Understanding Dementia
Dr Asso Fariadoon Ali Amin
MRCP(UK)
Why is Dementia Important?
Dementia is an acquired decline in memory and other cognitive function (s) in an alert non delirious person that is sufficiently severe to affect daily life ( home, work, or social function).
There are about 820,000 people in the UK with dementia The number is set to double by 2030 Prevalence:- rare before the age of 65 , increase with age , 65-69
(1.4%), 70-74 ( 2.8%), 75-79 ( 5.6%), 80-84 (11.1%), more than 85 (23.6%)
There are about 18,500 people in the UK under 65 who have dementia There is no cure
Prevalence of Alzheimer’s Disease
Prevalence of Alzheimer’s disease in an aging population.
Prevalence increases dramatically with age and approaches 50% of those over 85 years old.(Adapted from Evans et al., 1989.)
Dementia - Diagnosis
Diagnosis ICD-10 & DSM-IV:
Multiple cognitive defects which must include: Amnesia Functional impairment Clear consciousness Clear change from previous level Long duration (>6 months)
Forms of Dementia Alzheimer’s disease Vascular Dementia Dementia in Parkinson’s & Dementia with Lewy Bodies Frontotemporal Dementia Reversible (<5%):- Subdural haematoma, normal pressure
hydrocephalus, metabolic, drugs Neurological dementias: Cerebral Vasculitis Corticobasal Degeneration Dementia in MS HIV/AIDS Dementia Huntington’s Dementia Lysosomal storage diseases Prion Diseases – CJD
Prevalence of the forms of dementia
Cause Percentage
Alzheimer’s disease 55%
Vascular dementia 20%
Dementia with Lewy Bodies 15%
Frontotemporal dementia 5%
Rarer causes (all) 5%
Clinical Diagnosis • History:- Take a careful history from the patient and the relative,
concentrate mainly on the onset and progression of symptoms, , take careful drug history, social history. Deterioration of cognitive function is slow in Alzheimer disease within years , faster in vascular dementia, and very rapid in reversible like metabolic causes.
• Deterioration occurs in :- retention of new information like appointments, events, or working a new
household appliance) Managing complex tasks e.g. Paying bills , cooking a meal) Language ( word finding difficulty) Behaviour ;- become aggressive, irritability, poor motivation and wandering) orientation getting lost in familiar places. recognition:- failure to recognise people Ability to self care :- bathing , dressing. Reasoning:- poor judgement
Alzheimer’s – Diagnosis
Fulfil criteria for dementia syndrome Insidious onset Gradual progression No focal neurological signs No evidence for a systemic or brain disease
sufficient to cause dementia
Alzheimer’s Diagnosis DSM IV
The development of multiple cognitive deficits manifested
by both:
1. Memory impairment and:
2. One or more of the following cognitive disturbances:
a) Aphasia
b) Apraxia
c) Agnosia
d) Disturbed executive function
Alzheimer’s Diagnosis DSM IV The cognitive impairments above lead to significant
impairment in social or occupational functioning & are a decline from a previous level
The course is gradual in onset & shows continuous decline The cognitive impairments are not due to:
1) Other CNS conditions that cause progressive deficits in memory & cognition
2) Systemic conditions that cause dementia
3) Substance induced conditions The deficits do not occur during the course of delirium
Alzheimer’s - featuresCognitive symptoms
Amnesia – early features are impaired new learning & recall, disorientation in time & place, late features include impaired semantic memory & visuospatial memory
Aphasia (dysphasia) – deficits in cortical language function – early features are nominal aphasia, verbal perseveration, late features include mutism & echolalia
Apraxia (dyspraxia) – common forms are: ideomotor dyspraxia (cannot carry out motor function to command), constructional dyspraxia (manifested by inability to copy intersecting pentagons or draw a clockface)
Cognitive Features
Agnosia especially visual agnosia (inability to recognise objects) & prosopagnosia (inability to recognise faces)
Frontal-executive dysfunction – inflexible (concrete thinking). Difficulties with problem solving or planning, difficulty correctly sequencing behaviour.
