Dementia: Diagnosis and Treatment
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Transcript of Dementia: Diagnosis and Treatment
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Dementia: Diagnosis and Treatment
Debra L. Bynum, MD
Division of Geriatric Medicine
University of North Carolina at Chapel Hill
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Case
Mr. Jones is a 72-year-old gentleman brought to you by his daughter for progressive memory loss. He denies any problems. Previously an accountant, he is now unable to balance his check book. He has had difficulty with getting lost while driving to the store. He was diagnosed with depression two years ago after his wife died. In addition, he has HTN and DM. His father was diagnosed with Alzheimer’s disease at the age of 85. On exam, his BP is 170/90; he is oriented, scores 26/30 on the MMSE (0/3 recall and difficulty with the intersecting pentagon); he is unable to do the clockface.
A few months later, his MMSE is 24/30; on exam he has some mild cogwheel rigidity and a slight shuffling gate, but no tremor. His daughter reports that he has been having vivid visual hallucinations and paranoid thought.
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Questions:
1. What are some limitations to the MMSE?
2. Is there any association between HTNand dementia in the elderly?
3. What are the risk factors for dementia?
4. What type of dementia might Mr. Jones have?
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Outline
Risk factors and definition of dementia
Types of dementias
MMSE and testing
Treatment options
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Question:
What are some risk factors for the development of dementia?
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Risk Factors for DementiaAge Family hx of AD or Parkinson’s (10-30% risk of AD in patients with first degree relative)Head traumaDepression (?early marker for dementia)Low educational attainment??hyperlipidemia?diabetesHTN !!!
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Risk Factors for AD
Gender (confounding in literature – women more likely to live longer, be older….)
Down’s syndrome
?estrogen (probably not)
?NSAIDS (probably not)
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Question:
What is the definition of a dementia? What is the “line” between “normal” memory loss with age and dementia…
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Cognitive Decline with Aging
Mild changes in memory and rate of information processing
Not progressive
Does not interfere with daily function or independence
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Mild Cognitive Impairment
12% of people over age 70
Usually memory affected
Does not significantly interfere with daily function
3 times increased risk of developing AD
10–15% /year will develop dementia
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DSM Criteria
1. Memory impairment2. At least one of the following: Aphasia Apraxia Agnosia Disturbance in executive functioning
3. Disturbance in 1 and 2 interferes with daily function or independence4. Does not occur exclusively during delirium
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Activities of Daily Living
ADLs: bathing, toileting, transfer, dressing, eating
IADLs (executive functioning): Maintaining household Shopping Transportation Finances
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Diagnosis of Dementia
Delirium: acute, clouding of sensorium, fluctuations in level of consciousness, difficulty with attention and concentrationDepression: patient complains of memory lossDelirium and depression: markers of dementia?5% people over age 65 and 35–50 % over 85 have dementia, therefore pretest probability of dementia in older person with memory loss at least 60%
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Question:
What are some classic features of an Alzheimer’s type dementia?
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Alzheimer’s Disease
Role of the Hippocampus
Patient HM with surgery for seizures to remove bilateral medial temporal lobes resulting in severe anterograde amnesia
Formation of new memories
Spatial navigation
Early evidence for damage in this area
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Alzheimer’s Disease
60–80% of cases of dementia in older patientsEarly personality changesLoss of short term memoryFunctional impairmentVisual spatial disturbances (early finding)ApraxiaLanguage disturbancesDelusions/hallucinations (usually later in course)
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Alzheimer’s Disease
Depression occurs in 1/3Delusions and hallucinations in 1/3Extracellular deposition of amyloid-beta protein, intracellular neurofibrillary tangles, and loss of neurons at autopsyClinical diagnosis: 87% of diagnosed AD confirmed pathologically (but high pretest probability increases predictive value of clinical diagnosis!!!)
