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DEMENTIA

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Dementia Learning Objectives: Define dementia Describe the common dementias in the elderly Differentiate the issues of reversibility, comorbidity, ... – PowerPoint PPT presentation

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Title: DEMENTIA


1
DEMENTIA
Michael J. Mintzer, MD Associate Professor of
Medicine University of Miami School of
Medicine Director of Community Academic
Partnerships Miami VAMC and GRECC
2
Dementia
  • Learning Objectives
  • Define dementia
  • Describe the common dementias in the elderly
  • Differentiate the issues of reversibility,
    comorbidity, and arrestability
  • Describe the current dilemmas in the
    pharmacological treatment of dementia

3
Dementia
  • Definition
  • A The development of multiple cognitive deficits
    manifested by both
  • (1) Memory impairment (impaired ability to learn
    new information or to recall previously learned
    information)
  • (2) One or more cognitive disturbances
  • (a) aphasia (language disturbance)
  • (b) apraxia (impaired ability to carry out
    motor activities despite intact motor
    function)
  • (c) agnosia (failure to identify objects
    despite intact sensory function)
  • (d) disturbance in executive functioning
    (planning, organizing, sequencing,
    abstracting, etc.)

4
Dementia
  • Definition
  • B The cognitive deficits in Criteria A1 and A2
    each cause significant impairment in social or
    occupational functioning and represent a
    significant decline from previous level of
    functioning
  • C Features specific to the clinical presentation
    of (1) Alzheimer's Disease, or (2) vascular
    disease, or (3) other general medical condition,
    or (4) the persisting effects of a substance, or
    (5) multiple etiologies or (6) "not otherwise
    specified.
  • D,E,F The cognitive deficits in Criteria A1 and
    A2 are not due to a different specific illness
    (i.e., a different form of dementia, delirium or
    psychiatric illness).

5
Dementia
  • Etiologies
  • Degenerative (Alzheimers, Lewy body,
    Parkinsons)
  • Vascular (MID, large stroke, vasculitis,
    Binswangers)
  • Metabolic (hypothyroid, B12 deficiency)
  • Infectious (AIDS, Syphilis, late post TB)
  • Hypoxic (s/p CPR, s/p anesthesia?, s/p RT?)
  • Toxic (heavy metal)
  • Intracranial lesion (mass)
  • Trauma (dementia pugilistica)

6
Dementia
  • Most Common Causes of Dementia in the Elderly
  • Alzheimers disease (AD)(50-60)
  • Diffuse Lewy body disease (DLBD)(15-20)
  • Vascular dementia (VD)(15-20)
  • Parkinsons dementia (1-3)
  • Frontotemporal dementia (1-2)
  • All other

In the past, DLBD was included in this category.
In addition, up to 10 of dementias are mixed AD
plus VD
7
Dementia
  • Reversible or not!
  • The definition does NOT define permanence of the
    lesion (pseudodementia?)
  • Data suggests there are very few reversible
    dementias in the elderly (depression, chronic
    intoxication by medication, hypothyroidism)
    (Larson)
  • Co-morbid conditions account for most of the
    reversibility in dementia in the elderly (Larson)
  • Arrestable or Remediable may be better terms
    (Maletta)

8
Dementia
  • Minimum Cognitive Impairment (MCI)
  • Definition
  • What do we do with it?

9
Dementia
  • Clinically helpful EARLY clues
  • Alzheimers Memory
  • Diffuse LBD Attention, Exec Func, Visio-spatial
  • Vascular Focal signs, temporal relationship
  • FT / Picks Behavioral, social skills, hygiene
  • Parkinsons Dementia does NOT occur early in
  • Parkinsons disease

10
Dementia
  • Alzheimers disease
  • Deposition of beta-amyloid in senile plaques
    diffusely in the brain, often around blood
    vessels
  • Neurofibrillary tangles
  • Loss of neurons
  • Brain shrinkage especially cortex

11
Alzheimers Risk Factors
  • Age
  • Prevalence doubles every 5 years after age 60
  • Family History
  • Fourfold increase risk overall. The presence of
    the ApoE4 allele increases risk but is not
    predictive.
  • Gender
  • Woman probably more than men
  • Head Trauma
  • Repeated, especially in men
  • Downs Syndrome
  • Characteristic brain pathology by age 40
  • Educational Level / Mental Activity

12
Risk Factors (continued)
  • Estrogen plus progesterone
  • Doubles risk of dementia
  • Environment ?
  • Hypertension ?
  • Elevated Cholesterol ?
  • Depression ?

13
Dementia
  • Medications for Alzheimers disease
  • Acetylcholinesterase inhibitors indicated for
    mild to moderate dementia. Increases
    acetylcholine in synapses
  • Memantine (Namenda?) indicated for moderate to
    severe dementia and used with ACI. Selective
    blocks the excitotoxic effects of glutamate while
    allowing the physiologic transmission for normal
    cell function

14
Acetylcholinesterase inhibitors
  • Do they work when they work?
  • Using family fewer problem behaviors
  • Using NH placement save 2 yrs
  • Using metrics (MMSE) - minimal incremental
    improvement

15
Memantine
  • Works for moderate to severe
  • Works alone
  • Works with ACI

16
Alzheimers Disease
  • What else works?
  • Vitamin E
  • Statins?

17
Factors Contributing to Aßs
Aßs
24S-OH cholesterol cerebrocholesterol
cholesterol
ApoE4
Aging
inflammation
LRP
APP
CNS growth/repair
Adapted from Hazzard 2004 AGS annual meeting
18
Cholesterol Alzheimers
  • In human studies there are more ß-amyloid plaques
    in patients dying from heart disease than from
    other causes (Sparks 1991)
  • Cholesterol gt240 between age 40-50 predicted
    higher AD risk 30 years later (Notkolo 1998)
  • In animal studies, rabbits fed high cholesterol
    diet led to plaques that regressed when
    cholesterol was removed
  • What do we do with our effective cholesterol
    lowering drugs?

Adapted from Hazzard 2004 AGS annual meeting
19
Cholesterol Alzheimers
  • Its too early to recommend adding statins for
    the treatment of Alzheimers
  • We need well controlled studies across the
    spectrum of dementia

Adapted from Hazzard 2004 AGS annual meeting
20
Lets Add to the Confusion
  • ACI and memantine(?) might work for vascular
    dementia, too ! ! !

21
Summary
  • Dementia is easy to diagnose
  • There are features that help differentiate the
    common dementias in the elderly
  • Reversible dementias are uncommon in the elderly
    but many dementias are arrestable
  • Treating comorbid conditions allows those with
    dementia to function at their best
  • Current drugs used for Alzheimers may help
    vascular dementia as well
  • Vitamin E is worth a try but not statins
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