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Approach to dementia
- 1. Approach to Dementia DrAshwin Lathiya SR Neurology GMC Kota
- 2. • MCI anddementia • Subtypes • History taking • Neurological examination • Diagnostic Criteria • Investigations • Take home message OUTLINE
- 3. 73/F, educated tillgraduation, F/c/o HTN, T2DM, hyperlipidemia p/w 3yr H/O Progressive memory loss. Husband reported that she frequently misplaced personal items, forgot passwords, & repeated same questions. She had trouble locating car in the parking lot & had been late in paying bills. She had difficulty completing tasks; shown less interest in previous hobbies but did not report low mood. She denied any motor problems or disruption of sleep. Her Husband Had taken over managing finances & bill paying and had to remind her to take her medications. She was otherwise independent with day to day function. MMSE 21/30, losing points for orientation, word recall and serial 7s.Moderate impairment on tests of verbal and visual memory, mild deficits on tests of executive, language, and visuospatial functions. Rest neurological examination normal.
- 4. Normal Aging MCI (Mildcognitive impairment) Dementia
- 5. Dementia is adisorder that is characterized by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition) Mild neurocognitive disorder refers to a condition involving cognitive impairment in one or more domains, often memory, with relative preservation of functioning and the absence of dementia. Most common form of dementia in older adults is AD (60-80%)
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- 8. Dementia Subtypes Cortical SubcorticalMixed AD PD Multi infarct dementia FTD HD DLB PSP CBS CJD Reversible (non degenerative) Dementia D- Depression, Drugs E- Endocrine (TSH,PTH) M-Metabolic(hypoglycemia, CLD, CKD) E-Encephalitis(limbic), Epilepsy N- Nutritional (B1,B6,B12, folate), NPH T- Tumor, toxin, trauma(SDH) A- Alcohol abuse
- 10. History taking • Historyfrom the caregiver and the patient separately. • Detailed history about onset, duration and tempo of progression of disease. • Medicine History including over the counter drugs • Drinking habits • Any Headache • Any difficulty with senses of smell or taste • Any difficulty with balance, walking or bladder control • Any recent head trauma • Any depressive symptoms • P/H/O: stroke • P/H/O: Anemia, thyroid ds, low vitamin B12,any STD • Any risk factor for HIV • F/H/O dementia or AD
- 11. History taking Symptom s/oDepression Depressed mood, sadness Lack of energy, tiredness, fatigue Loss of interest in activities Helplessness/Hopelessness/worthlessness Suicidal ideation Difficulty concentrating Difficulty with memory Acute onset (min-hr) Delirium Progressive symptoms Degenerative or Progressively expanding SOL Stepwise symptoms Repeated vascular events Relapsing & Remitting Demyelinating or inflammatory causes Remitting Transient vascular event or metabolic cause
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- 15. Key Parts ofthe History
- 16. Neurocognitive assessment Screening tool •MMSE • MoCA • CDT
- 18. Nasreddine ZS, etal. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53:695–9.
- 19. Mattson MP. Superiorpattern processing is the essence of the evolved human brain. Front Neurosci. 2014;8:265.
- 21. Basic clinic assessmentfor each cognitive domain
- 22. Sachdev, P. S.et al. Nat. Rev. Neurol.2014
- 23. Budson, Andrew &Price, Bruce. (2005). Memory: Clinical Disorders. 10.1038/npg.els.0004052.
- 24. Memory Stages Traditional Term Cognitive Neuroscience Term Awareness Level Anatomy Example Immediate memory Working memory Explicit Phonologic:PFC Spatial: PFC, Visual asso cortex Phonologic: keeping phone number in head before dialing Spatial: mentally following a road/ rotating an object in mind Short-term memory Episodic memory Explicit Medial temporal lobe Remembering a short story/ What you had for dinner last night/ What you did in last birthday? Long-term memory Semantic memory Explicit Lateral temporal and other cortices Who was the first president of India?/Color of the lion/How fork differs from a comb? Motor memory Procedural memory Implicit Basal ganglia, cerebellum Driving a car Budson, Andrew & Price, Bruce. (2005). Memory: Clinical Disorders. 10.1038/npg.els.0004052.
- 25. Disease Working memory Episodic memory Semantic memory Procedural memory Alzheimer disease++ +++ ++ - Frontotemporal dementia +++ ++ ++ - Semantic dementia - + +++ ? Lewy body dementia ++ ++ ? ? vascular dementia ++ + + + Parkinson disease ++ + + +++ Huntington disease +++ + + +++ Progressive supranuclear palsy +++ + + ++ Budson, Andrew & Price, Bruce. (2005). Memory: Clinical Disorders. 10.1038/npg.els.0004052.
- 26. A filing analogyof episodic memory Budson, Andrew & Price, Bruce. (2005). Memory: Clinical Disorders. 10.1038/npg.els.0004052.