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Alzheimer’s Disease
Onset usually near age 65; older age, more likely diagnosisAbsence of focal neurological signs (but significant overlap in the elderly with hx of CVAs…)Aphasia, apraxia, agnosiaFamily hx (especially for early types)Normal/nonspecific EEG MRI: bilateral hippocampal atrophy (suggestive)
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Question:
What features would make you think more about a vascular etiology to a dementia?
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Vascular Dementia
Onset of cognitive deficits associated with a stroke (but often no clear hx of CVA but multiple small, undiagnosed CVAs)
Abrupt onset of sxs with stepwise deterioration
Findings on neurological examination
Infarcts on cerebral imaging (but ct/mri findings often have no clear relationship)
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Overlap
Most patients previously categorized as either Alzheimer’s type or vascular type dementias probably have BOTH
Likelihood of AD and vascular disease significantly increases with age, therefore likelihood of both does as well
Vascular risk factors predispose to AD -- ?does it allow the symptoms of AD to be unmasked earlier??
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Question:
What is the risk of dementia with Parkinson’s disease?
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Dementia with Parkinson’s
30% with PD may develop dementia; Risk Factors: Age over 70 Depression Confusion/psychosis on levodopa Facial masking upon presentation
Hallucinations and delusions May be exacerbated by treatment
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Some Other Dementias
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Dementia with Lewy Bodies
Cortical Lewy Bodies on path
10–20% of dementias
Compare to PD: Lewy Bodies in substantia nigra
Overlap with AD and PD
40% patients with AD have LBs on path
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Dementia with Lewy Bodies
Visual hallucinations (early)
Parkinsonism
Cognitive fluctuations
Dysautonomia
Sleep disorders
Neuroleptic sensitivity
Memory changes later in course
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Dementia with Lewy Bodies
Visual hallucinations 2/3 of patients with DLB Rare in AD May precede other symptoms of DLB Psychosis, paranoia and other psychiatric
manifestations early in course
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Dementia with Lewy Bodies
Cognitive Fluctuations 60–80% Episodic Loss of consciousness, staring spells, more
confused or delirious like behavior Days of long naps Significant impact on functional status
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Dementia with Lewy Bodies
Parkinsonism 70–90% More bilateral and symmetric than with PD Tremor less common Bradykinesia, rigidity, gait changes
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Dementia with Lewy Bodies
Sleep disorders REM sleep behavior disorder/parasomnia Acting out of dreams: REM dreams without
usual muscle atonia 85% of patients with DLB May precede other symptoms by years
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DLB: Neuroleptic Hypersensitivity
30–50% of patients
May induce Parkinsonian symptoms or cognitive changes that are not reversible, leading to rapid decline in overall status
NOT dose related
Slightly less likely with newer atypical antipsychotics, but can STILL happen
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DLB: Treatment
More progressive course than AD or Vascular dementia
Possibly better response to cholinergic drugs than AD or vascular dementias
?response of psychiatric type symptoms to cholinergic agents/cholinesterase inhibitors
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Progressive Supranuclear Palsy
Uncommon
Vertical supranuclear palsy with downward gaze abnormalities
Postural instability
Falls (especially with stairs)
“Surprised look”
Difficulty with spilling food/drink
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Frontotemporal Dementia
Impairment of executive function Initiation Goal setting Planning
Disinhibited/inappropriate behavior (90%)Cognitive testing may be normal; memory loss NOT prominent early feature5–10% cases of dementiaOnset usually 45–65 (rare after age 75)Familial: 20–40%
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Pick’s Disease
Subtype of frontal lobe dementiaPick bodies (silver staining intracytoplasmic inclusions in neocortex and hippocampus)?Serotonergic deficit?Language abnormalities and behavioral disturbances Logorrhea (abundant unfocused speech) Echolalia (spontaneous repetition of words/phrases) Palilalia (compulsive repetition of phrases) Fluent or non-fluent forms
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Primary Progressive Aphasia
Patients slowly develop non-fluent, anomic aphasia with hesitant, effortful speechRepetition, reading, writing also impaired; comprehension initially preservedSlow progression, initially memory preserved but 75% eventually develop non-language deficits; most patients eventually become muteAverage age of onset = 60Subset of FTD
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“Reversible” Causes of Dementia
?10% of all patients with dementia; in reality, only 2–3% at most will truly have a reversible cause of dementia
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“Modifiable” Causes of Dementia
MedicationsAlcoholMetabolic (b12, thyroid, hyponatremia, hypercalcemia, hepatic and renal dysfunction)Depression? (likely marker though…)CNS neoplasms, chronic subduralNPH
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Question:
An elderly patient with ataxia, incontinence, memory loss and “large ventricles” scan should raise suspicion for …?
