Dementia - PowerPoint PPT Presentation

Loading...

PPT – Dementia PowerPoint presentation | free to download - id: 599e7-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Dementia

Description:

Dementia is a symptom of disease rather than a single disease entity! ... Clinical features of stroke profile hypertension, diabetes, etc. are present. ... – PowerPoint PPT presentation

Number of Views:766
Avg rating:3.0/5.0
Slides: 26
Provided by: cho46
Learn more at: http://www.med.muni.cz
Category:
Tags: dementia

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Dementia


1
Dementia
2
Dementia
  • Progressive deterioration of intellect,
    behavior and personality as a consequence of
    diffuse disease of the brain hemispheres,
    maximally affecting the cerebral cortex and
    hippocampus.
  • Dementia is a symptom of disease rather
    than a single disease entity!!!

3
  • Memory must be impaired to make the diagnosis of
    dementia.
  • Loss of memory for recent events is the earlist
    feature of dementia.
  • Subsequent symptoms include abnormal behavior,
    loss of intellect, mood changes, and difficulty
    coping with ordinary routes.
  • Insight may be retained initially, but is then
    usually lost.
  • Ultimately, there is loss of self-care,
    wandering, incontinence, and often paranoia.

4
  • Dementia has to be distinguished from delirium
    which is an acute disturbance of cerebral
    function with impaired conscious level,
    hallucinations and autonomic overactivity as a
    consequence of toxic, metabolic or infective
    conditions.
  • Depression can mimic the initial phases of
    dementia and it is termed pseudodementia (which
    is amenable to antidepressant medication).

5
  • Dementia may occur at any age but is more common
    in the elderly, accounting for 40 of long-term
    psychiatric in-patients over the age of 65 years.
  • The prevalence in persons aged between 50 and 70
    years is about 1 and in those approaching 90
    years reaches 50.
  • An annual incidence rate is 190/100 000 persons.

6
  • Clinical course
  • The rate of progression depends upon the
    underlying cause.
  • The duration of history helps establish the cause
    of dementia Alzheimers disease is slowly
    progressive over years, whereas encephalitis may
    be rapid over weeks. Dementia due to
    cerebrovascular disease appears to occur stroke
    by stroke.

7
Dementias classificationBased on cause
  • Alzheimers disease (60 of all dementias)
  • Cerebrovascular (multiinfarct state, subcortical
    small vessel, amyloid angiopathy,) (20)
  • Neurodegenerative (DLB, Picks disease,
    Huntingtons chorea, Parkinsons disease)
  • Infectious (Creutzfeld-Jakob disease, HIV
    infection, progressive multifocal
    leucoencephalopathy)
  • Normal pressure hydrocephalus
    TREATABLE!
  • Nutritional (thiamine deficiency in alcoholics!,
    B12 deficiency, folate deficiency)
  • Metabolic (hepatic disease, thyroid d.,
    parathyroid d., Cushings syndrome)
  • Chronic inflammatory (MS, )
  • Trauma (head injury, Punch drunk syndrome)
  • Tumour (e.g. subfrontal meningioma)

8
Dementias classificationBased on site
9
Dementias history and clinical examination
  • When obtaining a history from a demented person
    and relative, establish rate of intellectual
    decline, impairment of social function, general
    health and relevant disorders (e.g. stroke, head
    injury), nutrition status, drug history, family
    history of dementia.
  • Tests to assess intellectual function are
    designed to check memory, abstract thought,
    judgement, specific focal cortical functions.
  • The Mini Mental State Examination (MMSE)
  • On neurological examination note focal signs,
    involuntary movements, pseudobulbar signs, gait
    disorder.

10
Dementias further investigation
  • Blood tests (to exclude hypothyroidism, vitamin
    B12, thiamine and folate deficiency, Lyme
    disease, HIV infection, metabolic disorders and
    inflammatory diseases).
  • Cranial imaging (CT or/and MRI) (tu, NPH)
  • PET and SPECT?
  • EEG (slowing in AD, normal in pseudodementia,
    periodic complexes in CJD)
  • Genetic testing (rarely Huntington mutation,
    apolipoprotein E4 mutation in AD)
  • Brain biopsy (if treatable cause is suspected)

11
Alzheimer's disease
  • The commonest cause of dementia.
  • The disorder rarely occurs under the age of 45
    years.
  • The incidence increases with age.
  • The cause of AD is not known (neurodegenerative
    d.).
  • Up to 30 of cases are familial (the loci were
    found on chromosome 21 and 19).
  • Pathology the presence of senile plaques and
    neurofibrillary tangles in the brain.
  • Diagnosis of AD may be established during life by
    early memory failure, slow progression and
    exclusion of other causes.

12
Alzheimer's disease
  • CT scanning aids diagnosis by excluding multiple
    infarction or a mass lesion.
  • MRI shows bilateral temporal lobe atrophy.
  • SPECT usually shows temporoparietal
    hypoperfusion.

13
Alzheimer's disease - treatment
  • - Acetylcholinesterase inhibitors (Donepezil
    Aricept, Rivastigmine Exelon, Galantamine
    Reminyl) have been shown to enhance cognitive
    performance in early disease. Memantine Ebixa,
    Axura, Namenda is approved for moderate disease.
    However they do not cure!
  • Treat concurrent depression, anxiety and sleep
    disorders. Neuroleptic use may be required for
    behavioral disturbance.
  • Mangement of AD requires careful advice and
    counseling of the patient and family and shared
    care involving the family, caregivers, GPs,
    hospital specialist, and community psychiatric
    services.
  • Long-term residential care is ofte required.

