Prof Dr. Fareed Minhas
Head, Institute of Psychiatry
Rawalpindi General Hospital
Rawalpindi
 Syndrome due to disease of brainchronic, progressive nature
 Disturbance of multiple higher cortical
functions such as ...
 Estimated 2 million people in US
suffer from severe dementia and 1 to
5 million experience mild to moderate
dementia at ...
 Alzheimer’s Disease (most common form
of dementia) costs the US at least $100
billion per year.
 Average lifetime cost ...
 DEGENERATIVE
Alzheimer’s disease
Pick’s disease
Huntington’s disease
Parkinson’s Disease
Normal pressure hydrocephalus
...
 VITAMIN DEFICIENCY
B 12
Thiamine
 TRAUMATIC
Post head injury
Punch drunk syndrome(boxers)
 INTRACRANIAL SPACE
OCCUPYIN...
DRUGS
Chronic drug abusers have incidence
of dementia. Drugs that cause it
are:
oAnticholinergics
oBarbiturates
oBenzodia...
 ADVANCING AGE
 INHERITENCE OF GENETIC
PREDISPOSITION
 UNTREATED INFECTIOUS OR
METABOLIC DISEASES/SUBSTANCE
ABUSE
 BRA...
SUSPECT DEMENTIA WHEN…

Cognitive changes
New forgetfulness, more trouble
understanding spoken and
written communication, ...
Problem behaviors
Wandering, agitation, noisiness,
restlessness, being out of bed at
night

Changes in day-to-day
function...
SIGNS OF DEMENTIA DEVELOPING…
Recent memory loss.
People with dementia
often forget things,
but they never
remember them.
...
SIGNS OF DEMENTIA DEVELOPING… Loss of
Misplacing things.
People who have
dementia may put
things in the wrong
places.
Pers...
ICD 10
Evidence of
decline in
both memory and
thinking sufficient
to impair personal
activities of daily
living

For six m...
 Multi-infarct dementia - stepwise
deterioration and patchy distribution of
deficits, focal neurological signs and eviden...
 Lewy Body Dementia - The central
feature is progressive cognitive decline
with resultant functional impairment.
Persiste...
 Fronto-temporal dementia –
∀− Uninhibited and socially inappropriate behavior
·  - Inappropriate sexual behavior
·  - Lo...
- Urinalysis and microscopy
- Complete blood cell count (anemia)
- Serum electrolyte levels, including Mg
- Serum chemistr...
Mini-Mental State Examination
Max Score
score

Orientation

5

What is the (year) (season) (date) (day) (month) 

5
(hospi...
Max
Score
3
one
objects

Score

Recall
Ask for the three objects repeated above. Give
point for each correct answer.
(Note...
ADDITONAL WORKUP FOR THE
DIAGNOSIS OF DEMENTIA…
Test
 Electroencephalography
Lumbar puncture
preceding

Indication
Possibl...
Test
Slit lamp examination
Apolipoprotein E
Genetic testing for
Alzheimer genes,
dementia genes

Indication
History and ex...
 DELIRIUM – acute transient

disturbance of mental functioning
 PSEUDODEMENTIA – a type
of severe depression common in
e...
There are 5 aspects to the
management of dementias :

 Treating any underlying disorder
Vascular dementia  lifelong aspi...
Tier 1
No dementia, management is
prevention

Tier 2
Dementia with no BPSD,
Management : selected
prevention
Teir 3
Dement...
Tier 4
Dementia with moderate BPSD
Management:Specialist in PHC

Tier 5
Dementia with severe BPSD
Management:Dementia-nurs...
 HMG Co-A Reductase

Inhibitors (lipid-lowering
agents) found to reduce the
risk of dementia
 High Homocysteine Levels
M...
Dementia prof. fareed minhas
Dementia prof. fareed minhas
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Dementia prof. fareed minhas

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Dementia prof. fareed minhas

