Dementia

Most common neurodegenerative disease

Alzheimer’s disease

Common complaint in the elderly

Forgetfulness

In the Philippines, the workforce retire as early as ___; therefore ___ = elderly

60 = elderly

Parameters for ability to recall

1. Details of recent events or a recent conversation

2. An important appointment or telephone number

3. Forget what to do or what to say

4. Misplace personal items (e.g., wallet, money, ballpen, key, eyeglasses, handkerchief, bag…)

True/False: Those with lower economies have higher proportions of population with elderly belonging to >65 years old and above

False; higher economies

True/False: Old age is a risk for dementia

True

True/False: Dementia is a major public health issue for developing countries

True

The majority of demented elders live in less developed regions such as _______ and this proportion will increase considerably in the future

South East Asia

Brought forward to the consciousness of the medical field by a physician named

Alwa Alzheimer

First AD patient

Auguste D: first AD patient

1. 51 years old female, from Frankfurt Germany

2. Progressive cognitive impairment

3. Focal symptoms, hallucinations, delusions

4. Died within 5 years

Syndrome of cognitive decline with variable non-cognitive features of behavioral and psychiatric symptoms and disturbances in ADL

Dementia

Sustained acquired decline in intellect which interferes with an individual’s daily activities

Dementia

Dementia - Order of forgetting

Grandchildren → youngest child → oldest child → spouse → mother or father

Patients usually call out their _______ during the late stages of their disease

Parents

With the advancement of the disease, patients tend

to refer to their children as their ______

sibling

Early signs and symptoms of dementia

1. Forgetful and absent-minded (do not improve with cues)

2. Fatigue

3. Difficulty recalling familiar words

4. Difficulty learning new things

5. Deterioration in judgement and social behavior

Dementia - deterioration in judgement and social behavior

1. “Ang kulit kulit na”

2. Becoming edgy, impatient, irritable

3. Sometimes these behaviors come in before the memory problem and are mistaken for psychiatric symptoms

Cognitive stimulation is done to educate pts with dementia; has to be done during?

early stages of dementia (mild to moderate)

Dementia - Intermediate signs and symptoms

• Loss of logic, memory, motor ability

• Impatience

• Restlessness

• Physical/verbal aggression

• Speech/verbal and math skills decline

• Social skills decline

• Paranoia

Dementia - Advanced signs and symptoms

• Bladder/bowel control declines

• Difficulty following simple commands

• Hallucinations

• Emotional deterioration

• Loss of insight

• Severe motor deterioration

10 Warning Signs

/table

Dementia - Clinical Manifestations among Filipinos

• Disturbance in memory: 100%

• Indifference: 75%

• Disturbed attention: 60%

• Disturbed abstract thinking: 55%

• Disorientation: 53%

• Acalculia/poor judgement: 52%’

• Apraxia: 50%

• Aphasia: 37%

• Personality change: 18%

• Delusion/hallucination: 13%

Normal Aging vs Dementia

/table

Differential Diagnosis of Dementia

• Alzheimer’s disease: most common differential diagnosis (64%)

• Vascular dementias and AD: 10%

• Dementia with Lew bodies, Parkinson’s dementia, Diffuse Lewy body disease: 9%

• Lewy body variant of AD, AD and dementia with Lewy bodies: 6%

• Other dementias (Frontotemporal dementia, Corticobasal degeneration, Progressive supranuclear palsy, Huntington’s disease, Creutzfeld-Jacob disease): 6%

