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Page 1: #ˇ˛ ˆ# $ · • Amnesia + + 4 SharePoint document libraries I: Introduction to sharing files Dementia and Delirium Quick Reference Table Feature Cortical Dementia Subcortical Dementia

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DementiaClinical Consideration for GP

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E-mail: [email protected]

http://epilepsy.kku.ac.thSharePoint document libraries I:

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The prevalence of dementia in elderly was 9.8

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The prevalence of dementia in elderly was 9.8

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Dementia: How to Approach

• Reversible ;chronic subdural hematoma,

NPH, metabolic, endocrine , drugs,

CNS infection

• Static / reversible; vascular dementia

• Irreversible; degenerative disease,

Alzheimer’s disease

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D E M E N T I AD : Degenerative (AD), depression, drugs

E : Endocrine

M : Metabolic

E : Epilepsy

N : Neoplasm, nutrition

T : Toxic, trauma

I : Infection, inflammation, infarction

A : Atherosclerosis, alcohol

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Differential diagnosis; 2D 4A

• D epression

• D elirium

• A phasia

• A gnosia

• A nxiety

• A mnesiaSharePoint document libraries I:

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Evaluation

1. Good history and PE, with familywith family

- Neurological and mental status examination

2. CT-brain without contrast initially

3. EEG for rule out epilepsy

4. EKG

5. Blood test

6. Lumbar puncture

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Evaluation : History• Impaired recent memory

• Poor decision making

• Performing routine tasks

• Managing money

• Personality change

• Onset and clinical course

• Education ,Social, Life style

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Evaluation : History

• Risk factor

• Family history

• Medical

– Systemic disease

– Neurological symptom

– Sleep disturbances

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Observation

• Performance

• Dressing

• Concentration and attention

• Patient – relative relationship

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Physical Examination

• Routine neurological examination

• Specific neurological examination

Parieatal lobe

Occipital lobe

Frontal lobe

Visual field

• Mental status examination

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Sensitivity was 88%, specificity was 74%

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Differential diagnosis; 2D 4A

• Depression

• Delirium

• Aphasia

• Agnosia

• Anxiety

• Amnesia

+ �+ � ��4�

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Dementia and Delirium Quick Reference Table

DeliriumSubcortical DementiaCortical DementiaFeature

Sudden

Hours to days

Fluctuating

Fluctuating

Slurred, incoherent

Anomia, dysgraphia

Encoding deficit

Impaired

Impaired

Apathetic, agitated

Often florid

Tremor, asterixis

Moderate-to-severe slowing

Insidious

Months to years

Progressive

Normal

Hypophonic, dysarthric

Normal or anomic

Retrieval deficit

Slow, delapidated

Preserved

Apathetic

Possible

Tremor, dystonia

Normal or mild slowing

Insidious

Months to years

Progressive

Normal

Normal

Aphasic

Learning deficit

Acalculia, concrete

Impaired

Disinhibited

Possible

None

Diffuse slowing

Onset

Duration

Course

Attention

Speech

Language

Memory

Cognition

Awareness

Demeanor

Psychosis

Motor signs

EEG

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Amnesia

• Impaired recent memory

• Global amnesia

• Preserved remote, immediate memory

• Intact general cognitive function

• Confabulation

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Anxiety

• Personality

• Multiple complaints

• Seek to doctor by themselves

• Loss of concentration

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Aphasia

• Atherosclerosis risks

• Acute /sudden onset

• Typical characteristic of sensory aphasia

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What is it?What is it?

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Object recognitionObject recognition

Object seen by the ‘EYE’

Object seen by the ‘BRAIN’

The answer is ‘ELEPHANT’

Object recognized

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Object recognition

Visual input-Acuity-Colour-Motion

Knowledge and memoryabout object

LanguageCapability

Answer

Attention

Visual Agnosia

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Q: Look at this. What is it?A: I don’t know

Q: Feel this. What is it?A: A key

Q: What do you use to unlock the lock?

A: A key

Memory, knowledgeand naming is intact

Q: Copy it.A: Reasonable

vision

Ability to use tactile information

Q: Look. What is it?A: I don’t know

Inability to use visual information SharePoint document libraries I:

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D E M E N T I AD : Degenerative, depression, drugs

E : Endocrine

M : Metabolic

E : Epilepsy

N : Neoplasm, nutrition

T : Toxic, trauma

I : Infection, inflammation, infarction

A : Atherosclerosis, alcohol

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Blood test

• CBC

• Blood chemistry

• TFT

• VDRL

• ESR

• ANA,RF

• B12

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�, !���-���M9��,9���(���,-�

CBC (,-��2��� hypersegmented neutrophils �- .)

