history: Alcohol – thiamine deficiency I.V. drug users – HIV infection
- 19. Approach to Dementia- History(Contd.) F. Occupational history: Working in chemical factory – lead, mercury etc. G. Family history: – HD – AD – Frontotemporal Dementia (FTD) – Wilson’s Disease – CADASIL – Some Hereditary Ataxias etc.
- 20. A. Problem withintellect- 1. Memory impairment & judgment 2. Abstract thinking B. Orientation problem- 1. Time (Day) 2. Place (Where) 3. Person (Who) C. Difficulties with language D. Change in personality 1. Anxiety 2. Agitation 3. irritability Approach to Dementia – clinical features
- 21. Approach to Dementia– clinical features A. Poor memory : Persistent complaint(recent > remote) B. Disturbed behaviour : 1. Personality 2. Mood 3. PerceptioN 4. Attention and Concentration C. As dementia worsens: 1. Less able to self care 2. Neglect social connection 3. Disoriented 4. Slowing of thought 5. Behaviour aimless, stereotypic mannerism 6. Persecutory delusion 7. Mute
- 22. Table: Dementia associatedprominent behavioral features Major Types Dementias Associated behavioral disturbances A. Alzheimer disease Depression, Irritability & Anxiety, Apathy, Delusions, Paranoia &Psychosis A. Lewy body dementia Fluctuating confusion, Hallucinations, Delusions, Depression & Rapid eye movement behavior disorder (RBD) A. Vascular dementia Depression, Apathy, Psychosis A. Frontotemporal dementia Early impaired judgment, Disinhibition, Apathy, Depression, Delusions & Psychosis. A. Parkinson’s disease Depression, Anxiety, Drug associated hallucinations and Psychosis & RBD. A. Corticobasal degeneration Depression, Irritability, RBD and Alien hand syndrome.
- 23. Neurological examination: 1.Mental state: Difficultiesin assessing in I. Lethargic II.Inattentive III.Aphasic IV.Agitation: Evening disorientation & agitation is called Sun downing occurs in Primary Dementia a. Alertness/ attentiveness: Depends on education level Serial 7s Count back words Approach to Dementia – Physical Examination
- 24. b. Memory: Immediate recall Shortterm/long term memory c. Aphasia: Fluency -Non fluent speech -Loss of grammar/syntax -Word finding difficulties Naming -Anomia- Non specific Auditory comprehension of single & multi step commends -Single step: Show two fingers -Multi step: With your eyes closed tap your right knee with two fingers of your left hand Approach to Dementia – Examination
- 25. Repetition ofunfamiliar phrases Reading aloud Writing -Name -Directed sentences -Spontaneous sentences Listen for paraphasic error -Phonemic: tadle for table -Semantic: door for window d. Calculations: Educational level -Two digit addition/multiplication Approach to Dementia – Examination Contd.
- 26. e. Hemineglect: Targetcancellation - Circle all letters - Look for left right asymmetry - Bisect horizontal line f. Apraxia: Impairment of the execution of a learned/ imitated movement in absence of weakness/sensory loss/ Incoordination Opening a look with key Ideometer ideational g. Drawing Copy a complex figures Approach to Dementia – Examination Contd.
- 27. Approach to Dementia- examinations (contd.) So “ A thorough examination is essential” is mandatory AD: Does not affect motor system untill late stage VaD: Hemiparesis, pseudobulbar palsy or other deficits. FTD: Axial rigidity, supranuclear gaze palsy Dementia with Lewy body (DLB): Parkinsonian features PSP: Unexplained falls, Axial rigidity CBD: Dystonia, asymmetric motor deficit, alien hand, myoclonus
- 28. Approach to Dementia- examinations (contd.) B12 deficiency: Myelopathy, peripheral neuropathy Other vit. Deficiency and heavy metal poisoning: Peripheral neuropathy Hypothyroidism: Dry cool skin, hair loss, bradycardia HD: Chorea CRF: Anemia, HTN CLD: Features of portal hypertension, palmar erythema, gynaecomastia etc. Paraneoplastic eg Carcinoma bronchus – clubbing
- 29. Korsakoff’s syndrome: ophthalmoplegia, confabulation, Neurosyphilis:Argyll Robertson pupil HIV infection: Opportunistic infections, Kaposi's sarcoma Chronic lead poisoning: Blue lines in gums Arsenicosis: Mee’s lines Wilson’s disease: K. F. Ring Approach to Dementia - examinations (contd.)