Dyslexia Dysgraphia Acalculia R/L disorientation
Non-cognitive symptoms Psychotic: Delusions often paranoid
Hallucinations: commonly visual
Mood: Depression
Anxiety
Euphoria
Behavioural: Apathy
Over activity
Aggression
Non-cognitive symptoms Neurovegetative Symptoms: Sleep disturbance, day-night reversal in about 30% patients Eating: poor oral intake or binge eating Sexual disinhibition Personality change
Physical Symptoms: Primitive reflexes (grasp & palmomental reflexes) Incontinence (often a late feature in AD) Weight loss Deterioration in gait Falls
Vascular Dementia
Evidence of dementia and Cerebrovascular disease: focal signs on neurological
testing & evidence of cerebrovascular disease on brain imaging (CT or MRI): multiple large infarcts, single infarct in the angular gyrus, thalamus, basal forebrain or PCA or ACA territories, or multiple basal ganglia & white matter lacunar infarcts or extensive periventricular white matter lesions or a combination of the above
A relationship between the onset of dementia & the presence of cerebrovascular disease: Onset of dementia within 3 months of a stroke Abrupt deterioration in cognitive function or a fluctuating
or stepwise deterioration
Vascular DementiaOther features which may be associated:
Early gait disturbance: ‘Marche a petit pas’, Parkinsonian (lower limbs), apraxic-
ataxic History of unsteadiness or frequent falls Early urinary symptoms not explained by urological
disease Pseudobulbar palsy, depression, psychomotor retardation
& abnormal executive function
Dementia with Lewy Bodies (DLB)(Consensus Criteria)
(1) Evidence of dementia with: (2) Two of the following core features are essential in order to diagnose possible DLB:
• fluctuations with pronounced variations in alertness & attention• recurrent visual hallucinations that are typically well formed &
detailed• spontaneous features of parkinsonism e.g. rigidity, bradykinesia,
tremor
(3) Other supportive features: Repeated falls, syncope, systematised delusions, hallucinations in modalities other
than vision
Parkinson's disease Dementia Elderly with Parkinson's are more likely to develop
dementia. Motor symptoms proceed by at least one year. Then
followed by cognitive function deterioration No hallucination.
Frontal Lobe Dementia Neurodegenerative disease with insidious onset and low progression. Onset is often early ( 35-75), and either behavioural or language
symptoms dominate the clinical picture. Forgetfulness is mild, insight is lost early. Difficulties at work may be the first sign.
Using MMSE can miss the diagnosis ( require FLT) Behavioural problems include disinhibition, mental rigidity, inflexibility,
impairment of executive function, decrease personal care and repetitive behaviours.
Language dysfunction:- include word finding difficulties, problem with naming or understanding words. Lack of spontaneous conversation.
