An Approach to Dementia

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An Approach to Dementia

• Heather Anderson, MD
• KUMC Department of Neurology

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Overview--Dementia

• Definition
• Epidemiology
• Classification
• Assessment

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DEMENTIA

• A syndrome of progressive decline that
  relentlessly erodes multiple intellectual
  abilities, causing cognitive and functional
  deterioration

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• Dementia of the Alzheimers type is a disorder
  that is characterized by impairment of memory and
  at least one other cognitive domain (aphasia,
  apraxia, agnosia, executive function). These must
  represent a decline from previous level of
  function and be severe enough to interfere with
  daily function and independence. Symptoms are not
  due to delirium, another medical condition, or a
  psychiatric condition.

American Psychiatric Association Diagnostic and
Statistical Manual, 4th ed, Text Revision, 2000.
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Epidemiology

• Prevalence 5 million in U.S. in 2007 with AD
  may rise to 16 million by 20501
• Prevalence rates increase with advancing age2
• gt65 yrs about 15 with mild dementia
• gt80 yrs maybe gt40 with mild dementia
• 1 Alzheimers News Release, 21 Mar 2007
• 2CH Kawas, Ratzman R Epidemiology of dementia
  and Alzheimer disease. In Terry RD, Katzman R,
  Bick KL, et al (eds)Alzheimer Disease, ed 2.
  Philadelphia, Lippincott Williams Wilkins,
  1999, p. 95.

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Epidemiology

• Most common causes of dementia are
• Alzheimers Disease 2/3 of dementia cases
• Diffuse Lewy body disease
• Vascular dementias
• Frontotemporal dementias
• Subcortical dementias progressive supranuclear
  palsy, parkinsonian syndromes, multiple
  sclerosis, AIDS, Huntingtons disease

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Classification

• Assess and classify dementia by qualitative
  differences in the presentation of the patient
• Most clinically useful distinction is between
  cortical and sub- or noncortical dementia
• AD, the most common dementia, presents with
  cortical features while reversible causes for the
  most part do not

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Classification

• Cortical features (active)
• lack of extrapyramidal motor findings
• large amts of abnormal speech and behavior
• Subcortical features (passive)
• slowness of thought or action
• apathy
• extrapyramidal motor findings

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Classification
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Assessment triggers

• Any concerns about cognitive decline of function
  from patient or others should trigger initial
  assessment for dementia.
• Symptoms that may indicate dementia
• learning and retaining new information
• handling complex tasks
• reasoning ability
• spatial ability and orientation
• language
• behavior

Clinical practice guideline, No. 19. Recognition
and initial assessment of Alzheimers disease and
related dementias. Agency for Health Care Policy
and Research, US Dept of Health and Human
Services, November 1996.
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Assessment focused history

• Chronology of the problem History from a loved
  one
• mode of onset abrupt vs. gradual
• progression stepwise vs. continuous decline
• duration of symptoms
• Medical history
• Family history
• Social and cultural history education, literacy,
  socioeconomic status, recent life events
• Medication evaluation for possible drug toxicity

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Assessment focused PE

• Neurological exam including mobility and balance
  assessment
• Vision and hearing screening
• Evidence of cardiac or pulmonary dysfunction
• Signs of caregiver abuse or self-neglect

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Assessment mental status

• Most commonly used brief screening test is
  Folsteins Mini-Mental State Exam1 (MMSE)
• lt24 suggests dementia
• Mini-Cog2 assessment instrument
• Repeat 3 unrelated words
• Clock drawing
• Recall 3 words

1Folstein MF, Folstein SE, McHugh PR. Mini-mental
state a practical method for grading the
cognitive state of patients for the clinician. J
Psychiatr Res 197512189-98. 2Borson S, Scanlan
JM, Chen P, et al. The mini-cog as a screen for
dementia Validation in a population-based
sample. J Am Geriatr Soc 2003511451-54.
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Assessment functional status

• Activities of Daily Living (ADLs)
• transferring, ambulating, bathing, toileting,
  feeding, dressing
• Instrumental Activities of Daily Living (IADLs)
• grocery shopping, food preparation, housekeeping,
  transportation, money management, medication
  management

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Assessment tests

• Remember that relatively few patients (lt15) are
  found to have an isolated, potentially reversible
  condition, so intensity of evaluation should be
  limited if the likelihood of a reversible
  condition is low.
• American Academy of Neurology 2001
• CBC, serum electrolytes with BUN/creatinine and
  glucose, serum B12 level, liver function tests,
  thyroid function tests, structural imaging.

Petersen RC, Stevens JC, Ganguli M, et al.
Practice parameter Early detection of dementia
Mild cognitive impairment (an evidence-based
review). Neurology 2001561133-1142.
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Assessment rule out similar symptoms

• Mild Cognitive Impairment
• Delirium
• Depression
• Normal Aging

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Assessment interpretation

• Normal functional and mental status
• reassure family and patient
• reassess in 6-12 months
• OR refer for 2nd opinion
• Abnormal functional and mental status
• tests to r/o medical condition
• support and education for caregivers
• Mixed
• more complete neuropsychological testing
• consider age, education, and cultural confounders

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Assessment follow-up

• Discuss caregiving relating to patients
  functionality with family
• Financial, legal, medical planning
• Community resource education
• Advance directives
• Repeat MMSE in 6-12 months (AD expected to drop 4
  points per year)

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Therapy

• Supportive care to patients
• Safety matters
• Daily living routine and environment
• Monitoring of medical conditions
• Advance care planning

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Therapy

• Supportive care to caregivers
• Education
• Teaching problem-solving skills
• Accessing resources
• Long-range planning
• Emotional support
• Respite options

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Treatment

• Medications for Alzheimers Disease
• Acetylcholinesterase inhibitors
• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Razadyne)
• NMDA receptor antagonist
• Memantine (Namenda)

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Take-Home Points

• It is essential that you know the baseline
  cognitive status on the patient
• You must get the history of cognitive
  status/decline from a friend or loved one
• Dont rely on the patients history
• Remember This is a memory patient!
• Think ahead for discharge planning
• Strategies to maximize patient independence/safety
  while addressing the caregivers
  needs/limitations