- 30. Assessment Scales 1. Minimental scale (MMS) 2. Clinical dementia rating (CDR) 3. Geriatric mental state (GMS) 4. Cambridge evaluation for mental disorders (CAMDEX) 5. Community screening instrument for dementia (CISD)
- 31. Assessment Scales ofCognitive and Neuropsychiatric examinations Mini – Mental Status Examination (MMSE) is important for: A. Diagnosis B. Prognosis C. Treatment
- 32. Assessment Scales ofCognitive and Neuropsychiatric examinations (contd.) Mini – Mental Status Examination (MMSE): Points Orientation: Name – season/date/day/month/year – 5 (1 for each) Name – hospital/floor/town/state/country – ` 5 (do) Registration: Identify three objects by name and ask patient to repeat – 3 (do) Attention and calculation : Serial 7s, substract from 100 –------- 5 (do) Recall: Recall the three objects presented – 3 (do) Earlier
- 33. Assessment Scales ofCognitive and Neuropsychiatric examinations(contd.) Mini – Mental Status Examination (MMSE-contd.): Points Language : Name pencil and watch – 2 (1 for each) Repeat “no ifs, ands or buts – 1 Follow a 3 step command (eg. Take this paper, fold it in half and place it on the table) – 3 (1 for each) Write “ close your eyes” and ask patient to obey written command – 1 Ask patient to write a sentence – 1 Ask patient to copy a design - 1 Total 30 • Note: score 24 or below indicates cognitive impairment
- 34. Stages of thedisease by MMS A. 27-30 = Normal B. 25-26 = Possible C. 10-24 = Mild-moderate D. 6-9 =Mod-severe E. <6 = Severe
- 35. 1. Motor: a. Focalweakness/neurological sign: Structure brain disease - MID, SDH, ICSOL b. Adventitial movements : Tremor, chorea, myoclonus - degenerative dementia, sub cortical c. Co-ordination & gait: Slow settling- PD/PD plus Ataxia- Wernick-korsakoff NPH Approach to Dementia – Examination Contd.
- 36. d. Primitive reflexes/ Frontal release signs: I. Palmar grasp: Baby naturally grabs objects placed in palm. II. Palmomental reflex: stroking on the thenar eminence of the hand causes contraction of sub mental muscles . III. Rooting reflex: Baby finds breast to suckle. IV. Sucking reflex: Baby sucks breast / bottle / teat to get milk. V. Snout reflex: Involved in suckling. VI. Glabellar reflex: May protect eyes in certain situations. Selected physical examination Secondary reversible cause Factors for deteriorating, Intercurrent infection, Electrolyte imbalance Approach to Dementia – Examination Contd.
- 37. Primitive reflexes /Frontal release signs
- 38. Primitive reflexes /Frontal release signs
- 39. Clinical differentiationof MajorDementias Disease Initial symptom Mental status Neuropsy- chiatry Neurology Imaging AD Memory loss Episodic memory loss Initially normal Initially normal Entorhinal & hippocam- pal atrophy Vascular (VaD) Often sudden, variable initial symptoms, focal lesions Frontal/exec -utive cognitive slowing, can spare memory Apathy, delusions, anxiety Usually motor slowing, spasticity, can be normal Cortical or subcortical infarctions etc. FTD Apathy, reduced judgment,/insi ght/speech/ language, hyperorality Frontal/ executive, language,sp are drawing Apathy, euphoria, depression Vertical gaze palsy,axial rigidity, dystonia Frontal & or temporal lobe atrophy
- 40. Disease Initial symptom Mental status Neuropsyc- hiatry Neurol -ogy Imaging DLB Visual hallucination, REMsleep disorder, delirium,Parkins- onism, Capgras syndrome Frontal/ executive, spares memory Visual hallucinations , depression, delusions Parkins- onism Posterior parietal , hippocampus -- larger than in AD PRION Dementia, mood change, anxiety, movement disorder Variable, frontal/ex- ecutive, memory Depression, anxiety Myoclon -us, rigidity, Parkins- onism Cortical ribboning, basal ganglia hyperintensities on FLAIR MRI Clinical differentiationof Major Dementias( Contd.)
- 41. Investigations for Dementia Objectives: •To arrive to a confirmed diagnosis in collaboration with history and clinical findings • To find out the reversible types of Dementia.
