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