APPROACH TO DEMENTIA IN PRIMARY CARE

APPROACH TO DEMENTIAAPPROACH TO DEMENTIAIN PRIMARY CAREIN PRIMARY CARE

HÜLYA AKAN, MDHÜLYA AKAN, MD

Assocc Prof of Family Assocc Prof of Family MedicineMedicine

DEFINITIONDEFINITION

A syndrome, not a diagnosisA syndrome, not a diagnosis An An acquiredacquired degeneration degeneration of of

iintellectual ntellectual and and cognitive abilitiescognitive abilities, , which persists at least several months which persists at least several months or takes chronically worsening course or takes chronically worsening course leading to major impairment in the leading to major impairment in the patient’s everyday lifepatient’s everyday life

Is not a normal process of agingIs not a normal process of aging

PREVALENCEPREVALENCE

Prevalence doubles every 5 years after age 60.Prevalence doubles every 5 years after age 60. Over 85 years,it is about %25-45Over 85 years,it is about %25-45 The percentage of geriatric population is The percentage of geriatric population is

increasing all over the world. It shows that with increasing all over the world. It shows that with increasing geriatric population, the number of increasing geriatric population, the number of dementia patients will increasedementia patients will increase

It is the 6th leading cause of death in It is the 6th leading cause of death in elderly population in the USAelderly population in the USA

Approximately 2/3 of dementias are Approximately 2/3 of dementias are Alzheimer Alzheimer type dementia.type dementia.

Is it a community health Is it a community health problem?problem?

Geriatric population is increasing all over the Geriatric population is increasing all over the worldworld

Only 10% of dementia is reversible, of these most Only 10% of dementia is reversible, of these most of them to some extentof them to some extent

Median life expectancy for AD patients 3-15 yearsMedian life expectancy for AD patients 3-15 years Needs continous care at home and after than at Needs continous care at home and after than at

an institutyan instituty As many as 90% of patients with dementia are As many as 90% of patients with dementia are

eventually institutionalized. Median time to eventually institutionalized. Median time to nursing-home placement is 3-6 yrs after nursing-home placement is 3-6 yrs after diagnosis. (what about in Turkey?)diagnosis. (what about in Turkey?)

What is Cognition?What is Cognition?

The operation of the mind by which we The operation of the mind by which we become aware of objects of thought or become aware of objects of thought or perception; it includes all aspects of perception; it includes all aspects of perceiving,thinking and rememberingperceiving,thinking and remembering

MemoryMemory OrientationOrientation LanguageLanguage JudgementJudgement PerceptionPerception AttentionAttention Ability to perform tasks in orderAbility to perform tasks in order

What is normal cognitive What is normal cognitive change in elderly?change in elderly?

Cognitive changes seen in normal agingCognitive changes seen in normal aging- Age Associated Memory Impairement (AAMI)- Age Associated Memory Impairement (AAMI)- Aging-Associated Cognitive Decline (AACD)- Aging-Associated Cognitive Decline (AACD) Mild cognitive impairement (MCI)Mild cognitive impairement (MCI) Dementia : usually complaint of relatives not the Dementia : usually complaint of relatives not the

patientpatient

Cognitive changes seen in Cognitive changes seen in elderlyelderly

Perform more slowly on timed tasksPerform more slowly on timed tasks Slower reaction timeSlower reaction time SubjectiveSubjective problems such as difficulty problems such as difficulty

recalling names or where an object placedrecalling names or where an object placed The persons often remembers information The persons often remembers information

laterlater Intact learningIntact learning Any deficits in memory function are Any deficits in memory function are subtle, subtle,

stable and do not cause functional stable and do not cause functional impairementimpairement

Mild Cognitive ImpairementMild Cognitive Impairement

Not within normal limits for the patient’s age and Not within normal limits for the patient’s age and education but not severe enough to qualify as education but not severe enough to qualify as dementiadementia

Subjective memory complaintSubjective memory complaint Objective memory impairement in the context of Objective memory impairement in the context of

normal abilities on most other cognitive domains normal abilities on most other cognitive domains (language,executive function); and intact (language,executive function); and intact functional statusfunctional status

May represent very early form of AD. Among May represent very early form of AD. Among patients with MCI; 10-15% per year convert to AD patients with MCI; 10-15% per year convert to AD compared with 1-2% of age-matched controlscompared with 1-2% of age-matched controls

They may progress to other types of dementias or They may progress to other types of dementias or remain stable-FOLLOW UPremain stable-FOLLOW UP

DementiaDementia

Most severe type of cognitive disordersMost severe type of cognitive disorders Diagnosis requires multiple deficit in Diagnosis requires multiple deficit in

multiple domains of cognitive functioningmultiple domains of cognitive functioning Memory + At least one another that Memory + At least one another that

represent a significant change form represent a significant change form baseline and that are severe enough to baseline and that are severe enough to cause impairement in daily functioningcause impairement in daily functioning

Causes of DementiaCauses of DementiaCerebral disorders Cerebral disorders without without extrapyrimidal extrapyrimidal featuresfeatures

