Dementia

Front 1

Definition of Dementia

Back 1

Must have impairments in 2 of the following areas of cognitive function: (1) Memory and learning; (2) Abstract thinking; (3) Complex thinking and executive function; (4) Visuospatial abilities; (5) Language

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The Usual Pattern of AD

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(1) Starts in hippocampus and temporal lobes (memory impairment and naming/language); (2) Then affects parietal lobes (visuospatial function, calculations, orientation in space); (3) Later in disease course frontal lobes (executive dysfunction); (4) Personality changes subtle – loss of insight, loss of initiative; (5) Later in disease can develop paranoia, behavioral difficulties, hallucinations, parkinsonism, myoclonus, seizures

Front 3

Normal Aging versus AD

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NORMAL AGING: Memory losses are 'retrieval' deficiencies; Retained insight; No ADL changes; minor delay in word finding; visuospatial/social engagement intact; ALZHEIMER'S DISEASE: Anterograde amnesia; insight lost; ADLs compromised, anomia, visuospatial impaired, apathy, withdrawal

Front 4

Mild Cognitive Impairment

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(1) An isolated cognitive impairment without concomitant decline in function. (2) Usually memory (amnestic MCI) but can be language or visuospatial (nonamnestic MCI) or multidomain MCI; (3) Amnestic MCI is usually a precursor to AD. Other types of MCI may or may not progress to AD or another form of dementia.

Front 5

Treatment of AD

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(1) Cholinesterase inhibitors - Donepezil, Galantamine, Rivastigmine; (2) NMDA partial antagonist - Memantine

Front 6

FTD vs. AD

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FTD: younger onset, family history, progression of disease is more rapid; Nucleus Basalis of Meynert is not affected, so Pts with FTD do not benefit from Aricept; management of FTD more difficult, requires more mood and behavioral management

Front 7

Dementia with Lewy Bodies

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Intracytoplasmic neuronal inclusions alpha-synuclein & ubiquitin; Brain stem nuclei (SN, LC, dorsal vagus), nucleus basalis of Meynert, hypothalamus, sympathetic ganglia, cortex (paler) and fewer and limbic structures; Second most common degenerative dementia (approximately 25% from community series)

Front 8

DLB: diagnosis

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Central feature essential for diagnosis = dementia; Memory may not be impaired early; Attention, executive function, and visuospatial function are most affected

Front 9

Core features of DLB

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(1) Fluctuating cognition with pronounced variations in attention and alertness; (2) Recurrent visual hallucinations are typically well formed and detailed; (3) Spontaneous features of Parkinsonism

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Suggestive and Supportive features of DLB

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(1) REM sleep behavior disorder; (2) SEVERE neuroleptic sensitivity; (3) Autonomic features - falls, syncope, orthostasis, urinary incontinence; (4) Hallucinations in other modalities; (5) Systematized delusions; (6) Depression

Front 11

Temporal sequence of symptoms

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(1) DLB should be diagnosed when dementia occurs before or concurrently with Parkinsonism - generally defined as within 1 year of each other

Front 12

Treatment of DLB

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(1) Cholinesterase inhibitors - may work better than in AD; (2) Parkinsonism symptoms - Sinemet; avoid dopamine agonists b/c of high rate of visual hallucinations; (3) Hallucinations and other psychotic symptoms - treat with atypical antipsychotics - quetiapine (seroquel). 50% of DLB patients are VERY SENSITIVE TO NEUROLEPTICS and may DIE FROM SMALL DOSE OF TYPICAL NEUROLEPTICS FOR AGITATION!

Front 13

Subcortical Dementias

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MS, PD, Wilson's Disease, Huntington's disease, HIV dementia, NPH, Diffuse ischemic white matter disease

Front 14

Normal Pressure Hydrocephalus

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Clinical Triad – Dementia, gait disturbance, bladder dysfunction. SLOPPY D's!

Front 15

Multi-infarct dementia

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Multiple cortical or sub-cortical strokes that has a mosaic of deficits

Front 16

Stroke Dementia

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One stroke strategically located results in cognitive deficits that meet criteria for dementia

Front 17

Diffuse white matter disease, aka subcortical leukoencephalopathy aka Binswanger disease

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(1) Subcortical dementia with chronic progressive pattern; (2) Sometimes in conjunction with lacunar strokes but usually confluent white matter changes; (3) Hallmark is attention and concentration deficit with psychomotor slowing

Front 18

Management of Vascular Dementia

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Benefit from cholinesterase inhibitors - if stop vascular disease, stabilizes the dementia

Front 19

Delirium vs. Dementia

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Acute onset, impaired attention, hallucinations COMMON in delirum;