14
Multi-infarct dementia (MID)
  • This is an overdiagnosed condition which accounts
    for less than 10 of cases of dementia.
  • MID is caused by multiple strokes - SILENT
    STROKES
  • Dementia occurs stroke by stroke, with
    progressive focal loss of function.
  • Clinical features of stroke profile
    hypertension, diabetes, etc. are present. More
    often in males.
  • Diagnosis is obtained from the history
    and confirmed by CT or MRI scan
    (the presence of multiple areas of
    infarction).
  • Treatment Maintain adequate blood
    pressure control, anti-platelet
    aggregants (aspirin).

15
Frontotemporal dementia (Pick's disease)
  • This progressive condition accounts for 5 of all
    dementias.
  • Usually sporadic, it more commonly affect women
    between 40 and 60 years.
  • Personality and behaviour are initially more
    affected than memory.
  • Frontal lobe dysfunction predominates with
    apathy, lack of initiative and personality
    changes.
  • CT or MRI scans show frontal (and/or temporal)
    atrophy, often asymmetrical.
  • SPECT reveal anterior hypoperfusion, EEG is
    usually normal.
  • The disorder is characterized pathologically by
    argyrophylic inclusion bodies within the
    cytoplasm of cells of the frontotemporal cortex.
  • There is no treatment, death occuring within 2-3
    years of the onset.

16
Primary progressive aphasia
  • This condition is one of a group of disorders
    characterized by asymmetrical cortical
    degeneration.
  • Dominant hemisphere perisylvian atrophy is
    associated with loss of language, which, after
    many years, becomes a more widespread dementia.
  • Pathologically non-specific cell loss, Picks
    pathology or spongiform changes are described.
  • MRI and SPECT confirm focal changes.

17
Dementia with Lewy bodies (DLB)
  • One of the most common types of progressive
    dementia.
  • Progressive cognitive decline, combined with
    three additional defining features  (1)
    pronounced fluctuations in alertness and
    attention (2) recurrent visual hallucinations,
     and (3) parkinsonian motor symptoms, such as
    rigidity and the loss of spontaneous movement. 
  • The symptoms of DLB are caused by the build-up of
    Lewy bodies accumulated bits of alpha-synuclein
    protein - inside the nuclei of neurons in areas
    of the brain that control particular aspects of
    memory and motor control. Lewy bodies are often
    also found in the brains of people with
    Parkinson's and Alzheimers diseases.These
    findings suggest that either DLB is related to
    these other causes of dementia or that an
    individual can have both diseases at the same
    time. 
  • DLB usually occurs sporadically, in people with
    no known family history of the disease. However,
    rare familial cases have occasionally been
    reported.

18
Normal pressure hydrocephalus
  • term applied to the triad of
  • Dementia
  • Gait disturbance
  • Urinary incontinence
  • occuring in conjunction with hydrocephalus and
    normal CSF pressure.
  • Two types
  • NPH with a preceding cause (SAH, meningitis,
    trauma, radiation-induced).
  • NPH with no known preceding cause idiopathic
    (50).

19
Normal pressure hydrocephalus
  • Aetiology is unclear.
  • It is presumed that at some preceding
    period, impedence to normal SCF flow causes
    raised intraventricular pressure and ventricular
    dilatation. Compensatory mechanisms permit a
    reduction in CSF pressure yet the ventricular
    dilatation persists and causes symptoms.

20
Normal pressure hydrocephalus
  • Diagnosis is based on clinical picture
    plus CT scan/MRI evidence of ventricular
    enlargement.
  • NPH must be differentiated from pts whose
    ventricular enlargement is merely the result of
    shrinkage of the surrounding brain, e.g. AD.
    These pts do not respond to CSF shunting, whereas
    a proportion of NPH pts (but not all) show a
    definitive improvement with ventriculo-peritoneal
    shunting.

21
AIDS dementia complex
  • Approximately two-thirds of persons with AIDS
    develop dementia, mostly due to AIDS dementia
    complex.
  • In some patients HIV is found in the CNS at
    postmortem. In others an immune mechanism or an
    unidentified pathogen is blamed.
  • Dementia is initially of a "subcortical " type.
  • CT - atrophy MRI - increased T2 signal from
    white matter.
  • Treatment with Zidovudine (AZT) halts and
    partially revers neuropsychological deficit.

22
Trauma
  • Reduction of intellectual function is common
    after severe head injury.
  • Chronic subdural haematoma can also present as
    progressive dementia, especially in the elderly.
  • Punch-drunk encephalopathy (dementia pugilistica)
    is the cumulative result of repeated cerebral
    trauma. It occurs in both amateur and
    professional boxers and it manifests by
    dysarthria, ataxia and expy signs associated with
    subcortical dementia. There is no treatment for
    this progressive syndrome.

23
Tumour
  • Dementia rarely may be due to intracranial
    tumour, especially when tumours occur in certain
    anatomical sites.
  • Mental or behavioral changes occur in 50-70 of
    all brain tumours as distinct from dementia which
    is associated with frontal lobe tumours, III
    ventricle tumours and corpus callosum tumours.
  • Cognitive impairment also occurs as a non
    metastatic complication of systemic malignancy.

24
Dementia diagnostic approach
25
Mild cognitive impairment (MCI)
  • MCI is a relatively recent term, used to describe
    people who have some problems with their memory
    but do not actually have dementia.
  • Some people (80?) will be in the early stages of
    Alzheimers disease or another dementia. Others,
    however, will have MCI as a result of stress,
    anxiety, depression, physical illness or just an
    off day.
  • It is estimated that 15 of the population may be
    experiencing MCI.
  • Currently extensive research on MCI is ongoing.
  • At the moment there is not enough evidence to
    recommend any specific treatments.
About PowerShow.com