Approach to dementia

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Approach to dementia

  1. 1. APPROACH TO DEMENTIA Guide: DR.PARIDHI SHIVDE Canditate: DR.SARATH MENON .R DEPARTMENT OF NEUROLOGY, MGM MEDICAL COLLEGE ,INDORE.
  2. 2. DEMENTIA- “OUT OF ONE’S MIND”  DEMENTIA- the disease with acquired deterioration in cognitive/ intellectual abilities without impairment of consciousness  Cognitive deficit represent a decline from previous level of functioning
  3. 3. DSM – IV – DIAGNOSTIC CRITERIA 1. Memory impairment 2. At least one of the following:  Aphasia  Apraxia  Agnosia  Disturbance in executive functioning 3. Disturbance in 1 and 2 interferes with daily function 4. Does not occur exclusively during delirium
  4. 4. EPIDEMIOLOGY  ~ 5 to 8 % at age 65 to 70  ~ 15 to 20 % at age 75 to 80  up to 40 to 50 % over age 85 • Alzheimer's disease is most common dementia  50-75% • Dementia with Lewy bodies  15 to 35 % • Vascular dementia  5 – 20 %
  5. 5. ETIOLOGY NEURO- DEGENERATIVE Alzheimer's Ds; Dementia with Lewy Bodies; Fronto- temporal dementia; Parkinson’s Ds VASCULAR Infarction; Hemodynamic insufficiency NEUROLOGICAL Multiple Sclerosis; Normal Pressure Hydrocephalus ENDOCRINE Hypothyroidism NUTRITIONAL Def. of Vit. B12, Thiamine, Niacin INFECTIOUS HIV; Prion Ds; Neurosyphilis; Cryptococcus METABOLIC Hepatic/ Renal Insufficiency; Wilson’s Ds TRAUMATIC Subdural Haematoma; Dementia pugilistica TOXIC AGENTS Alcohol; Heavy Metals; Anticholinergic Med; CO
  6. 6. CORTICAL VS. SUBCORTICAL DEMENTIA Cortical  Symptoms: major changes in memory, language deficits, perceptual deficits, praxis disturbances,lack of extrapyramidal features  Affected brain regions: temporal cortex (medial), parietal cortex, and frontal lobe cortex  Examples: Alzheimer’s disease, diffuse Lewy body disease, vascular dementia, frontotemporal dementias
  7. 7. Subcortical  Symptoms: behavioral changes, impaired affect and mood, motor slowing, executive dysfunction, less severe changes in memory, extra pyramidal findings  Affected brain regions: thalamus, striatum, midbrain, striatofrontal projections  Examples: Parkinson’s disease, progressive supranuclear palsy, normal pressure hydrocephalus, Huntington’s disease, Creutzfeldt-Jakob disease, chronic meningitis CORTICAL VS. SUBCORTICAL DEMENTIA
  8. 8. MIXED  Both cortical and sub-cortical area involved.  Example: vascular dementia, Dementia with Lewy bodies, Corticobasal degeneration, Neurosyphilis
  9. 9.  D = Delirium  E = Emotions (depression)& Endocrine Disease  M= Metabolic Disturbances  E = Eye & Ear Impairments  N = Nutritional Disorders  T = Tumors, Toxicity, Trauma to Head  I = Infectious Disorders  A= Alcohol, Arteriosclerosis REVERSIBLE DEMENTIA
  10. 10.  Alzheimer’s  Lewy Body Dementia  Pick’s Disease (Frontotemperal Dementia)  Parkinson’s  Vascular  Huntington’s Disease  Jacob-Cruzefeldt Disease IRREVERSIBLE DEMENTIA
  11. 11. HOW TO DIAGNOSE A CASE OF DEMENTIA IN NEUROLOGY OPD  Clinical history  Symptoms analysis  Focussed physical examination  Cognitive and neuropsychiatric examination  Laboratory evaluation
  12. 12. CLINICAL SYMPTOMS  COGNITIVE IMPAIRMENT  FUNCTIONAL IMPAIRMENT  NEURO-PSYCHIATRIC MANIFESTATIONS  BEHAVIOURAL DISTURBANCES  MOOD CHANGES  ANXIETY  PERSONALITY CHANGES  PSYCHOSIS  SLEEP DISTURBANCES
  13. 13. FOCUSED HISTORY  Chronology of the problem- from loved ones - mode of onset – abrupt vs gradual - progression - stepwise vs continous decline - duration of symptoms  Medical history  Family history  Socio-economic history  Evaluation for toxic agent exposure
  14. 14. PHYSICAL EXAMINATION  Neurological examination-mobility and balance assessment  Focal neurological deficits  Extra-pyramidal signs  Vision & hearing screening  Cardiac and pulmonary evaluation
  15. 15. COGNITIVE & NEUROPSYCHIATRIC EXAMINATION  Folstein Mini-Mental Status Examination (MMSE)
  16. 16. MMSE SCORE RANGE 24-30 Normal 18-23 Mild 10-17 Moderate < 10 Severe
  17. 17. INVESTIGATIONS ASSESSMENTS RATIONALE Labs: Complete blood count, serum electrolytes, renal and hepatic function, glucose, albumin and protein, vitamin B12 and folate, rapid plasma reagin (syphilis), thyroid- stimulating hormone, urinalysis Rule out correctable or contributory causes of dementia Imaging: Computed tomography without contrast or magnetic resonance imaging Rule out infarcts, mass lesions, tumors, and hydrocephalus Neurological examination Correlate imaging findings with clinical examination Neuropsychological testing Mini-Mental State Examination: Screening test of cognitive function
