Who are you again?

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Who are you again?
No ifs, ands, or, buts..
Treatment Prevention
Definitions
Assessment
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What is the definition of dementia?
Acquired cognitive deficits sufficient to
interfere with social or occupational functioning
in person without depression or clouding of
consciousness
Alzheimers disease 60 Mixed 20 Lewy
body 10 Vascular dementia 5 Fronto-temporal 4
CJD lt1
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What is vascular dementia?

• patchy loss of neurons in areas of infarcts
  (multi-infarct, lacunar, periventricular)
• cognitive changes depend on area of infarct
• recall improves with cuing, more aware of memory
  problem
• Diagnosis
• dementia
• vascular component by hx, px or imaging
• temporal relationship between
• abrupt onset
• stepwise decline
• impaired executive function
• gait disorder
• emotional lability
• clinical/neuroimaging evidence of cerebrovascular
  disease

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What is fronto-temporal dementia?

• EtOH, COPD, Picks, CBGD, Huntingtons
• memory relatively well-preserved
• core diagnosis (in italics)
• insidious onset
• slow progression
• behavioural changes loss of social awareness
  (disordered social conduct), disinhibition,
  emotional blunting, mental rigidity,
  inflexibility, hyperorality, perseveration,
  distractibility, loss of insight, declining
  hygiene, character change
• language changes with reduction in verbal output

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DAILY DOUBLE
Name 1 test that can be used to check frontal
lobe function
word list - name as many 4-legged animals as can
in 1 min trails - trail A (A-B-C-D..), trail B
(A-1-B-2-C-3..) similarities/differences -
apple/orange, vinegar/salt
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What is Lewy body dementia?

• neuronal loss in limbic, substantia nigra,
  autonomic system
• memory loss motor changes hallucinations
  early
• like an AD PD
• 2 of (probable DLB) or 1 (possible) of
  following
• .fluctuating sx, with variation in alertness and
  attention
• .recurrent visual hallucinations, typically
  well-formed and detailed
• .spontaneous extrapyramidal signs/motor features
  of Parkinsonism
• Features supportive for diagnosis are
• repeated falls
• hypersensitivity to neuroleptics
• delusions
• nonvisual hallucinations
• syncope/transient LOC
• drug-unresponsive depression
• REM sleep acting out, vivid violent dreams

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What is Alzheimers disease?
DAILY DOUBLE

• DSM IV criteria for AD
• The development of multiple cognitive deficits
  that is manifested by BOTH of
• memory deterioration
• gt1 of aphasia (language)
• agnosia (objects)
• apraxia (motor activities)
• executive function impairment (planning,
  organising, sequencing)
• is a significant decline compared to previous fn
• causes significant impairment in
  social/occupational function
• gradual onset, continuing decline

NOT due to cerebrovascular dz, Huntingtons dz,
Parkinsons dz, systemic conditions know to cause
dementia (hypothyroidism, vit B12 deficiency,
folic acid deficiency, neurosyphilis, HIV
infection), substance-induced conditions,
delirium, major depressive disorder,
schizophrenia
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What is the course of Alzheimers disease?
Early memory impairment recentgtremote Middle/L
ate behavioural disturbances agitation,
aggression, combativeness, shouting,
disinhibition psychotic sx paranoia,
delusions, hallucinations wandering
behaviour gait, motor disturbances, incontinence
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What are the most important elements of the HPI?
Memory deterioration - recent, remote Aphasia
- probs understanding language, names of things,
reading/writing Apraxia - inability to carry
out goal-oriented motor functions e.g. getting
dressed in correct order Agnosia -
inability to recognise people and
objects Executive function - ability to
anticipate, select, initiate an action, plan and
organise a procedure e.g. financial
planning Depression Delusions Hallucinations Perso
nality changes Apathy Agitation
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What are important questions in PMH, FH, SH?
PMH Systemic diseases, ca, neurological,
psychiatric, thyroid disorders HTN, a fib, Head
injury EtOHism, FH Dementia, AD (2-4 x
increased risk if 1st degree relative),
Huntington's dz SH EtOH, smoking, substance
abuse Occupational exposures Level of education
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What medication hx is it important to elicit?

• narcotics
• anticholinergics
• benzodiazepines
• psychotropics
• OTC, herbal

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How can you assess functional status?
IADL SHAFT Shopping Housekeeping Accounting Food
preparation Transportation
ADL DEATH Dressing Eating Ambulating Toileting H
ygiene

• FAQ (functional activities questionnaire)
• bill paying
• assembling records relating to business affairs
• shopping alone
• playing a game of skill
• performing a task involving multiple steps
  (writing letter, stamping envelope, placing in
  mailbox)
• preparing a balanced meal
• being aware of current events
• understanding and discussing TV, book etc
• remembering and keeping appointments
• driving, arranging to take bus, walking to
  familar places

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What is the prevalence of comorbid depression?

• prevalence in pts with AD is 6-20
• weight sleep changes
• sadness
• crying
• suicidal statements
• excessive guilt

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What parts of physical exam are important in
dementia?