Alzheimer diseaseAlzheimer disease Prominent memory loss, language Prominent memory loss, language impairement, visuospatial impairement, visuospatial disturbance,depression,anxiety,delusionsdisturbance,depression,anxiety,delusions

Pick diseasePick disease Apathy,disinhibition,anosognosia,logorrhea,Apathy,disinhibition,anosognosia,logorrhea,echolalia,palilaliaecholalia,palilalia

Creutzfeld-Jakob diseaseCreutzfeld-Jakob disease Myoclonus, ataxia,periodic EEG complexesMyoclonus, ataxia,periodic EEG complexes

Normal-pressure Normal-pressure hydrocephalushydrocephalus

Incontinence , gait disorderIncontinence , gait disorder

Cerebral disorders Cerebral disorders with extrapyrimidal with extrapyrimidal featuresfeatures

Dementia with Lewy bodiesDementia with Lewy bodies Fluctuating cognitive didorder, visual Fluctuating cognitive didorder, visual halucinations,parkinsonismhalucinations,parkinsonism

Corticobasal ganglionic Corticobasal ganglionic degenerationdegeneration

Parkinsonism, apraxia,cortical sensory Parkinsonism, apraxia,cortical sensory loss,alien-hand syndoromeloss,alien-hand syndorome

Huntington disaseHuntington disase Chorea,pschosisChorea,pschosis

Progressive supranuclear palsyProgressive supranuclear palsy Supranuclear opthalmaplegia,pseudobulbar Supranuclear opthalmaplegia,pseudobulbar palsy,axial distonia in extensionpalsy,axial distonia in extension

CancerCancer Brain tumorBrain tumor Headache, focal neurologic Headache, focal neurologic signs,papiledemasigns,papiledema

Meningeal neoplasiaMeningeal neoplasia Focal weakness or sensory Focal weakness or sensory deficit,areflexia,pyrimidal signs,headachedeficit,areflexia,pyrimidal signs,headache

InfectionInfection AIDSAIDS Oppurtunistic infections,memory loss,psychomotor Oppurtunistic infections,memory loss,psychomotor retadation,ataxia,pyrimidal signs,white matter lesions retadation,ataxia,pyrimidal signs,white matter lesions on MRIon MRI

NeurosyphilisNeurosyphilis Reactive CSF VDRL,pschosis,Argyll-robertson Reactive CSF VDRL,pschosis,Argyll-robertson pupils,facial tremor,strokes, tabes dorsalispupils,facial tremor,strokes, tabes dorsalis

Progressive multifocal Progressive multifocal leukoencephalyleukoencephaly

Visual disturbances,white matter lesions on MRIVisual disturbances,white matter lesions on MRI

MetaboliMetabolic c disorderdisorderss

AlcholismAlcholism Prominent memory loss, nystagmus,gait ataxiaProminent memory loss, nystagmus,gait ataxia

HypothyroidismHypothyroidism Myxedema, hair loss,skin changes, hypothermia, Myxedema, hair loss,skin changes, hypothermia, headache, hearing loss, tinnitus, vertigo, ataxia, headache, hearing loss, tinnitus, vertigo, ataxia, delayed relaxation of tendon reflexesdelayed relaxation of tendon reflexes

Vitamin B12 deficiencyVitamin B12 deficiency Macrocytic anemia,low serum vit. B 12 level, psychosis, Macrocytic anemia,low serum vit. B 12 level, psychosis, sensory disturbance, spastic paraparezissensory disturbance, spastic paraparezis

Organ Organ failurefailure

Dialysis demetiaDialysis demetia Dysarthria, myoclonus, seizuresDysarthria, myoclonus, seizures

Non-Wilsonian Non-Wilsonian hepatocerebral hepatocerebral degenerationdegeneration

Cirhosis, eosaphageal ulcers, fluctuating mental Cirhosis, eosaphageal ulcers, fluctuating mental satatus, dysarthria, pyrimidal and extrapyrimidal signs, satatus, dysarthria, pyrimidal and extrapyrimidal signs, ataxiaataxia

Wilson diseaseWilson disease Cirhosis, dysarthria, pyrimidal and extrapyrimidal signs, Cirhosis, dysarthria, pyrimidal and extrapyrimidal signs, ataxia, decreased serum ceruloplasmin, Keiser-Fleischer ataxia, decreased serum ceruloplasmin, Keiser-Fleischer rings of kornearings of kornea

TraumaTrauma Headache, variable pyramidal and exrtapyramidal signsHeadache, variable pyramidal and exrtapyramidal signs

Vascular Vascular disorderdisorderss

Chronic subdural Chronic subdural hematomahematoma

Headache, hemiparezis,extraaxial collection on CT or Headache, hemiparezis,extraaxial collection on CT or MRIMRI

Vascular dementiaVascular dementia Hypertension, diabetes, stepwise progression of Hypertension, diabetes, stepwise progression of deficits,hemiparezis,aphasia, infarcts on CT or MRIdeficits,hemiparezis,aphasia, infarcts on CT or MRI