  18. 18. DIFFERENTIAL DIAGNOSIS  DELIRIUM  MILD COGNITIVE IMPAIRMENT (MCI)  AGE-RELATED COGNITIVE DECLINE  MENTAL RETARDATION  SCHIZOPHRENIA  DEPRESSION  FACTITIOUS D/O  ALCOHOL ABUSE
  19. 19. DIAGNOSTIC APPROACH COGNITIVE IMPAIRMENT ? DETERIORATION FROM A PREVIOUSLY HIGHER LEVEL ? CONSCIOUSNESS ALTERED? MULTIPLE COGNITIVE FUNCTIONS INVOLVED ? DEMENTIA YES YES YES NO NO YES NO MENTAL RETARDATION DELIRIUM APHASIA AMNESTIC D/O, etc
  20. 20. DEMENTIA –SUB TYPES
  21. 21. CASE 1  70 yr old female present with progressive memory loss for past 1 yr.She also complaints of difficulty in naming objects and driving car and house keeping.for the past 1 month she has difficulty in dressing ,eating and gets agitated easily and wanders around at night.  MMSE – 15/30  Neurological exam- normal  Vision & hearing- normal
  22. 22. MRI FINDINGS- DIAGNOSIS?
  23. 23. ALZHEIMER’S DISEASE (AD)  About 70% of all cases of dementia in elderly  Incidence increases with age  Occurs in up to 30% of persons >85 years old  Characterized by:  Progressive loss of cortical neurons  Formation of amyloid plaques (beta-amyloid is major component) and intraneuronal neurofibrillary tangles (hyperphosphorylated tau proteins is major constituent)
  24. 24. DIAGNOSTIC CRITERIA FOR DEMENTIA OF THE ALZHEIMER TYPE (DSM-IV, APA, 1994) A. Development of multiple cognitive deficits 1. Memory impairment 2, other cognitive impairment B. These impairments cause dysfunction in In social or occupational activities C. Course shows gradual onset and decline D. Deficits are not due to: 1. Other cns conditions 2. Substance induced conditions F. Do not occur exclusively during delirium G. Are not due to other psychiatric disorder
  25. 25. CLINICAL MANIFESTATION  Begin with memory impairment language visuospatial skills  Anosognosia- unaware of difficulties  Cognitive decline-driving,shopping,house-keeping  Language impaired- naming,comprehension then - fluency  Apraxia- seq. motor task can’t perform  Visuo spatial deficits  Delusions ,capgras syndrome – late stages  End stage-rigid,mute ,incontinent & bed-ridden
  26. 26. AD DIAGNOSIS  Neurological exam & neuropsychological testing  Brain imaging: brain atrophy due to extensive neuronal loss and hippocampal atrophy  Diagnosis confirmed by histology of post-mortem brain  ‘Plaques’ & ‘tangles’ in hippocampus & cerebral cortex.
  27. 27. CASE 2  76 yr old male presented in neuro opd with c/o progressive memory loss,emotional lability,gait disturbance for past 5 months  h/o of 3 episodes of cerebrovascular accidents + recent attack 7 months back  h/o HTN,DM,CAD+  O/E- incresed tone in all limbs,power 3+ in RT.UL &LL. 4+ in LT side, B/L extensor plantar
  28. 28. VASCULAR DEMENTIA  Refers to cognitive decline caused by ischemic, hemorrhagic, or oligemic injury to the brain as a consequence of cerebrovascular or cardiovascular disease.  Part of a spectrum of vascular disease causing cognitive impairment, which also includes mild cognitive impairment of vascular origin & mixed Alzheimer's disease plus cerebrovascular disease.  Kraepelin first described “arteriosclerotic dementia” in 1896
  29. 29. DIAGNOSIS & CLINICAL FEATURES (NINDS- AIREN)
  30. 30. VASCULAR DEMENTIA  Multi-infarct dementia- recurrent strokes - step wise progression - HTN,DM,CAD MRI- multiple areas of infarction  Binswanger’s d/s– Diffuse white matter disease - lacunar infarction C/F:confusion,personality changes,psychosis pyramidal signs & cerebellar signs + gait disorder,urinary incontinence,dysarthria emotional lability
  31. 31. CASE 3  55 YR old woman presented with 2yr history of progressive alteration in social behavior. The pt had h/o social disinhibation,abusive language,euphoria.there is complaints of excessive food intake and weight gain for past 1 yr and pt was taken to psychiatrist once.  o/e- vitals stable..neurological exam –WNL  MMSE-18/30
  32. 32. MRI
  33. 33. FRONTOTEMPORAL DEMENTIAS  Often begins with marked behavioral disturbances, unlike AD  Classic form – Pick’s disease  Patients frequently hot-tempered and socially disinhibited  memory & visuo spatial skills spared  Impaired planning,judgement and language  Echolalia +  Overlap with PSP,CBD, motor neuron disease  Illness progresses for years, like AD  Inevitable decline  MRI- lobar atrophy of frontal and/or temporal  About 50% of patients have family history
  34. 34. CASE 4  82 yr old male came to opd with c/o progressive decline in memory for the past 6-8 months.He also complaints of having decreased sleep and occasional nightmares.He occasional sees his deceased wife at times.  o/e- vitals stable ,rigidity of limbs+ - gait- slow stepping gait,bradykinesia+ MMSE- 21/30 WHAT IS THE DIAGNOSIS?