Serum electrolyte

Glucose

BUN/creatinine

Liver function tests

Thyroid function tests

Screen for syphilis (VDRL �(� treponent test �(������2��:��-)

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�, !���-���m9��,9��"9�2�,92

Genetic study : �2��'�, !0�,'�����?���0�����8�".��,,9.1329� Familial AD : presenilin ��� APP mutations � Familial prion disease : prion gene mutations� Familial FTD : tau gene mutations� Huntingtonss disease, SCA. DRPLA : CAG repeats testing� Mitochondrial disorders : mitochondrial DNA mutation� CADASIL : notch 3 mutations

Genetic markers

�!,-��"9!)�:�-����. leptomeningeal metastasis, CNS infection, reaqctiveserum syphilis serology, hydrocephalus, rapidly progressive or unusual dementia, immunosuppression, CNS vasculitis

LP and CSF examination

EEG !���*���8.+� 0��+' . 9�9!{�.1 ��2����(��2!���8� �+'� Creutzfeld >Jakob disease

EEG

�2(��2��-��'�����9�9� �,'��(���!�.���2'2��-�23�+���!��5�� 2+#�����L����� B12 0���+���. ���.��2��L����'�, !����+(���(���-

Serum B12

�2(��2��-���'�����9�9�Calcium

�2(��2��-�����.�(��-��'�+������9�9�Anti HIV

�3,���� 7 recommendation for CT scan CT, MRIMRI, nuclear SPECT, PET scanMEI, nuclear SPECT, PET scan

Neuroimaging� Structure� Functional � Metabolic

�2.��,#�, !�-��"9�2�,92

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M E D I C A L

M: Metabolic

E: Endocrine

D: Drugs, degenerative (AD)

I : Infection, inflammation

C: Complex partial seizures

A: Atherosclerosis, alcohol

L: Low vitamin

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Neurodegenerative

1.Alzheimer’s disease

2.Progressive supranuclear palsy

3.Parkinson’s disease

4.Other parkinsonism plus syndrome

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Dementia Deficits Table

N

N

N

N

50 – 80

SI

N

SI

I

N

I

I

N

50 –80

SI

N

SI

SI

N

I

I

N

50 – 80

SI

N

SI

I

I

I

SI

SI

<50

SI

SI

I

I

Orientation

Memory

Immediate

Delayed

Recognition

% Retained

Executive function

Language

Naming

Fluency

Visuospatial

PSPHDPDAD

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Surgical condition

1. Chronic subdural hematoma

2.Brain tumor

3.Hydrocephalus : NPH

Ataxic, incontinence, cognitive impairment

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History

•65 year-old

•3 months headache

•Progressive cognitive

impairment

•No history of injury

•Papilledema

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History

• 45 year-old

•Heavy smoking

•Sub-acute progressive

headache

•Cognitive impairment

•Parietal lobe sign

•Increased ICP

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History

•67 year-old

•Chronic progressive

cognitive impairment

•Ataxia

•Urinary incontinence

•LP 30 cc

•VP shuntSharePoint document libraries I:

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Clinical features can be scored using the Hachinski scale

A score of > 7 suggests multi-infarct dementia

A score of < or = to 4 indicates probable primary degenerative dementia

2222211111111

Abrupt onset

Fluctuating course

History of stroke

Focal neurologic symptoms

Focal neurologic signs

Stepwise deterioration

Nocturnal confusion

Preservation of personality

Depression

Somatic complaints

Emotional incontinence

Hypertension

Evidence of atherosclerosis

ScoreClinical Finding

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Sensitivity 85.3%, specificity 72.9%

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Vascular cognitive impairment• Post-stroke dementia

• Vascular dementia

–Cortical (multi-infarct)

–Subcortical (Binswanger’s disease)

–Strategic infarct dementia

–Hypoperfusion

–ICH

• Mixed (AD and Va dementia)

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Strategically localized infarcts

• Angular gyrus

• Basal ganglia

• Thalamic nuclei

• Hippocampus and retrosplenial area

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Risk Factor for Dementia in Thai Elderly

0.009

0.001

0.001

0.024

0.040

0.001

0.001

0.001

141±24

86±13

250±51

27±11

39.6±42

4.9±0.7

41.1±5.1

57.77±11.3

139±25

83±13

251±51

36±51

48.6±63.4

5.1±0.4

40.5±4.7

54.79±10.4

134±22

81±11

230±53

28±19

22.8±16

4.3±0.6

39.2±5.0

53.59±10.9

SBP

DBP

Cholesterol

SGOT

GGT

Albumin

Hct

Weight

P valueNormalCognitive impairment

Dementia

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History

•45 year-old

•Acute cognitive impairment

•CPS to GTC

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AphasiaAphasia

AnxietyAnxiety

Metabolic

EndocrineDrugsInfection

CPSAtherosclerosisLow vitamin

AgnosiaAgnosia

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Question?

• Brain imaging

• Drug

• Benefit

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Question and Comment

Thank you for your interest