PeudodePeudodementiamentia

DepressionDepression Depressed mood, anhedonia,anorexia, weight loss, Depressed mood, anhedonia,anorexia, weight loss, insomnia or hypersomnia, suicidalityinsomnia or hypersomnia, suicidality

Most Common Types of Most Common Types of DementiaDementia

Alzheimer Disease 40-50%Alzheimer Disease 40-50% Mixed AD/Vascular dementia 15-20%Mixed AD/Vascular dementia 15-20% Lewy Body dementia 10-20%Lewy Body dementia 10-20% Pick’s type (frontotemporal) 5-10%Pick’s type (frontotemporal) 5-10% Vascular dementia 5-10%Vascular dementia 5-10% Other 5%Other 5%

Reversible Causes of Reversible Causes of DementiaDementia

Toxic affects of medications or drug Toxic affects of medications or drug interactions (especially elderly people use interactions (especially elderly people use lots of drugs prescribed or unprescribed)lots of drugs prescribed or unprescribed)

Hydrocephalus-brain tumorHydrocephalus-brain tumor InfectionInfection Electrolyte imbalanceElectrolyte imbalance MalnutritionMalnutrition Endocrine and metabolic disordersEndocrine and metabolic disorders

VariableVariable DementiaDementia DeliriumDelirium DepressionDepressionOnsetOnset İnsidous/gradualİnsidous/gradual AbruptAbrupt Fairly abruptFairly abrupt

DurationDuration Months-yearsMonths-years Days-weeksDays-weeks Weeks-monthsWeeks-months

Source of complaintSource of complaint Usually family, Usually family, caregiver,friendcaregiver,friend

Providers,familyProviders,family Patients themselvesPatients themselves

Level of Level of conciousness/alertnconciousness/alertnessess

Usually normalUsually normal Varies throughout Varies throughout the daythe day

Usually normalUsually normal

OrientationOrientation Disoriented later in Disoriented later in diseasedisease

Usually disoriented Usually disoriented earlyearly

Usually normalUsually normal

Attention/Attention/concentrationconcentration

GoodGood PoorPoor PoorPoor

EffortEffort GoodGood Poor or fluctuatingPoor or fluctuating PoorPoor

““Don’t know” Don’t know” answersanswers

UncommonUncommon -------- CommonCommon

Memory loss for Memory loss for recent vs. Remote recent vs. Remote informationinformation

Greater for recentGreater for recent Greater for recentGreater for recent ~equal for both~equal for both

Lost of social skillsLost of social skills LateLate Abrupt Abrupt changes,labilechanges,labile

EarlyEarly

Thought Thought process/contextprocess/context

ImpoverishedImpoverished DisorganizedDisorganized May be slowMay be slow

Psychomotor Psychomotor symptomssymptoms

Normal until late in Normal until late in the diseasethe disease

Hyper- or hypoactiveHyper- or hypoactive HypoactiveHypoactive

ALZHEIMER DISEASEALZHEIMER DISEASE

Most common type of dementiaMost common type of dementia DSM IV Diagnostic Criteria DSM IV Diagnostic Criteria Developement of gradual cognitive deficits Developement of gradual cognitive deficits

manifested bothmanifested both - impaired memory- impaired memory - aphasia, apraxia,agnosia, disturbed executive - aphasia, apraxia,agnosia, disturbed executive

functionfunction Significantly impaired social, occupational functionSignificantly impaired social, occupational function Gradual onset, continuing declineGradual onset, continuing decline Not due to CNS or other physical conditions Not due to CNS or other physical conditions

(e.g,parkinson, delirium)(e.g,parkinson, delirium) Not due to axis I disorder (eg. Schizophrenia)Not due to axis I disorder (eg. Schizophrenia)

RISK FACTORS OF ALZHEIMERRISK FACTORS OF ALZHEIMER

KNOWNKNOWN AgeAge Specific mutations on chromosomes 1,14,21Specific mutations on chromosomes 1,14,21 Family historyFamily history Down syndromeDown syndrome Apolipoprotein E Apolipoprotein E εε4 genotype4 genotypePROBABLEPROBABLE Low education levelLow education level WomenWomen DepressionDepression Brain traumaBrain trauma

How Does Alzheimer Patient How Does Alzheimer Patient Apply to the Physician?Apply to the Physician?

Usually the complaint of family or Usually the complaint of family or caregivers not patient him/herselfcaregivers not patient him/herself

In early dementia patient usually apply to In early dementia patient usually apply to the physician for other reasonsthe physician for other reasons

Patient aim to deny the illness – no in-sightPatient aim to deny the illness – no in-sight Family members usually aim to relate the Family members usually aim to relate the

symptoms to other reasons- loss of symptoms to other reasons- loss of partner, aging, recent operation etcpartner, aging, recent operation etc

How to Diagnose Alzheimer How to Diagnose Alzheimer DiseaseDisease

Probable Diagnosis( usually clinical Probable Diagnosis( usually clinical diagnosis)diagnosis)

HistoryHistory Physical examinationPhysical examination Cognitive testsCognitive tests DSM IV CriteriaDSM IV Criteria