• VS incl postural
• vision
• hearing
• CNs
• motor, sensory function esp localising sx,
  Parkinsonism, stroke
• reflexes

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Whats normal anymore?MMSE
NORMALS LIMITATIONS CORRECT FOR EDUCATION, AGE
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How is clock drawing scored?
Give 1 point for each of the following all 12
correct numbers, hands in correct position,
closed circle, numbers in correct position
lt4 needs further evaluation
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FREEBIE!
400 FREE!
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How are DSM IV criteria tested?
memory aphasia apraxia agnosia e
xecutive fn
hold pt repeats 6 or 7 digits forward, 3 or 4
digits backwards recent pt recounts simple short
story, 4-5 sentences remote significant
national/international events language
production -verbal name body parts or objects
in room - written writes 1 sentence describing
what is wearing comprehension -
verbal simple command e.g. walk over to
window - written simple written request pt
demonstrates e.g. how to use toothbrush coins gi
ve pt instructions to plan, initiate and sequence
a task
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Draw a clock!
4 points 400!!
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What bloodwork is recommended by CMA guidelines?
CBC, lytes, Ca2 TSH, glucose Thats it!!
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Name 3 additional tests to consider
Optional additional tests ? lipids,
BUN/creatinine ESR, serum cortisol ammonia, LFTs,
B12/folate, water soluble vitamins drug levels,
heavy metal levels VDRL, HIV blood gas carotid
dopplers CXR, ECG, EEG, LP, mammography
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Name 4 indications for CT head in dementia

• Indications for CT head
• age lt60 y.o.
• rapid decline (months)
• short duration (lt2 yrs)
• recent head trauma
• new localising sx (Babinski, hemiparesis)
• unexplained neuro finding (HA, sz)
• urinary incontinence gait disturbance early on
  (NPH)
• incontinence
• anticoagulation, bleeding dz
• cancer history
• atypical presentation
• gait disturbance

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What are 2 non-pharmacological therapies for
dementia?

• verbal/physical prompts with positive
  reinforcement
• memory training
• read newspapers, watch educational shows on TV
• reminders about content of conversations

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Who do we screen?
No evidence to recommend screening for cognitive
impairment in absence of sx Memory complaints
should be followed up
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What is the pharmacological treatment of dementia?
Acetylcholinesterase inhibitors (AChE)

• donepezil (Aricept) AchE 2 point improvement
  MMSE after 3 mos
• rivastigmine (Exelon) AchE butyrcholinesterase
  inhib
• galantamine (Reminyl) AchE nicotinic receptor
  inhib

Indicated for AD MMSE 10-26 Lewy body mixed
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Acetylcholinesterase Inhibitors
Donepezil Rivastigmine Galantamine Indication
AD AD, Lewy body AD, mixed Metabolism hepati
c renal hepatic renal Dose interval daily
in AM BID BID Initial dose 5 mg 1.5 mg 4
mg Min titration interval 4 weeks 4 weeks 4
weeks Lowest therapeutic 5 mg daily 3 mg BID 4
mg BID Target dose 10 mg daily 4.5 6 mg BID 8
mg BID Max dose 10 mg 6 mg BID 12 mg BID ODB
coverage covered LU 354 (1st 3 mos) LU
355 (after 3 mos)
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Give me 1 tip on starting therapy...
Start low, go slow! Reassess in 4 weeks to
increase dose, reassess at 2 weeks if necessary
to assess tolerability Warn pt of common
side-effects nausea, anorexia, diarrhoea,
dizziness, agitation Repeat MMSE at 3 mos need
improvement or stabilization. Expected decline in
MMSE on treatment is lt3 points/year
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Name 1 treatment for behavioural problems
At some point during illness, 90 pts have
behavioural problems. Review possible triggers
(illness, pain, mealtimes, loneliness) Non-pharma
cological treatment familiar routines sensory
stimulation auditory, visual, tactile low
lighting levels, music, simulated nature sounds
may be calming exercise program with outdoor
daily walking if possible (decreases wandering,
agitation) pet therapy Pharmacological
treatment low dose neuroleptic drugs
(risperidone, olanzepine, quetiapine).e.g.
risperidone 1mg daily shown to be effective
and well-tolerated SSRI trazodone (esp for
sleep disturbances) CAUTION with benzodiazepines
use only in low doses and PRN AVOID
neuroleptics with marked anticholinergic effects
e.g. chlorpromazine
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Name 2 interventions for the prevention of
dementia
treat vascular risk factors antihypertensives,
statins (hypercholesterolemia),
anticoagulants (a fib), smoking cessation, DM
control, antiplatelets, carotid
endarterectomy (stroke prevention) correction of
metabolic disturbances improved basic
education decrease head injury incidence ?post-me
nopausal HRT (case control, cohort
studies) ?NSAIDs ginkgo biloba no evidence for
or against Vit E 2000 IU daily no evidence for
or against
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When do you refer? Give me 1 instance....

• early behavioural changes
• delusions
• fluctuating course
• early motor changes

• atypical pattern
• uncertainty about diagnosis after initial
  assessment and follow-up
• request by family/pt for another opinion
• presence of significant depression esp if
  refractory to tx
• treatment problems or failure
• need for additional help in management
• when genetic counselling is indicated
• when research studies into diagnosis and
  treatment are being carried out

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