  1. 1. Prof Dr. Fareed Minhas Head, Institute of Psychiatry Rawalpindi General Hospital Rawalpindi
  2. 2.  Syndrome due to disease of brainchronic, progressive nature  Disturbance of multiple higher cortical functions such as memory, thinking, orientation, comprehension, calculation,learning capacity, language and judgment  Consciousness is not clouded  Associated deterioration in emotional control, social behavior and motivation  Decline of intellectual functioning interferes to a variable extent with personal activities of daily living
  3. 3.  Estimated 2 million people in US suffer from severe dementia and 1 to 5 million experience mild to moderate dementia at some point.  5 to 8% people above 65 yrs have dementia and the number doubles every 5 yrs  7.9% of all canadians above 65 yrs have dementia  In 2001, Australia's population was approximately 19 million, of which an estimated 165 000 people had dementia. Projections are that by 2041 Australia's population will be 25 million, with an estimated 460 000 people with dementia.
  4. 4.  Alzheimer’s Disease (most common form of dementia) costs the US at least $100 billion per year.  Average lifetime cost in US per patient of dementia is $174,000  The federal government research appropriation is $500 million per annum  Half of all nursing home patients in US suffer from dementia, mostly Alzheimer’s type. The average per patient cost for nursing home care averages $42,000/yr but can increase to $70,000/yr
  5. 5.  DEGENERATIVE Alzheimer’s disease Pick’s disease Huntington’s disease Parkinson’s Disease Normal pressure hydrocephalus  VASCULAR Cerebrovascular disease Cranial Arteritis  TOXIC Alcohol Occupational exposure (chemicals etc) Heavy metals (eg.lead)  METABOLIC Uremia Liver failure Remote effects of carcinoma
  6. 6.  VITAMIN DEFICIENCY B 12 Thiamine  TRAUMATIC Post head injury Punch drunk syndrome(boxers)  INTRACRANIAL SPACE OCCUPYING LESIONS Subdural hematoma Tumors  INFECTIONS Encephalitis Creutzfeld-Jacob HIV infection Syphilis  ANOXIC Cardiac arrest Respiratory failure CO poisoning  ENDOCRINE Hypothyroidism Hypocalcaemia
  7. 7. DRUGS Chronic drug abusers have incidence of dementia. Drugs that cause it are: oAnticholinergics oBarbiturates oBenzodiazepines oCough suppressants oDigitalis oMonoamine oxidase inhibitors oTricyclic antidepressants
  8. 8.  ADVANCING AGE  INHERITENCE OF GENETIC PREDISPOSITION  UNTREATED INFECTIOUS OR METABOLIC DISEASES/SUBSTANCE ABUSE  BRAIN TUMOR  HEAD INJURY  CARDIOVASCULAR DISEASE (eg hypertension, atheroschlerosis)  KIDNEY FAILURE / LIVER DISEASE / THYROID DISEASE  VITAMIN DEFICIENCIES (B12, Thiamine, Folic Acid)
  9. 9. SUSPECT DEMENTIA WHEN… Cognitive changes New forgetfulness, more trouble understanding spoken and written communication, difficulty finding words, not knowing common facts such as the name of the current U.S. president, disorientation Psychiatric symptoms Withdrawal or apathy, depression, suspiciousness, anxiety, insomnia, fearfulness, paranoia, abnormal beliefs, hallucinations Personality changes Inappropriate friendliness, blunting and disinterest, social withdrawal, excessive flirtatiousness, easy frustration, explosive spells
  10. 10. Problem behaviors Wandering, agitation, noisiness, restlessness, being out of bed at night Changes in day-to-day functioning Difficulty driving, getting lost, forgetting recipes when cooking, neglecting self-care, neglecting household chores, difficulty handling money, making mistakes at work, trouble with shopping
  11. 11. SIGNS OF DEMENTIA DEVELOPING… Recent memory loss. People with dementia often forget things, but they never remember them. Difficulty performing familiar tasks. They might cook a meal but forget that they cooked it Problems with language. People who have dementia may forget simple words or use the wrong words. This makes it hard to understand what they want. Poor judgment. People who have dementia, however, might forget all about the child and just leave the house for the day. Problems with language. People who have dementia may forget simple words or use the wrong words. Problems with abstract thinking. They forget what the numbers are and what has to be done with them.
  12. 12. SIGNS OF DEMENTIA DEVELOPING… Loss of Misplacing things. People who have dementia may put things in the wrong places. Personality changes. People who have dementia may have drastic changes in personality. They might become irritable, suspicious/ fearful Changes in mood. Everyone is moody at times, but people with dementia may have fast mood swings, going from calm to tears to anger in a few minutes. initiative. People who have dementia may become passive. They might not want to go places or see other people. Signs specific to subtypes. The details given in the section of diagnosis