Definite DiagnosisDefinite Diagnosis

- Brain biopsy- Brain biopsy

COMMON COGNITIVE DISORDERS IN ADCOMMON COGNITIVE DISORDERS IN AD

Memory LossMemory Loss - Diffuculty in learning- Diffuculty in learning - Short term memory loss- Short term memory loss DisorientationDisorientation - Time disorientation- Time disorientation - Place confusion - Place confusion AphasiaAphasia -Anomia: naming of objects-Anomia: naming of objects -Difficulty in finding words-Difficulty in finding words -Meaningless, undirected speech-Meaningless, undirected speech -Difficulty in understanding-Difficulty in understanding

COMMON COGNITIVE DISORDERS IN COMMON COGNITIVE DISORDERS IN ADAD

Apraxia:Apraxia: -Ideamotor apraxia: Difficulty in turning -Ideamotor apraxia: Difficulty in turning

an idea into movement (brushing teeth)an idea into movement (brushing teeth) -Extremity-kinetic apraxia:Difficulty in -Extremity-kinetic apraxia:Difficulty in

determining the place of own body parts in determining the place of own body parts in space (putting dress, sitting on chair)space (putting dress, sitting on chair)

Complex Visual dysfunctionComplex Visual dysfunction - Agnosia: difficulty in recognizing- Agnosia: difficulty in recognizing - Visual spatial dysfunction- Visual spatial dysfunction

COMMON COGNITIVE DISORDERS IN COMMON COGNITIVE DISORDERS IN ADAD

Disorder in applyingDisorder in applying -Disorder in planning-Disorder in planning -Disorder in judgement-Disorder in judgement Disorder in abstract thinkingDisorder in abstract thinking Disorder in solving problemDisorder in solving problem - Disinhibition- Disinhibition AnosognoziAnosognozi - Unawareness of the disorder- Unawareness of the disorder - Denial of the disease- Denial of the disease

Common Noncognitive Signs in Common Noncognitive Signs in ADAD

Personality ChangesPersonality Changes - Passive- Passive - Self-oriented- Self-oriented - Agitated/irritable- Agitated/irritable ApathyApathy - Difficulty in beginning- Difficulty in beginning - Insufficiency to continue effort- Insufficiency to continue effort DepressionDepression AnxietyAnxiety

Common Non-cognitive Signs Common Non-cognitive Signs in ADin AD

DelusionsDelusions - Paranoia- Paranoia - Misidentification- Misidentification HallucinationsHallucinations AgitationAgitation - Nonspecific motor behaviours- Nonspecific motor behaviours - Verbal agressiveness- Verbal agressiveness - Physical agressiveness- Physical agressiveness Sleep disturbancesSleep disturbances - Circadian lapse- Circadian lapse - Insufficient sleep- Insufficient sleep

How to approach a patient How to approach a patient presenting with cognitive presenting with cognitive

problemproblem First step : Is it a disturbance of level of First step : Is it a disturbance of level of

conciousness (acute confusional state, coma) or conciousness (acute confusional state, coma) or content of conciousness (wakefullness preserved)content of conciousness (wakefullness preserved)

Second step: Determine the cognitive function Second step: Determine the cognitive function and the degree of cognitive impairement, decide and the degree of cognitive impairement, decide dementiadementia

Third step: Differantiate reversible and Third step: Differantiate reversible and irreversible dementia and also pseudodementia irreversible dementia and also pseudodementia (e.g. depression)(e.g. depression)

Check prescribed, unprescribed drugs and also Check prescribed, unprescribed drugs and also herbal drugs and substance abuse (e.g,alcohol)herbal drugs and substance abuse (e.g,alcohol)

Consider neurologic and neurophysciatric Consider neurologic and neurophysciatric consultationconsultation

Consider the treatment of reversible causes Consider the treatment of reversible causes of dementiaof dementia

Consider treatment of dementiaConsider treatment of dementia Consider daily activities scalas, determine the Consider daily activities scalas, determine the

care needs of the patientcare needs of the patient Counselling of the patient, family and Counselling of the patient, family and

caregiverscaregivers Consider treatment of behavioural disordersConsider treatment of behavioural disorders

HISTORY TAKINGHISTORY TAKING

Most important part of the diagnosisMost important part of the diagnosis Altough it may be unreliable, first try to take the Altough it may be unreliable, first try to take the

history from the patient.history from the patient. Asking questions about past and present social Asking questions about past and present social

life and medical history gives lots of information life and medical history gives lots of information about recent and remote memory. Don’t forget about recent and remote memory. Don’t forget patient may feel uneasy with lots of questions patient may feel uneasy with lots of questions and aim to deny self memory problem (and aim to deny self memory problem (no no insightinsight))

Since patient has memory problem, you must Since patient has memory problem, you must confirm history by some one accompanying confirm history by some one accompanying her/him. This also gives some clues about the her/him. This also gives some clues about the degree of the problem.degree of the problem.