Neuroimaging usually demonstrate frontal/temporal atrophy 50% positive FH FLD include many spectrum like FL Degenration, Picks disease, MND
with dementia
Normal Pressure Hydrocephalus Wide gate (gate disturbance) Urinary incontinence Cognitive impairment CT large ventricle disproportional to cerebral atrophy MMSE and gait assessment before LP LP is diagnostic and therapeutic ( normal pressure, remove
20-30ml and re-assess gait and cognitive function) Some improve with ventricular-peritoneal shunt. Gait is
more likely to improve. Complication infection and SDH
Differential Diagnosis
Causes of memory problems / confusion that are not dementia
Delirium
Depression ‘pseudo-dementia’
Mild cognitive impairment or benign cognitive impairment of aging
Learning difficulties
Previous brain injury
Memory Complaints in Aging, Depression & Dementia
Aging Depression DementiaComplaint May report a mild or
subtle memory problem
More likely to complain about their memory
Expresses variable, non-specific memory problems or may be unaware
Functional
Interference
No interference with daily functioning
Minimal interference- functional problems more likely due to mood disorder
Clearly interferes with daily functioning: missing appointments, unpaid bills, medication compliance
Cognitive Status
Onset of problem unclear. Cognition is normal on testing
Onset may be reported as sudden, subtle deficits on testing only
Gradual onset & progression
Cognition impaired on testing
Mood Not associated with depression or anxiety
Associated with a depressed or anxious mood
May be associated with fluctuating or blunted affect
Assessment Important points in the history:
Duration, fluctuation, progression Forgetfulness, repetitiveness Misplacing or losing things Judgement – ability to manage finances Safety concerns Changes in personality or behaviour Loss of hygiene Falls Insight PMH Medications and compliance
Assessment IIMental state examination
Appearance & behaviour Speech Mood Delusions Hallucinations Personality – past & present Insight Cognition
Assessment III
Cognitive Assessment MMSE & Frontal Lobe Score MMSE & Clock Drawing Test Addenbrooke’s Cognitive Examination – Revised (ACE-R) Alzheimer’s Disease Assessment Scale for Cognition
(ADAS-Cog)
Assessment of Mood Geriatric Depression Score Hospital Anxiety & Depression Score
Assessment IV
Physical Assessment
Focal neurological weakness Evidence of Parkinsonism Evidence of intercurrent illness causing a delirium Evidence of significant anaemia or hypothyroidism Evidence of dyspraxia
Investigations
All patients should have FBC, U&E’s, LFT’s, Ca, glucose to look for systemic causes of confusion
B12, Folate, TFT’s VDRL if clinically suspect syphilis Cranial imaging to confirm / exclude : Cerebral tumours, Normal Pressure Hydrocephalus, subdural
haematoma & to assess degree of vascular insufficiency DaTSCAN (Ioflupane SPECT) for clinically difficult to
diagnose Dementia with Lewy Bodies EEG – not generally indicated but is abnormal in sporadic
CJD
DaTSCAN in DLB
Normal DaTSCAN DaTSCAN in PD & DLB – Decreased dopaminergic neurones in the striatal area
Management in Dementia - General Assess for physical illness & depression Establish functional abilities & any risks Capacity assessment Carer assessment Education of carers Assess social care needs & support required Planning for future care: advance directives, power of
attorney Cholinesterase inhibitors Management of behavioural problems Terminal care
Mild Dementia (Mild symptoms or MMSE 20-24)
Appropriate counseling around the diagnosis Advice on how to maintain health & well-being Ensuring the individual has care to meet their needs prior to
discharge Written information about dementia – leaflets produced by
the Alzheimer’s Society Advice on Power of Attorney & how to plan for the future Details of how to contact the Alzheimer’s Society for
ongoing support Convey the diagnosis to the GP so they can arrange follow up
& refer to memory clinic if & when appropriate
Moderate Dementia(Moderate symptoms or MMSE 10-20)
As for mild dementia plus: Assess eligibility for memory clinic & cholinesterase
inhibitors Discussions should take place about how someone would
wish to be treated in the future: ceilings of treatment, palliative care if appropriate on the ward
Severe Dementia
If the patient has a clinical picture of dementia with severe symptoms with or without an MMSE of <10:
As for mild to moderate dementia Consider stopping cholinesterase inhibitor Discussions should take place about how someone would
wish to be treated in the future: ceilings of treatment, palliative care, where the individual would wish to die.
