Clin Med - Dementia

what is the definition of dementia?

ACQUIRED syndrome of decline in memory and other cognitive sufficient to affect ADLs in an ALERT patient

• progressive and disabling

• NOT an inherent aspect of aging, delirium, depression, normal cognitive lapses

what are basic ADLs? (DEATHS)

• dressing

• eating and feeding (including setting up food and bringing it to the mouth)

• ambulation

• toileting

• hygiene

• sexual activity

what are instrumental ADLs? (SHAFFTTT)

not necessary for fundamental functioning but allow independent living

• shopping for groceries or clothing

• housework

• accounting

• food preparation

• farmaceuticals

• technology

• telephone

• transportation

assessment: physical examination for dementia

• neurologic status (ESP hearing!)

• mental status

• functional status

• includes quantified screens for cognition (MMSE) and neuropsych testing (must r/o depression)

what are the 4 cognitive domains?

recent memory, language, visuospatial ability, executive function (1 or more)

what is visuospatial ability?

comprehension and effective manipulation of nonverbal, graphic, or geographic information

what is executive function?

ability to plan, perform abstract reasoning, solve problems, focus despite distractions, and shift focus when appropriate

what is the mini-cog test?

• 3 minute instrument to screen for cognitive impairment in older adults

• 3 item recall test for memory and a simply scored clock-drawing test (CDT)

• detects mild cognitive impairment (cognitive impairment too mild to meet diagnostic criteria) (oversensitive)

what is the grading for the mini-cog?

if recall 0 = demented

if recall 1-2, if clock abnormal = demented, if clock normal = nondemented

recall 3 = nondemented

what do you need to do before making a diagnosis of any form of dementia?

rule out metabolic causes, so do a metabolic test

what is the routine metabolic testing utilized when ruling out metabolic causes?

• CBC

• NA+, CA++, MG+++

• BUN/Cr

• fasting glucose

• RPR

• TSH

• vitamin B12 level

• urine culture

what are some optional tests used to rule out metabolic causes from dementia?

• toxicology*

• ammonia level*

when do you consider brain imaging in someone with dementia?

• presence of normal-pressure hydrocephalus

• recent fall

• onset occurs <65 y/o

• neurologic signs are asymmetric/focal

what is normal-pressure hydrocephalus triad? signs: wobbly, wet, wacky

syndrome of dilated brain ventricles with normal CSF pressure, ataxia, and urinary continence, dementia

what are options for brain images?

• noncontrast CT head scan

• MRI

• PET

what does normal aging look like?

• “senior moments”

• no consistent, progressive deviation on testing or memory

• some decline in processing

• reminders are affected

• ADLs are intact

what does mild cognitive impairment look like?

• subjective complaint of decline in at least one cognitive domain

• is a risk factor for developing dementia (but normal aging is not)

• no impairment in independent living

• 50% of MCI maintain a stable level of impairment or return to normal in 3-5 yr

what are overlapping symptoms of dementia vs. delirium?

• hallucinations

• impaired attention

• confusion

• alteration of sleep cycles (insomnia is a cause of delirium, but is a result of dementia)

• occurs together in older hospitalized/institutionalized patients

what are distinguishing signs of delirium?

• acute onset

• fluctuations in cognition over hours or days

• impaired level of consciousness (patients with dementia appear alert)

• evidence of a metabolic cause

what is the overlap of symptoms between dementia and depression?

• impaired concentration

• loss of interest in usual activities/hobbies

• psychomotor retardation - slowing of spontaneous thoughts and movements

• alterations in sleep cycle (pts w/ dementia have insomnia, insomnia is typical of depression but pts with depression also might have HYPERsomnia, which is atypical symptom of depression)

what is different in primary depression vs. dementia?

• demonstrate dec motivation during cognitive testing

• express cognitive complaints that exceed measured deficits

• maintain lang and motor skills despite dec motivation (whereas pt with dementia typically has high motivation and wants to show that they’re “ok” but their testing is worse)

what is the one symptom that is common between dementia, delirium, and depression?

sleep disorders

commons between delirium and dementia

hallucination and confusion

what is the timeline of alzheimer’s dementia?

gradual onset and progressive decline

what are the cognitive symptoms of alzheimer’s dementia?

memory impairment is the CORE feature and the EARLIEST feature

• early: difficutly learning new info and retaining for few mins

  • late: unable to access older memories, disorientation, impaired judgement, impaired executive function

what are the motor and sensory symptoms of alzheimer’s dementia?

seen very late in illness: apraxia, aphasia, visuo-spatial dysfunction

what are some symptoms that may occur (or occurs later?) for alzheimers

• hallucinations

• extrapyramidal signs (motor) occurs late characterized by bradykinesia and rigidty (do NOT usually develop tremors)

on lab tests and neurologic exam, how does someone with alzheimer’s dementia perform?

normal

what might you see on imaging in alzheimer’s dementia?

global atrophy (cortex has shrunken), small hippocampal volumes

what are risk factors for alzheimer’s dementia?

top 2: age and family history

APOE4 allele

down syndrome

possible: trauma, less education, depressive disorder, CV RF

what are some possible protective factors for alzheimer’s dementia?