- 27. Examination Sign May beS/O Myoclonus, Hyperreflexia CJD Frontal release signs FTD Vertical gaze palsy, Procerus sign PSP Masked face Parkinsonism Pisa sign MSA Antecollis MSA Retrocollis PSP Camptocormia PD Sign May be S/O Head Trauma SDH Anemia B12 deficiency Macroglossia, Alopecia/ balding Hypothyroidism
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- 29. Doherty KM, vande Warrenburg BP, Peralta MC, Silveira-Moriyama L, Azulay JP, Gershanik OS, Bloem BR. Postural deformities in Parkinson's disease. Lancet Neurol. 2011 Jun;10(6):538-49
- 30. Camptocormia in thestanding, seated, and supine positions Doherty KM, van de Warrenburg BP, Peralta MC, Silveira-Moriyama L, Azulay JP, Gershanik OS, Bloem BR. Postural deformities in Parkinson's disease. Lancet Neurol. 2011 Jun;10(6):538-49
- 31. Probable AD dementia(NINCDS-ADRDA) 1. Meets criteria for dementia A. Insidious onset. B. Clear-cut history of worsening of cognition by report or observation C. The initial and most prominent cognitive deficits evident on history and examination in one of the following a. Amnestic presentation b. Nonamnestic presentations Language presentation Visuospatial presentation Executive dysfunction McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7(3):263-269.
- 32. Jack CR Jr,Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease. Alzheimers Dement. 2018;14(4):535-562.
- 33. Jack CR Jr,Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease. Alzheimers Dement. 2018;14(4):535-562.
- 35. McKeith IG, BoeveBF, Dickson DW, et al. Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology 2017; 89:88. DLB
- 36. International Consensus Criteriafor bvFTD Rascovsky et al., 2011
- 37. Possible corticobasal syndrome(CBS) At least one of the following: • Limb rigidity and/or akinesia • Limb dystonia • Limb myoclonus and at least one of the following: • Orobuccal or limb apraxia • Cortical sensory deficit • Alien limb phenomena Probable corticobasal syndrome (CBS) Asymmetric presentation of at least two of the following: • Limb rigidity and/or akinesia • Limb dystonia • Limb myoclonus and at least two of the following: • Orobuccal or limb apraxia • Cortical sensory deficit • Alien limb phenomena CBS
- 40. Clinical feature (Dementiawith ) Probable diagnosis Myelopathy B12 deficiency Dry cool skin, hair loss, bradycardia Hypothyroidism Neuropathy Vitamin deficiency/heavy metal intoxication/Thyroid/Lyme/vasculitis Subacute onset amnesia with Neuropsychiatric manifestation Autoimmune encephalitis Recurrent head trauma Chronic SDH/ Dementia pugilistica High risk sexual behavior/ IV drug abuse HIV/Syphilis Unexplained fall, axial rigidity, vertical gaze palsy PSP Asymmetric akinesia, rigidity, dystonia, alien limb, apraxia, executive dysfunction CBS Sudden onset focal weakness, apathy, emotional lability, urinary incontinence, corticalor subcortical infarct, confluent WM disease VaD
- 41. Harper L, etal. J Neurol Neurosurg Psychiatry 2014;85:692–698. Algorithmic assessment of MRI in dementia
- 42. Approach to signal changeassessment
- 43. Harper L, etal. J Neurol Neurosurg Psychiatry 2014;85:692–698. Approach to cerebral atrophy assessment
- 45. Approach to Rapidlyprogressive Dementia • No clear definition for the time frame • Refer to conditions that progress from onset of first symptom to dementia (decline in more than one cognitive domain with functional impairment) in less than 1 to 2 years, although most occur over weeks to months Continuum (Minneap Minn) 2016;22(2):510–537
- 46. Continuum (Minneap Minn)2016;22(2):510–537
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- 48. • 73/F, educationtill graduation, F/c/o HTN, T2DM, hyperlipidemia p/w 3yr H/O Progressive memory loss. Husband reported that she frequently misplaced personal items, forgot passwords, & repeated same questions. She had trouble locating car in the parking lot & had been late in paying bills. She had difficulty completing tasks; shown less interest in previous hobbies but did not report low mood. She denied any motor problems or disruption of sleep. Her Husband Had taken over managing finances & bill paying and had to remind her to take her medications. She was otherwise independent with day to day function. MMSE 21/30, losing points for orientation, word recall and serial 7s.Moderate impairment on tests of verbal and visual memory, mild deficits on tests of executive, language, and visuospatial functions. Rest neurological examination normal.
- 50. Take home message •Dementia is important health issue in elderly with significant functional impairment. • History from the caregiver and the patient separately is of paramount importance. • History of first symptom is equally important as it may help to localize anatomical area of localization. • Recent Imaging technique has helped to further localization. • Early diagnosis is important.
- 51. References • Peterson RC,Graff-Radford J . Bradly’s Neurology in clinical practice.8th Ed. Elsevier 2021.Chapter 95: Alzheimer disease and other dementias. p 1452-1497. • Continuum (minneap minn) 2019;25(1, dementia):14–33. • Budson, Andrew & Price, Bruce. (2005). Memory: Clinical Disorders. 10.1038/npg.els.0004052. • McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging- Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7(3):263-269. • Jack CR Jr, Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease. Alzheimers Dement. 2018;14(4):535- 562. • Harper L, et al. J Neurol Neurosurg Psychiatry 2014;85:692–698.
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