Most of cognitive problems can be recognized and Most of cognitive problems can be recognized and tested during history takingtested during history taking

You may begin with asking “What do you like to do You may begin with asking “What do you like to do in your free times?” (Measure abstract thinking.For in your free times?” (Measure abstract thinking.For a meaningful response the patient must remember a meaningful response the patient must remember a list of activities and how they are organized). a list of activities and how they are organized). Alzheimer patients typically aim to answer with Alzheimer patients typically aim to answer with generalized terms (like reading). In this case generalized terms (like reading). In this case clinician may specify by asking “What are you clinician may specify by asking “What are you reading recently?” If patient has difficulty, the reading recently?” If patient has difficulty, the clinician must go into more detailed tests by saying clinician must go into more detailed tests by saying “It seems you have difficulty in remembering some “It seems you have difficulty in remembering some things. Maybe we better to do some more detailed things. Maybe we better to do some more detailed tests.”tests.”


Special attention to drug use: Most of geriatric Special attention to drug use: Most of geriatric patients use lots of unprescribed and patients use lots of unprescribed and prescribed drugs having anticholinergic prescribed drugs having anticholinergic effects. Another problem is that the patient effects. Another problem is that the patient may forget and aim to take drugs several may forget and aim to take drugs several times a day.Ask for drug use and if possible times a day.Ask for drug use and if possible ask for a written list and check with the patient ask for a written list and check with the patient and caregiver.and caregiver.

Special attention to hearing and visional Special attention to hearing and visional problems. These are also very common in problems. These are also very common in elderly people. Undiagnosed problems may elderly people. Undiagnosed problems may interfere with cognitive tests and may lead to interfere with cognitive tests and may lead to lower scores.lower scores.

HISTORYHISTORY Duration of symptoms and nature of progression Duration of symptoms and nature of progression

of symptomsof symptoms Presence of specific symptoms related to:Presence of specific symptoms related to: -Memory (recent and remote)-Memory (recent and remote) -Language (word finding problems, diffuculty -Language (word finding problems, diffuculty

expressing self)expressing self) - Visuospatial skills (getting lost)- Visuospatial skills (getting lost) - Executive functioning (calculations,planning, - Executive functioning (calculations,planning,

carrying out multistep tasks)carrying out multistep tasks) - Apraxia (not able to do previously learned - Apraxia (not able to do previously learned

motor tasks eg:slicing of bread)motor tasks eg:slicing of bread) - Behaviour or personality changes- Behaviour or personality changes -Psychiatric symptoms -Psychiatric symptoms

(apathy,hallucinations,delusions,paranoia)(apathy,hallucinations,delusions,paranoia)

HISTORYHISTORY

Functional assesment (ADLs, IADLs)Functional assesment (ADLs, IADLs) Social support assesmentSocial support assesment Medical history, comorbiditiesMedical history, comorbidities Through medication review, including over-Through medication review, including over-

the-counter medications, herbal productsthe-counter medications, herbal products Family historyFamily history Review of systems including screening for Review of systems including screening for

depression and alcohol/substance abusedepression and alcohol/substance abuse

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Cognitive examinationCognitive examination General physical examination with special General physical examination with special

attention to:attention to:

- Neurologic examination, looking for focal - Neurologic examination, looking for focal findings, extrapyrimidal signs, gait and findings, extrapyrimidal signs, gait and balance assessmentbalance assessment

- Cardiovascular examination- Cardiovascular examination

- Signs of abuse and neglect- Signs of abuse and neglect Screen for impairments in hearing and visionScreen for impairments in hearing and vision

Cognitive ExaminationCognitive Examination

Rapid cognitive testRapid cognitive test MMSEMMSE Clock Draw TestClock Draw Test

Rapid Cognitive TestRapid Cognitive Test

Most of the items can be performed Most of the items can be performed during history taking and physical during history taking and physical exam.exam.

Normal healthy adults usually finish Normal healthy adults usually finish this test in 5 minutes or less.this test in 5 minutes or less.

It can show if there is need more It can show if there is need more detailed tests.detailed tests.


1- Abstract Thinking: “What do you like to do 1- Abstract Thinking: “What do you like to do in your free times?”in your free times?”

A: If the answer is appropiate and well A: If the answer is appropiate and well constructed or if there is no cognitive or constructed or if there is no cognitive or behavioral signs, it may not needed behavioral signs, it may not needed further asssesment.further asssesment.

B: If the answer is very concrete, B: If the answer is very concrete, suspicious or not including details, go on suspicious or not including details, go on item 2. item 2.