• Vascular dementias, multi-infarct dementia: 5%

Causes of Dementia

• Alzheimer’s disease: 60%

• Cerebrovascular disease: 19%

• AD with infarcts: 16%

• Others: 5%

  • Chronic. Subdural hematoma, slow-growing tumor, NPH

Most common cause of dementia in the elderly

Alzheimer’s Disease

Average duration of Alzheimer’s Disease

8-11 years

Alzheimer’s prevalence doubles every ______

5 years from 6-8% at 65 years

AD Risk Factors - Age

genetic change in age, environmental factors, lifestyle factors

AD Risk Factors - Gender

Females > males

AD Risk Factors - Ethnicity

• cross natural differences; genetics; sociocultural background

• Ex: cumulative incididence at the age of 80

  • Hispanics = 38%

  • Blacks = 28%

  • Whites = 14%

  • Asians = 15-20%

AD Risk factors - co- morbid conditions

Brain infarction, myocardial infarction

AD Risk Factors - Life Events

• China: positive association especially bereavement

• All others: lack of association

• Depression sets the tone for development of dementia

AD Risk Factors - whole list

1. Age

2. Gender

3. Ethnicity

4. Education

5. Occupation

6. Head trauma

7. Co-morbid conditions

8. Life events

Aging and AD

• Age is the most important risk factor for dementia

  • Age 65+ (up to 12%)

  • Age 75+ (up to 23%)

  • Age 85+ (up to 47%)

• Increased metabolic stress, transcription errors (nuclear and mitochondrial), abnormal protein folding, altered cellular homeostasis, comorbidities

Brain Battering Hypothesis

People with lower education in multiple cultures have higher dementia prevalence, “brain-battering hypothesis

Neuroimaging and prospective data suggest adult education also enhances ___________

“cognitive reserve”

Clinical Features of AD - Early Cognitive

• Memory

  • Poor recall of new information

• Language

  • Dysnomia

  • Mild loss of fluency

• Visuaospatial

  • Misplace objects

  • Difficulty driving

Clinical Features of AD - Early Behavioral

• Delusions

• Depression

• Insomnia

Clinical Features of AD - Early Neurologic

• abnormal face- hand teat

• Frontal release signs

Clinical Features of AD - Intermediate Memory

Remote memories affected

Clinical Features of AD - Intermediate Language

• Nonfluent, paraphasias

• Poor comprehension

• Impaired repetition

Clinical Features of AD - Intermediate Visuospatial

• Getting lost

• Difficulty copying figures

Clinical Features of AD - Intermediate Behavioral

• delusions

• Depression

• Agitation

• Insomnia

Clinical Features of AD - Intermediate Neurologic

• Abnormal face-hand test

• Agraphesthesia

• Frontal release signs

Clinical Features of AD - Late Cognitive

• Memory: Untestable

• Language: Near-mutism

• Visuospatial: Untestable

Clinical Features of AD - Late Behavioral

• agitation

• Wandering

Clinical Features of AD - Late Neurologic

• Incontinence

• Frontal release signs

• Rigidity

• Loss of gait

• ± myoclonus

DMS-IV Diagnostic Criteria for Dementia of the Alzheimer’s Type

• Gradual, progressive decline in memory plus

• One or more of the following:

  • Aphasia

  • Apraxia

  • Agnosia

• Executive function disturbance

• Significant impairment in social/occupational functioning and represent a significant decline from a previous level of functioning

• Not due to delirium, drugs or medical/psychiatric/neurological disorder

NINCDS-ADRDA Criteria for Alzheimer’s Disease

• Dementia by clinical examination, MMSE, n/p tests

• Deficits in 2 or more areas of cognition

• Progressive worsening of memory and other cognitive functions

• No disturbance in consciousness

• Onset between 40-90 years

• Absence of systemic disorders or brain disease

• Supported by: (+) FH of similar disorder, impaired ADL and altered behavior, cerebral atrophy on neuroimaging

Atypical Features suggesting Non-Alzheimer Dementia - Onset and course of the dementia

• Onset before age 60

• Sudden rather than insidious onset

• Occurrence of marked cognitive fluctuation

• Subacute or rapidly progressive course

Atypical Features suggesting Non-Alzheimer Dementia - Psychiatric and behavioral symptoms

• Disinhibited behavior

• Marked apathy

• Kluver-Bucy syndrome: individuals having behavioral problems (affected temporal lobe)

• Putting objects in mouths

• Engaging in inappropriate sexual innuendos and behavior)

• Visual agnosia

• Becoming fearless

• Irritable

• Memory loss

• Visual hallucinations