- 42. Investigations for Dementia(contd.) A. Routine: 1. Thyroid function test: eg. Hypothyroidism 2. Serum Vit. B12 Assay- Pernicious Anaemia 3. Complete blood count (may give a clue): Vitamin deficiency states Organ failure Endocrinopathies neoplastic conditions Toxic causes. eg, Basophilic Stippling of RBC in lead poisoning Vacuolated lymphocytes in Niemann-Pick disease 4. Electrolytes: Eg. Increased K+ inCRF, Addison’s Disease
- 43. Investigationsin Dementia (contd.) A.Routine (contd.): 5. VDRL: Neurosyphilis, False positive in SLE 6. CT/MRI of brain (MRI preferable in most cases) Brain atrophy in different topography in different conditions Stroke, Binswanger’s disease CNS infections ICSOL Hydrocephalus Leukodystrophies Wilson’s Disease Hallervorden-Spatz Disease
- 44. Neuroimaging findings indifferent Dementias
- 45. Fig: Vascular dementia-Infract Neuroimaging findings in different Dementias
- 46. Fig: FTD Neuroimaging findingsin different Dementias
- 47. Fig: DLB/ AD Neuroimagingfindings in different Dementias
- 48. Investigations for Dementia(contd.) B. Optional Focused Tests: 1. Chest Skiagram:- Cardiomegaly- Stroke, Hypothyroidism, Anaemia, Alcoholism, Etc. Ca- Bronchus Pulmonary Tuberculosis Vasculitis- SLE, Wegener’s Granulomatosis Sarcoidosis 2. CSF Study: CNS INFECTIONS. Eg. HIV, Neurosyphilis Decreased Aß42-Amyloid & increased tau protein in AD- Not diagnostic
- 49. Investigations for Dementia(contd.) B. Optional Focused Tests (contd.) : 3. Liver Function tests 4. Renal function tests 5. Urine toxin screen. Eg. Lead, Arsenic, Mercury 6. Apolipoprotein- E genotyping- in “AD” 7. DNA testing for Presenilin -1 (ps-1)-in “AD”
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- 52. 1. Alzheimer's diseaseis the commonest form of dementia. In this brain, the gross appearance of the brain reveals marked atrophy. 2. The brain weighs lighter and there is atrophy of the gyral convolutions with widening of the sulcal spaces. Alzheimer'sdisease
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- 56. 1. Neurofibrillary tanglesare twisted, disfigured cytoplasmic filaments found in cortical neurons. 2. They contains altered intermediate filaments. They can be demonstrated by special silver staining methods. 3. Together with neuritic plaques, they constitute the histological substrates of Alzheimer's disease. Neurofibrillary tangles in Alzheimer's disease
- 57. Investigations for Dementia(contd.) B. Optional Focused Tests (contd.): 8. DNA repeat expansion (CAG) OF Gene encoding Huntingtin on chromosome-4 Diagnostic for HD. 9. Decreased transkeltolase activity in Korsakoff’s syndrome 10. Measurement of PrPsc in CJD------------ Diagnostic
- 58. Investigations in Dementia(contd.) C. Occasionally helpful: 1. EEG:- Repetitive bursts of diffuse high voltage sharp waves in CJD Non-convulsive seizure Encephalopathies 2.Parathyroid function 3. Adrenocortical function 4. ESR: Vasculitis, CNS infections, Malignancy
- 59. Investigations in Dementia(contd.) C. Occasionally helpful (contd.): 5. Angiogram: Specially isolated CNS vasculitis 6. Brain & Meningeal biopsy: Not routine Isolated CNS vasculitis Potentially treatable neoplasm Young persons where diagnosis is uncertain 7.SPECT: Not routine In atypical “AD”- Hypometabolism & hypoperfusion in posterior temporo-parietal cortex 8.PET:- Almost exclusively a research tool
- 60. Conclusion Proper diagnosisof Dementia is essential for therapeutic & prognostic purposes. Thorough history & clinical examination are indispensable. In many situations, these two can produce the confirmed diagnosis even without laboratory investigations. A patient of Alzheimer’s disease may have stroke without Dementia & vice- versa. In many situations, laboratory investigations are adjunctive, not diagnostic. In some situations, laboratory investigations are confirmatory. Eg. CNS infections, ICSOL, Wilson’s disease, toxic conditions, HD, etc.
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