2-Focal Cortical function2-Focal Cortical function a: Learning:” I want you to repeat and a: Learning:” I want you to repeat and

keep in mind these three words, umbrella, keep in mind these three words, umbrella, rose, afraid”rose, afraid”

b: Memory/counting assessment: “If I give b: Memory/counting assessment: “If I give you one lira, five kuruş, ten kuruş and you one lira, five kuruş, ten kuruş and twenty five kuruş, how much money I twenty five kuruş, how much money I would have given to you?”would have given to you?”

c: Naming:”Please tell me the name of the c: Naming:”Please tell me the name of the things I show you (shirt, jacket,pen etc)”things I show you (shirt, jacket,pen etc)”


d: d: Temporaparietal testsTemporaparietal tests 1- “Show how you nail on with your right hand”1- “Show how you nail on with your right hand” 2- Show how you use key when you are opening the lock with your left hand”2- Show how you use key when you are opening the lock with your left hand” 3- “Show how you slice a loaf of bread by using your both hands”3- “Show how you slice a loaf of bread by using your both hands” 4-Touch your left ear with your right hand”4-Touch your left ear with your right hand” 5- “Use your left hand to show my left hand”5- “Use your left hand to show my left hand” 6- “Before showing the ceil please show the door.”6- “Before showing the ceil please show the door.” e: Drawings:e: Drawings: 1- “Draw a clock and put the numbers in it and show the time 08:20.”1- “Draw a clock and put the numbers in it and show the time 08:20.” 2- “Please draw the same of this figure”2- “Please draw the same of this figure”


f: Memory: “Please tell me the words that I f: Memory: “Please tell me the words that I have told you to memorize few minutes ago.”have told you to memorize few minutes ago.”

How to interprate?How to interprate?

A: If the patient performs the tests in section 2, A: If the patient performs the tests in section 2, assess again in 6-12 monthsassess again in 6-12 months

B: If patient can’t success in 2 or more parts of B: If patient can’t success in 2 or more parts of section 2 , consider more detailed assesment. section 2 , consider more detailed assesment.

Clock Draw TestClock Draw TestInstructionsInstructions ““Draw the face of the clock, putting the Draw the face of the clock, putting the

numbers in the correct position. I’ll then ask numbers in the correct position. I’ll then ask you to indicate a time after you are done.”you to indicate a time after you are done.”

Ask the patient to draw in the hands at ten Ask the patient to draw in the hands at ten minutes after eight.”minutes after eight.”

ScoringScoring Draw a closed circle: 1 pointDraw a closed circle: 1 point Place numbers in correct position: 1 pointPlace numbers in correct position: 1 point Includes all 12 correct numbers: 1 pointIncludes all 12 correct numbers: 1 point Correct indication of time: 1 pointCorrect indication of time: 1 point

Clock Draw TestClock Draw Test

InterprationInterpration CTD 4: approximates MMSE nearly 30 or MCICTD 4: approximates MMSE nearly 30 or MCI CDT 2: puts the patient in moderate cognitive CDT 2: puts the patient in moderate cognitive

impairement, MMSE about high teensimpairement, MMSE about high teens CTD 1 reflects moderate to low scores on CTD 1 reflects moderate to low scores on

mmse- low teensmmse- low teens Clinical judgement MUST be appliedClinical judgement MUST be applied Abnormal results needs further assesmentAbnormal results needs further assesment

MMSEMMSEMini – Mental State ExamMini – Mental State Exam

Not “ gold standart”, but most commonly Not “ gold standart”, but most commonly acceptedaccepted

30-point scale to evaluate orientation, 30-point scale to evaluate orientation, concentration, verbal and visual spatial skillsconcentration, verbal and visual spatial skills

Subject to level of educational attainment, Subject to level of educational attainment, language barrier and vision/hearing language barrier and vision/hearing requirementsrequirements

Scoring:Scoring: Early stages: 21 - 30Early stages: 21 - 30 Moderate stages: 11 - 20Moderate stages: 11 - 20 Late stages: 0 - 10Late stages: 0 - 10

LABORATORYLABORATORY

CBCCBC Electrolytes, Glucose, BUN/Cr.,Ca, LFTsElectrolytes, Glucose, BUN/Cr.,Ca, LFTs Thyroid funtion testsThyroid funtion tests Vit B12Vit B12 VDRL (Syphilis),HIV (AIDS)VDRL (Syphilis),HIV (AIDS) ESR, Urine analysisESR, Urine analysis Toxicology screen, 24 hour urine for heavy metalsToxicology screen, 24 hour urine for heavy metals EEG (optional)EEG (optional) Neuroimaging (optional)Neuroimaging (optional) -CT: to rule out other dx-CT: to rule out other dx -MRI: to rule out other dx-MRI: to rule out other dx PET, SPECT (optional)PET, SPECT (optional) CSF fluids: High tau and low beta amyloidCSF fluids: High tau and low beta amyloid

Is It Needed Neuroimaging?Is It Needed Neuroimaging?

Routine brain imaging in the Routine brain imaging in the diagnostic evaluation of a patient diagnostic evaluation of a patient with cognitive impairement dementia with cognitive impairement dementia is controversial.is controversial.

If there is oppurtunity, uncontrasted If there is oppurtunity, uncontrasted CT or MRI is advised.CT or MRI is advised.

