DEMENTIA

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DEMENTIA

• Dr. O.Martinovic, SpR to
• Dr. Heller

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Cognitive ageing

• Cognitive, or thinking ability is the product of
  fixed intelligence , the result of previous
  thinking , which often increases with age i.e
  wisdom
• fluid intelligence i.e. real time information
  processing which declines modestly in old age
• Intellectual function is maintained until at
  least 80 years of age, but processing is slower.
• Non critical impairments include forgetfulness,
  reduced vocabulary, slower learning

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Impairments in cognitive function without dementia

• Age-associated memory impairment older people
  learn new information and recall information more
  slowly but their performance is unchanged
• Minimal cognitive impairment more broad that
  memory alone and felt to be pathological i.e. due
  to cerebrovascular disease, full criteria for
  dementia are not met. Progression to dementia
  occurs in 5-10 cases

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DEMENTIA

• Acquired decline in memory and other cognitive
  functions in an alert( i.e. on-delirious person)
  that is sufficiently severe to affect daily life.
• Prevalence increases dramatically with age 1
  60-65 year olds, gt 30 of over 85 year olds

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Major dementia syndromes

• Dementia of Alzheimers type( 60-70)
• Vascular Dementia ( 10-20)
• Other neurodegenerative dementias(5-10) Dementia
  with Lewy Bodies( up to 20), PDD, Frontotemporal
  dementia
• Reversible dementias ( lt 5), drugs, metabolic,
  SDH,NPH
• Mixed pathology

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History

• Take from patient and informant
• Note onset, speed of progression, symptoms
• Careful Drug History
• Progressive decline in cognitive function over
  the years, ending in complete dependency and
  death. Deterioration may be stepwise( suggesting
  vascular ethiology), abrupt (single critical CVA)
  or rapid ( weeks, months-structural, metabolic or
  drug cause)

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Deterioration occurs in

• Retention of new information, short term memory
  loss with repetitive questioning
• Managing complex tasks
• Language
• Behaviour
• Orientation
• Recognition
• Ability to self care
• Reasoning

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Physical examination

• Look for peripheral stigmata of vascular disease,
  neuropathy, PD, Thyroid disease, liver disease,
  malignancy
• Mental state
• R/O DELIRIUM features include agitation,
  restlessness, poor attention and fluctuating
  conscious level
• R/O DEPRESSION features include low affect, poor
  motivation, negative perspective. Perform
  Geriatric Depression Scale
• Measure cognitive function
• Neurophysiological assessment

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INVESTIGATIONS

• Screen for reversible causesFBC,UE,
  CRP,ESR,LFTs, B12, Ca,TSH, glucose
• Resting ECG, CXR
• Neuroimaging
• Early onset lt 60
• Sudden onset or brisk decline
• Focal neurology
• High risk of structural pathology
• CT, MRI, SPECT

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DEMENTIA-COMMON DISEASES

• ALZHEIMERS DISEASE (AD)
• Most common cause of dementia syndrome
• Insidious onset, slow progression over the years
• Early profound short term memory loss, progresses
  to include broad , global cognitive dysfunction,
  behavioural change, functional impairment
• Behavioural problems common
• Early onset AD ( lt65) is uncommon

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VASCULAR DEMENTIA

• Suggested by Risk Factors (DM, HTN, SMOKING)
• Cognitive impairment may be patchy
• Frontal lobe, pseudobulbar, extrapyramidal
  features, emotional lability common
• Urinary incontinence and falls
• Other features may be cortical mimicking AD, or
  subcortical( apathy depression)
• Onset often associated with CVA or deterioration
  may be abrupt, stepwise

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• Physical examination often shows focal neurology,
  suggesting CVA or diffuse cerebrovascular
  disease( hyperreflexia, extensor
  plantars,abnormal gait)
• Other evidence of vascular pathologyAF, PVD
• Neuroimaging shows multiple large vessel
  infarcts,single infarct( i.e. thalamus),
  periventricular white matter change

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Differentiating between Alzheimers and Vascular
Dementia

• Presentations overlap, pathologies commonly
  coexist.
• Pragmatically In cases where vascular RF's
  present, treat them aggressively whether or not
  there is significant cerebrovascular pathology on
  imaging
• A trial of cholinesterase inhibitors

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Dementia and Parkinsonism

• DEMENTIA WITH LEWY BODIES
• PARKINSONS DISEASE WITH DEMENTIA

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Dementia with Lewy bodies

• Cognitive and behavioural problems precede motor
  symptoms
• Gradual progression, insidious onset
• Fluctuations in cognitive function and alertness
• Prominent auditory and visual hallucinations,
  paranoia, dellusions
• Haloperidol poorly tolerated, Quetiapine better
• Levodopa or dopa agonists may worsen the
  confusion

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Parkinsons Disease With Dementia

• Typical motor features present
• Presentation may resemble AD, VD, DLB
• Features of PD precede dementia for more than a
  year
• Other conditions MSA, PSP, Corticobasal
  degeneration may present with both PD and dementia

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Less common diseases

• Frontotemporal dementia
• Neurodegenerative disease, insidious onset, slow
  progression,
• Early onset behavioural change, language
  difficulties, mild forgetfulness, loss of insight
• FTD spectrum frontal lobe degeneration, Picks
  disease, MND with dementia

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Normal pressure hydrocephalus

• Gait Disturbance
• Incontinence of urine
• Cognitive impairment
• Neuroimagingenlarged ventricles disproportionate
  to the degree of cerebral atrophy
• LP assess baseline gait and cognition, opening
  pressure normal, remove 20-30 mls and check for
  improvement in gait and cognition in 1-2 hrs.
• Treatment VP shunt- gait more likely to improve
  than cognition

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Other Dementias

• Drug/toxin induced alcohol, psychoactive drugs
• Infections neurosyphilis, HIV ( in the young)
• Vasculitis

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Dementia- non Drug Treatment

• Modify reversible RFs ( constipation, anaemia,
  infection)
• Encourage physical mental activity
• Treat Depression
• Simplify meds ( Dosett boxes)
• Organise carers
• Inform patient and family of legal issues
  Driving, enduring power of attorney, Wills
• Discuss end of life issues( artificial feeding,
  comfort v.s life prolongation

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Risk management

• Falls
• Wandering
• Aggression
• Self neglect
• Financial Abuse

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Role of cholinesterase inhibitors

• Donepezil
• Galantamine
• Rivastigmine
• Variable response
• Symptomatic benefit, the underlying cause
  continues to progress at the same rate
• Of the dementias, AD,DLB,PDD have the greatest
  cholinegic deficit and they benefit most
• Only in mild to moderate, not severe dementia
• Effect on the cognitive function is modest.
  However, even a small improvement in cognition
  can translate to significant improvement in
  day-to-day function, reducing carer burden

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Managing behavioural problems

• Agitation, anxiety, irritability
• trazodone-gtrisperidone-gtolanzapine
• Benzodiazepines only for brief anxiety relief
• Depression citalopram

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Prevention

• Lifestyle-physical and cognitive activity
• HRT doubles dementia risk
• NSAIDs may be protective
• Antioxidants
• Antihypertensives
• Statins

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• Thank you

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