Anti-dementia drugs
Cholinesterase inhibitors: Donepezil: A reversible inhibitor of acetyl cholinesterase
Galantamine: As for Donepezil + nicotinic receptor agonist
Rivastigmine: Non-competitive inhibitor of acetyl cholinesterase,
Licensed for dementia in PD & DLB
N-methyl-D- aspartate (NMDA) receptor antagonist:
Memantine: Some evidence it is effective in more advanced
dementia, & beneficial in behaviourally disturbed AD in
conjunction with a cholinesterase inhibitor PDD,DLB,ALZ have greatest cholinergic deficit
What do NICE say? (November 2006)
The cholinesterase inhibitors can be prescribed for clinically moderate AD or those with an MMSE 10-20
NMDA receptor antagonists to be prescribed ‘de novo’ only in recognised clinical trials
Only specialists in Old Age Psychiatry or those geriatricians with specific expertise may start therapy
Patients need to be reviewed at 3/12 & then 6/12 intervals to assess response with an MMSE score, a global functional & behavioural assessment & carer views to be considered
If benefit noted they may continue on therapy until the MMSE<10
Management of Behavioural Problems
Non-Pharmacological intervention
Assess for intercurrent illnesses, pain ,constipation, urinary retention etcEnsure environment is appropriate for their needs: Lighting levels appropriate for the time of day Regular (at least 3xday) cues to orientate Use of clocks & calendars Hearing aids & glasses available & functioning Continuity of care from nursing staff Encouragement of mobility & engagement in activities Approach & handle gently, explain who you are, what you are going to do &
why
Non-pharmacological measures
Elimination of unexpected & irritating noise Good pain control Encourage visits from family & friends especially at meal
times Ensure adequate fluid & dietary intake Adequate CNS oxygen delivery Monitor bowels – avoid constipation Encourage a good sleep pattern Avoid inter & intra ward transfers Avoid catheters where possible
Pharmacological interventions
Indications for sedation: In order to carry out essential investigations or
treatment To prevent a patient endangering themselves or
others To relieve distress in a highly agitated or
hallucinating patient, after assessing whether there is a physical cause for that distress
Acutely: Haloperidol, Olanzapine, trazodone 50mg nocte to 300mg max. and Lorazepam
are the drugs of choice Do not use Haloperidol in patients with Parkinson’s disease or Dementia with Lewy Bodies
Medium term : Haloperidol or atypical antipsychotics: (up to 6 weeks) Amisulpiride, Quetiapine, Olanzapine, Risperidone (caution in cerebrovascular disease)
Longer term: Cholinesterase inhibitors, NMDA Receptor antagonists
Pharmacological intervention
Prevention of Dementia Life style Physical activity Cognitive activity Diet:- fish oil
Medication HRT NSAID Antioxidant Vitamin E&C Antihypertensive Statin
Give 3 key features of dementia How long should symptoms have been present for to
diagnose dementia? Give 3 different types of dementia. Which blood tests should be done routinely in a possible
dementia patient? Why? Give 3 differential diagnoses for cognitive dysfunction. Name 3 assessments of cognitive function. Name a treatment for dementia? What class of drug are
these? What are the standard criteria for eligibility for this drug? Give one key clinical feature of Alzheimer’s dementia. Give one key clinical feature of vascular dementia.
Dementia Questionnaire
Dementia Questionnaire
An 82 year old lady presents having had recurrent falls, she doesn’t know why she is in hospital, her niece reports that she was fully able to look after herself and was driving 4 weeks ago. She is covered in bruises and her obs/WCC/urine dipstix/chest X-ray are normal. What is the most likely diagnosis?
You are asked to review a 79year old surgical patient with “confusion” He has been confused since admission and looks thin and unkempt. He does not know where he is but is GCS 15. His son tells you he has stopped being able to cook meals, and does not recognise his grandchildren anymore. This has been going on for over a year. What is the likely diagnosis?
Dementia Questionnaire
An 86 year old lady is brought in with dehydration, apart from a raised urea her other investigations are normal. She reports having a memory problem which she is very anxious about, on testing her cognitive function is just below normal. She has trouble concentrating on the test. On the ward she is able to wash and dress herself, but keeps to herself. What is the likely diagnosis?
You are called to the ward at night because a patient is threatening the nurses with his Zimmer frame. The nurses report that he is usually a “lovely old man” but today he has been more agitated. He is currently being treated for a UTI. What is the likely diagnosis?
www.Alzheimer’s.org.uk
Bournemouth Office:
Alzheimer’s Society
c/o King’s Park Community Hospital
Gloucester Road
Bournemouth
BH7 6JE
Telephone: 01202 309084
Thank you for listening