New developments in New developments in diagnosisdiagnosis

Functional imagingFunctional imaging: FDG(fluorodeoxyglucose) : FDG(fluorodeoxyglucose) PET- PET- reduced use of glucose (sugar) in brain reduced use of glucose (sugar) in brain areas important in memory, learning and areas important in memory, learning and problem solvingproblem solving

Molecular imaging technologiesMolecular imaging technologies : highligts : highligts amiloid plaques in PETamiloid plaques in PET

Pittsburgh compound B (PIB) Pittsburgh compound B (PIB)

18F flutemetamol (flute)18F flutemetamol (flute)

Florbetapir F 18 (18F-AV-45)Florbetapir F 18 (18F-AV-45)

Florbetaben (BAY 94-9172)Florbetaben (BAY 94-9172)

How To Differentiate AD and How To Differentiate AD and Depression (Pseudodementia)Depression (Pseudodementia)

Depression is common in dementia Depression is common in dementia patients, also in elderlies.patients, also in elderlies.

Clinically when they are found together it Clinically when they are found together it may be very diffucult to differentiate.may be very diffucult to differentiate.

In every patient you think dementia, try to In every patient you think dementia, try to differentiate pseudodementia- depression.differentiate pseudodementia- depression.

Treatment of depression may improve Treatment of depression may improve cognitive problems.cognitive problems.

How To Differentiate AD and How To Differentiate AD and Depression (Pseudodementia)Depression (Pseudodementia)

DEMENTIADEMENTIA DEPRESSIONDEPRESSION

Insidious onsetInsidious onset Abrupt onsetAbrupt onset

Progressive deteriorationProgressive deterioration Plateau of dysfunctionPlateau of dysfunction

No history of depressionNo history of depression History of depression may existHistory of depression may exist

Patient typically unaware of Patient typically unaware of extent of deficits and does not extent of deficits and does not complain memory losscomplain memory loss

Patient aware of and may Patient aware of and may exaggerate deficits and exaggerate deficits and frequently complains memory frequently complains memory lossloss

Somatic complaints uncommonSomatic complaints uncommon Somatic complaints and Somatic complaints and hypochondriasis commonhypochondriasis common

Variable affectVariable affect Depressive affectDepressive affect

Few vegetative symptomsFew vegetative symptoms Prominent vegetative symptomsProminent vegetative symptoms

Impairement often worse at nightImpairement often worse at night Impairement usually not worse at Impairement usually not worse at nightnight

Neurologic examination and Neurologic examination and laboratory studies may be laboratory studies may be abnormalabnormal

Neurologic examination and Neurologic examination and laboratory studies normallaboratory studies normal

When To Refer To When To Refer To NeurologyNeurology

Abrupt onsetAbrupt onset Extrapyrimidal symptoms or focal Extrapyrimidal symptoms or focal

neurologic symptoms other than cognitive neurologic symptoms other than cognitive symptomssymptoms

Abnormal neurologic examination except Abnormal neurologic examination except cognitive impairementcognitive impairement

Rapid deteriotionRapid deteriotion During follow-up new neurologic signs or During follow-up new neurologic signs or

symptoms unrelated to ADsymptoms unrelated to AD If you are not sure of the diagnosisIf you are not sure of the diagnosis

When to Counsel for When to Counsel for Neuropsychologic Tests?Neuropsychologic Tests?

Neuropyschologic tests consist in-depth Neuropyschologic tests consist in-depth battery of standardized examinations that battery of standardized examinations that test multiple cognitive domains including test multiple cognitive domains including intelligence,memory,language, visuospatial intelligence,memory,language, visuospatial abilities,attention, reasoning and problem abilities,attention, reasoning and problem solving as well as other executive functions solving as well as other executive functions and applied by neurophysciatrists.and applied by neurophysciatrists.

Patients who have early or mild syptoms Patients who have early or mild syptoms (diffuculty in diagnosing or differentiating)(diffuculty in diagnosing or differentiating)

High premorbid intelligenceHigh premorbid intelligence Patients with low intelligence/educational Patients with low intelligence/educational

levellevel

Is it needed Genetic Is it needed Genetic Counselling?Counselling?

Late- onset AD (>60-65 yrs):Is associated with Late- onset AD (>60-65 yrs):Is associated with genes that increase the risk of AD but not in genes that increase the risk of AD but not in autosomal dominant fashion.autosomal dominant fashion.

εε4 increase AD 2-3 times, 4 increase AD 2-3 times, εε2 protective, but 2 protective, but absence of absence of εε4 does not rule out diagnosis. So it is 4 does not rule out diagnosis. So it is not needed in practical means.not needed in practical means.

Early-onset AD (<65 yrs, usually between 40-50 Early-onset AD (<65 yrs, usually between 40-50 yrs): Familial.Inherited autosomal dominant. It is yrs): Familial.Inherited autosomal dominant. It is not needed in practical means, but if children of not needed in practical means, but if children of the patient wish to know whether they have the patient wish to know whether they have inherited the gene, the family shoud be referred inherited the gene, the family shoud be referred for genetic counselling.for genetic counselling.

TREATMENTTREATMENT

MAIN GOALSMAIN GOALS Preserve function and anatomy for as Preserve function and anatomy for as

long as possiblelong as possible Maintain quality of life for both the Maintain quality of life for both the

patient and caregiverspatient and caregivers

DRUG TREATMENTDRUG TREATMENT

Cholinesterase Inhibitors: Effect sizes are Cholinesterase Inhibitors: Effect sizes are modest in clinical trails 40-50%modest in clinical trails 40-50%

A stable or improved MMSE over 6-12 mo A stable or improved MMSE over 6-12 mo suggests the drug is effective. suggests the drug is effective.