  35. 35. DIFFUSE LEWY BODY DISEASE  Patients have clinical parkinsonism with early and prominent dementia  Lewy bodies found in brain stem, limbic system, and cortex  Visual hallucinations and cognitive fluctuations common, capgras syndrome & REM sleep disorder  Longstanding PD without cognitive decline develop dementia  Better memory but severe visuospatial deficit  Patients sensitive to adverse effects of neuroleptics  May be second most common cause of dementia after AD
  36. 36. PARKINSON’S DISEASE  About 50% of patients have dementia by 85 years old  Affects executive function disproportionately  Dementia occur in later stage, or as a result of co morbidities- AD,DLB or side effects of drug  Associated depression & anxiety  Frontal lobe dysfnct- complex tasks,planning, -memorizing  Language & mathematical skills spared  Predictors- late onset,akinetic-rigid,severe depression - advanced stage
  37. 37. CASE 5  65 YR old male presented to neuro opd with c/o gait disturbance for past 1 yr. On history taking his son complained his father is having memory loss for past 6 months and it is progressing.  The pt also c/o of urinary incontinence+  Neurolog exam- no focal deficits  MMSE- 23/30
  38. 38. MRI- DIAGNOSIS ?
  39. 39. NORMAL PRESSURE HYDROCEPHALUS  Triad 1. Dementia: typically subcortical 2. Gait instability 3. Urinary incontinence  Walk with “feet stuck to floor”  Symptoms progress over weeks to months  CT shows ventricular enlargement with no eviddence of cortical atrophy
  40. 40.  Most important test – therapeutic LP 1. Remove large amount of CSF 2. Examine gait and cognitive function  Ventriculoperitoneal shunt may correct if:  Patients improve within minutes to hours of removal of 30 to 40 mL of spinal fluid  Trauma or subarachnoid hemorrhage  Cause is derangement of CSF hydrodynamics NORMAL PRESSURE HYDROCEPHALUS
  41. 41. CASE 6  50 YR old woman was admitted with c/o progressive memory loss and gait problem ,slurred speech within one month; The pt also had behavioral problem – insomnia,agitation,aggression duration of 3 weeks.the pt also c/o abnormal jerky hand movements for past 1 month  o/e- limb & gait ataxia +, reflexes-exagg. - tone increased all limbs, plantar b/l extensor - no focal weakness MMSE- 16/30
  42. 42. MRI- DIAGNOSIS?
  43. 43. CRUETZFELDT-JAKOB SYNDROME(CJD)  Rapid progressive dementing prion disorder  Focal cortical signs, rigidity  Onset between 40- 75 years  90% has MYOCLONUS vs 10% in AD  Progressive dementia and personality changes over weeks to months  Death <1 year from first symptom  EEG- diffuse slowing and periodic sharp waves or spikes  MRI- basal gangla abnormalities  CSF- detect specific aminoacid sequence (PrPSc)
  44. 44.  Aging  Mild loss of memory: names and dates  Most sensitive indicator of cognitive change: poor performance on delayed-recall tasks  Verbal fluency remain intact and vocabulary may increase DISORDERS OF MEMORY FUNCTION (AMNESTIC DISORDERS)
  45. 45. Transient global amnesia  Dramatic memory disturbance  Affects patients >50 years  Usually have only one episode, lasting 6 to 12 hrs.  Complete temporal and spatial disorientation  Orientation for person preserved  May be confused with psychogenic amnesia, fugue state, or partial complex status epilepticus  May be due to vascular insufficiency to hippocampus or midline thalamic projections DISORDERS OF MEMORY FUNCTION
  46. 46. DISORDERS OF MEMORY FUNCTION  Head injury  Retrograde amnesia > antegrade amnesia  With time, memories usually return but rarely to recall events surrounding trauma  Korsakoff’s syndrome  Near-total inability to establish new memory  Patients confabulate about recent events  Immediate memory NL,attention NL  Most common cause: thiamine and other nutritional deficiencies with chronic alcoholism
  47. 47. PSEUDO DEMENTIA  Severe depression  Memory & language intact  Vegetative symptoms –insomnia,anergy, - loss of appetite  Abrupt onset
  48. 48. THANK YOU

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