• NSAIDs

• antioxidants

• intellectual activity

• physical activity

• statins

by 90 years of age, nearly ___ of people who have 1st degree relatives with AD develop the disease themselves

half

what is vascular dementia?

2nd most common type

coexists with AD cases 15-20% of the time “mixed dementia”

what is the onset of vascular dementia (multi-infarct dementia)?

sudden or gradual

what is the progression of vascular dementia (multi-infarct dementia)?

stepwise with further ischemia

what are the cognitive symptoms of vascular dementia (multi-infarct dementia)?

depends on ischemia but trouble with executive function is common

what can vascular dementia (multi-infarct dementia) be associated with?

sensory or motor symptoms

correlates with region of ischemia

lab tests of vascular dementia (multi-infarct dementia)??

normal

what would you see on imaging for vascular dementia (multi-infarct dementia)?

cortical/subcortical ischemic changes/infarcts on MRI

what is lewy body dementia?

3rd most common type, lewy inclusion bodies seen in cortex and subcortical region (more common than parkinson’s)

what is the onset of lewy body dementia?

gradual, progression is gradual but usually faster than AD

what are symptoms of lewy body dementia?

dementia and at least 2 of the following (tend to fluctuate):

1. visual hallucination

2. parkinsonian signs

3. fluctuating alertness/attention

what are additional distinguishing features of lewy body dementia?

• autonomic dysfunction

• sleep disorders

• psych syndromes like hallucinations/delusions

• visuo-spatial deficits are often out of proportion to other cognitive deficits

delusions can have a stimulus, unlike ___, which there is none

hallucinations

what is the memory impairment of lewy body dementia?

begins in early stages but not as pronounced compared to deficits in attention, executive function, and visuo-spatial ability

what are the motor symptoms of lewy body dementia?

parkinsonism

lab tests of lewy body dementia?*

normal*

imaginging of lewy body dementia?

global atrophy possible

parkinson’s disease often looks similar to what?

lewy body dementia, and also parkinson’s dose have lewy bodies

if you see lewy bodies at the base of brain, problems with?

movement (motor symptoms) and autonomics, main feature of parkinson’s disease

if lewy bodies in the outer layer of the brain are linked to problems with?

mental abilities (cognitive symptoms), bigger feature of FB dementia

what is frontotemporal dementia (pick’s disease)?

uncommon, not much memory loss, RARE, young <60, rarely associated with ALS

what are cognitive symptoms of frontotemporal dementia (pick’s disease)?

executive, lang, and behavioral dysfunction (disinhibition, social impropriety, hyperorality, compulsiveness)

what is the most frequent cause of frontotemporal dementia (pick’s disease) and ALS?

non-coding repeat expansion of C9ORF72 gene

what would you see on imaging of frontotemporal dementia (pick’s disease)?

atrophy in frontal and temporal lobe

if parkinson’s disease is present for 1+ year before cognitive symptoms are seen, the diagnosis is?

parkinson’s disease w/ dementia

if parkinsonian symptoms present <1 yr at the same time or after onset of cognitive symptoms, diagnosis is?

lewy body dementia

alzheimer’s vs. parkinson’s

alzheimers: motor deficits late into illness. bradykinesia present but no tremor

parkinson’s has tremor

what is huntington’s dementia characterized by?

choreiform movement, but not tremor

cognitive impairment occurs late

inheritance is RF

what are most neurodegenerative disorders associated with?

accumulations of proteins

what protein is found in huntington’s dementia?

huntingtin protein

what proteins are found in alzheimer’s?

• amyloid plaques

• neurofibrillary tau protein tangles

• ubiquillin-1

what proteins are found in lewy body and parkinson dementia?

cytoplasmic a-synuclein inclusion bodies (lewy bodies)

what protein is found in frontotemporal dementia?

tau or ubiquilin-2

what are nonpharm management of dementia?

• physical activity

• family and caregiver education and support

• attention to safety: supervision, wandering, driving

• orientation and memory aids

what are pharm management for dementia?

cholinesterase inhibitors, NMDA receptor antagonists, antidepressants, psychoactive meds