- Rivastigmine- Rivastigmine - Donezepil- Donezepil - Tacrine- TacrineNMDA (N-methyl-D-Aspartate) AntagonistsNMDA (N-methyl-D-Aspartate) Antagonists - Memantine- MemantineOther pharmacologic agents tried have given Other pharmacologic agents tried have given

controversial resultscontroversial results

Treatement of Behavioural Treatement of Behavioural ProblemsProblems

Commonly seen behavioural and psychiatric Commonly seen behavioural and psychiatric problems in AD:problems in AD:

- Agitation and aggression- Agitation and aggression- Disruptive vocalizationDisruptive vocalization- Psychotic features (delusions,hallucinations,paranoia)Psychotic features (delusions,hallucinations,paranoia)- Depressive symptomDepressive symptom- ApathyApathy- Sleep disturbancesSleep disturbances- Wandering or pacingWandering or pacing- Resistance to personal care (bathing and grooming)Resistance to personal care (bathing and grooming)- IncontinenceIncontinence

Treatement of Behavioural Treatement of Behavioural ProblemsProblems

Antipsychotics Antipsychotics (haloperidol,risperidone,olanzapine, (haloperidol,risperidone,olanzapine, trazadon) trazadon)

Antidepressants (SSRIs Antidepressants (SSRIs eg:sitoprolam)eg:sitoprolam)

Mood stabilizers (eg: carbamazepine)Mood stabilizers (eg: carbamazepine)

Non-Pharmacological Non-Pharmacological TreatementTreatement

MusicMusic Reminiscence TherapyReminiscence Therapy Exposure to petsExposure to pets Outdoor walksOutdoor walks Bright light exposureBright light exposure

Non-Pharmacological Non-Pharmacological TreatementTreatement

Advice to family and care givers:Advice to family and care givers: Maintain familarity and routines as much as Maintain familarity and routines as much as

possiblepossible Decrease number of choicesDecrease number of choices Tell, don’t askTell, don’t ask Understand they can’t, rather than they Understand they can’t, rather than they

Won’tWon’t Don’t try logic or reasonDon’t try logic or reason Always keep the goals in mindAlways keep the goals in mind

Follow-upFollow-up

Repeat MMSE every 6-12 months: In AD 3 Repeat MMSE every 6-12 months: In AD 3 point decrease/every year is expectedpoint decrease/every year is expected

Determine new behavioral changes and Determine new behavioral changes and their causestheir causes

Repeat complete physical examination Repeat complete physical examination including weight and determine if any new including weight and determine if any new developed co-morbiditydeveloped co-morbidity

Assess the efficacy of the drugs given for Assess the efficacy of the drugs given for dementia (MMSE+ clinical judgement)dementia (MMSE+ clinical judgement)

Check medication listCheck medication list Check the stress level of caregiverCheck the stress level of caregiver

SAFETY ISSUESSAFETY ISSUES

DrivingDriving Home Safety: Every potential harms Home Safety: Every potential harms

must be discussed detailly eg: must be discussed detailly eg: stoves, carpets, lightining stoves, carpets, lightining

Wandering: sewn in clothing, Wandering: sewn in clothing, identification braceletidentification bracelet

Care giver assistanceCare giver assistance

PROGNOSISPROGNOSIS

Median life expectancy 3-15 yrsMedian life expectancy 3-15 yrs Needs continous careNeeds continous care Eventually becomes bed riddenEventually becomes bed ridden In advanced dementia patient has difficulty with In advanced dementia patient has difficulty with

even most basic things such as feeding themselveseven most basic things such as feeding themselves Often urinary and bowel incontinenceOften urinary and bowel incontinence Patients who do not die of other comorbidities tend Patients who do not die of other comorbidities tend

to develope concomitant complications to develope concomitant complications (malnutrition, pressure ulcers,recurrent infections)(malnutrition, pressure ulcers,recurrent infections)

The most common cause of death is pneumonia.The most common cause of death is pneumonia.

EVIDENCE BASED POINTSEVIDENCE BASED POINTS

AD is the most common form of dementia, accounting AD is the most common form of dementia, accounting approximately 66% of patients with dementiaapproximately 66% of patients with dementia

Routine brain imaging in the diagnostic evaluation of Routine brain imaging in the diagnostic evaluation of a patient with cognitive impairement dementia is a patient with cognitive impairement dementia is controversial. controversial.

Genetic testing, including APOE genotyping,is not Genetic testing, including APOE genotyping,is not indicated for clinical use.indicated for clinical use.

Actylcholinesterase inhibitors for tratement of AD Actylcholinesterase inhibitors for tratement of AD have modest benefits on cognition, physical have modest benefits on cognition, physical functioning and behaviour.functioning and behaviour.

Behavioral and psychologic symptoms of dementia Behavioral and psychologic symptoms of dementia are associated poor outcomes.are associated poor outcomes.

APPROACH TO DEMENTIA IN PRIMARY CARE

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