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Normal Pressure Hydrocephalus
Triad: Gait disturbance Urinary incontinence Cognitive dysfunction
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NPH: Clinical Features
Gait Early Feature Most responsive to shunting Magnetic/gait apraxia/frontal “ataxia”
Cognitive Psychomotor slowing, apathy, decreased attention
Urinary Urgency or incontinence
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NPH
Hydrocephalus in absence of papilledema, with normal CSF pressureBegins as transient/intermittent increased CSF pressure, leading to ventricular enlargement; ventricular enlargement leads to normalization of CSF pressureThought to be due to decreased CSF absorption at arachnoid villiCauses: SAH, tumors, CVA
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NPH
Diagnosis: initially on neuroimaging Ventricular enlargement our of proportion to
sulcal atrophyMiller Fisher test: objective gait assessment before and after removal of 30 cc CSFRadioisotope diffusion studies of CSFMRI: turbulent flow in posterior third ventricle and within aqueduct of sylviusMRI flow imaging SPECT (Single Photon emission CT): decreased blood flow in frontal and periventricular areas
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NPH: ?Shunting?
Limited data
Gait may be most responsive
Predictors of better outcome: Lack of significant dementia Known etiology (prior SAH) New (< 6 months) symptoms Prominence of gait abnormality
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Creutzfeldt-Jacob Disease
Rapid onset and deterioration
Motor deficits
Seizures
Slowing and periodic complexes on EEG
Myotonic activity
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Other Infections and Dementia
Syphilis
HIV
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Question:
What are some tools available to assess for the presence and severity of cognitive impairment?
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MMSE
24/30 suggestive of dementia (sens 87%, spec 82%)Not sensitive for MCISpuriously low in people with low educational level, low SES, poor language skills, illiteracy, impaired visionNot sensitive in people with higher educational background
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MMSE Tips
No on serial sevens (months backwards, name backwards… assessment of attention)Assess literacy priorAssess for dominant hand prior to handing paper overDo not over lead3-item repetition, repeat all 3 then have patients repeat; 3-stage command, repeat all 3 parts of command and then have patient do…
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Other Evaluation Tools
Trails B test Numbers 1–25 and letters scattered across page;
patient must connect, 1-A, 2-B, 3-C, etc; normally able to do in <10 minutes
Good for patients with high function/educationVerbal Fluency Test Name all within category in 30 seconds – 1 minute Letters FAS, animals, vegetables Tests executive function and language, semantic
memory Normally should name 20–30 in 60 seconds Highly associated with educational level Insight with grouping, rhyming, categories
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Additional Evaluation
Clockface
Short assessments with good validity: 3-item recall and clockface
Neurological exam (focality, frontal release signs such as grasp, jawjerk; apraxia, cogwheeling, eye movements)
Lab testing and neuroimaging
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Treatment of AD
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Tacrine
Cholinesterase inhibitor
1 systematic review with 5 RCTs, 1434 people, 1–39 weeks
No difference in overall clinical improvement
Some clinically insignificant improvement in cognition
Significant risk of LFT abnormalities: NOT USED
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Donepezil
AriceptCholinesterse inhibitorEasy titration (start 5/day, then 10)Side effects: GI (nausea, diarrhea)Can be associated with bradycardiaMain effect seems to be lessening of rate of decline, delayed time to needing nursing home/more intensive care
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Other Agents
RivastigmineGalantamineCholinesterase inhibitors?more side effects, more titration requiredFuture directions: Prevention of delirium in at-risk patients
(cholinergic theory of delirium) Behavioral effects in those with severe dementia? Treatment of Lewy Body dementia Treatment of mixed Vascular/AD dementia
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Comments about Cholinesterase Inhibitor Studies
Highly selected patients (mild – moderate dementia)
?QOL improvements
Not known: severe dementia and mild CI
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Memantine
NEJM April 2003Moderate to severe AD (MMSE 3–14)N-methyl D aspartate (NMDA) receptor antagonist; theory that overstimulation of NMDA receptor by glutamate leads to progressive neurodegenerative damage28-week, double blinded, placebo controlled study; 126 in each group; 67% female, mean age 76, mean MMSE 7.9
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Memantine
Found less decline in ADL scores, less decline in MMSE (-.5 instead of –1.2)
Problem: significant drop outs (overall 28% dropout rate) in both groups; data analyzed did not account for drop outs, followed those “at risk”
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Selegiline
Unclear benefit
Less than 10mg day, selective MAO B inhibitor
Small studies, not very conclusive
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Vitamin E (Alpha Tocopherol)NEJM 1997: selegiline, Vit E, both , placebo for tx of ADDouble blind, placebo controlled, RCT with mod AD; 341 patientsPrimary outcome: time to death, institutionalization, loss of ADLS, severe dementiaBaseline MMSE higher in placebo groupNo difference in Primary outcomes; adjusted for MMSE differences at baseline and found delay in time to NH from 670 days with Vit E to 440 days with placebo
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Ginkgo Biloba
1 systematic review of 9 double blind RCTs with AD, vascular, or mixed dementia
Heterogeneity, short durations
High withdrawal rates; best studies have shown no significant change in clinician’s global impression scores
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Other Treatments
NO good evidence to support estrogens or NSAIDS
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Other Treatments
Behavioral/agitation: Nonpharmacologic strategies Reasons for NH placement:
Agitation Incontinence Falls Caregiver stress
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?Antipsychotics
NO data to support any significant benefit for treating behavioral symptoms of dementia with antipsychotic agents
Small group of patients with active psychoses, disturbing hallucinations, or aggressive behaviors who may have some benefit
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Antipsychotics
Side Effects: Sedation Anticholinergic effects Prolonged QT Edema Orthostasis Weight gain Confusion
Warnings: FDA black box warning for increased mortality (OR
1.5–1.7), and increased ?increased stroke risk
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Antipsychotics
NO if you suspect DLB
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Antipsychotics
Risperidone (0.5 BID)
Olanzepine (zyprexa): 2.5–5 mg/day
Quetiapine (seroquel) Rapid titration, use in PD 12.5–200 mg/day
Clozapine Use in PD (least risk of tremor) Agranulocytosis and limited use
Ziprasidone (geodon) QT prolongation
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Prevention?
HTN and DM linked to ALL types dementiaStudies of treating systolic hypertension in the elderly (SHEPS and others): decreased risk of development of cognitive impairment in patients in treatment groupDecreased risk included vascular AND Alzheimer type dementiasCholinesterase inhibitors seem to work as well (or as poorly) for both vascular and Alzheimer type of dementiasWhat is the link? Both common, ?unmasking?
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?Link with Hyperlipidemia
Conflicting data
Retrospective studies suggest decreased risk in those patients who are treated with statins
PROSPER study 6000 patients age 70–80 with vascular risk
factors given pravastatin or placebo 3 year: no effect on cognitive function ?Long enough follow up?
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Future
Treating vascular risk factors to decrease development/unmasking of dementia?Actively seeking to differentiate different types of dementia, while alsoRecognizing significant OVERLAP of dementia etiologies in older patientsMove toward agents other than cholinesterase inhibitors?Move away from broad use of antipsychotic agents