  13. 13. ICD 10 Evidence of decline in both memory and thinking sufficient to impair personal activities of daily living For six months or More DSM IV Development of Multiple cognitive Deficits such as Memory impairment And apraxia/agnosia Disturbance of Executive functioning Of gradual onset , That does not Classify better in an Axis I disorder
  14. 14.  Multi-infarct dementia - stepwise deterioration and patchy distribution of deficits, focal neurological signs and evidence of vascular disease as indicated by history, physical examination and laboratory testing.   Abrupt onset   Stepwise progression   Fluctuating course   Nocturnal confusion   Relative preservation of personality   Depression   Somatic complaints   Emotional incontinence   History of hypertension   History of stroke   Focal neurological signs   Focal neurological symptoms   2 1 2 1 2 1 1 1 1 2 2 2 Modified Hachinski Ischemia Score (ATLEAST 4 SCORING FOR DIAGNOSIS)
  15. 15.  Lewy Body Dementia - The central feature is progressive cognitive decline with resultant functional impairment. Persistent memory impairment may occur with disease progression. Deficits on tests of attention, frontal­subcortical skills and visuospatial ability may be prominent. Essential Features Two of the following core features: - Fluctuating cognition and pronounced variations in attention and alertness - Recurrent visual hallucinations that are typically well formed and detailed - Spontaneous motor features of parkinsonism Features Supportive of the Diagnosis: - Repeated falls - Syncope - Transient loss of consciousness - Neuroleptic sensitivity - Systematized delusions - Hallucinations
  16. 16.  Fronto-temporal dementia – ∀− Uninhibited and socially inappropriate behavior ·  - Inappropriate sexual behavior ·  - Loss of concern about personal appearance and hygiene · -   Compulsive eating and oral fixation ·  - Apathy, loss of initiative, lack of concern for others ·  - Speech and language difficulties /memory loss  Binswanger’s (subcortical) - 2 of the following required : -Hypertension or known systemic vascular disease (for example, coronary artery disease, peripheral vascular disease) -Evidence of cerebrovascular disease (for example, stroke) -Subcortical brain dysfunction (for example, abnormal gait, muscular rigidity, neurogenic bladder)
  17. 17. - Urinalysis and microscopy - Complete blood cell count (anemia) - Serum electrolyte levels, including Mg - Serum chemistry panel, including LFTs - Thyroid function tests - Serum vitamin B12 - Erythrocyte sedimentation rate* - Serologic tests for syphilis (or similar) - Chest radiography* - Electrocardiography* - Toxicology screening* - Urine toxicology - Serum toxicology (alcohol, salicylates, other)
  18. 18. Mini-Mental State Examination Max Score score Orientation 5 What is the (year) (season) (date) (day) (month)  5 (hospital) Where are we: (state) (county) (town or city) (floor)? Registration 3 Name three common objects (e.g., "apple," "table," "penny"): (Take one second to say each. Then ask the patient to repeat all three after you have said them. Give one point for each correct answer. Then repeat them until he or she learns all three. Count trials and record. Attention and clalculation 5   Spell "world" backwards. The score is the number of letters in correct order. (D___L___R___O___W___)
  19. 19. Max Score 3 one objects Score Recall Ask for the three objects repeated above. Give point for each correct answer. (Note: recall cannot be tested if all three were not remembered during registration.)   Language 2 Name a "pencil" and "watch." Repeat the following: "No ifs, ands or buts." Follow a three-stage command: 3 and "Take a paper in your right hand, fold it in half put it on the floor." 1 Close your eyes. 1 Write a sentence. 1 Copy the following design.   Total score:____
  20. 20. ADDITONAL WORKUP FOR THE DIAGNOSIS OF DEMENTIA… Test  Electroencephalography Lumbar puncture preceding Indication Possible seizures; Creutzfeldt-Jakob disease Onset of dementia within the six months; dementia rapidly progressive Heavy metal screen History of potential exposure HIV History of potential exposure Lyme disease titer History of exposure and compatible clinical picture Ceruloplasmin, Wilson's disease, metachromatic arylsulfatase, electrophoresis leukodystrophy, multiple myeloma
  21. 21. Test Slit lamp examination Apolipoprotein E Genetic testing for Alzheimer genes, dementia genes Indication History and examination suggest Wilson's disease Need to increase likelihood that diagnosis of Alzheimer's disease is correct Family history is strong, and onfirmation is clinically other necessary
  22. 22.  DELIRIUM – acute transient disturbance of mental functioning  PSEUDODEMENTIA – a type of severe depression common in elderly  DEPRESSION - A mental disorder, depression can cause difficulty in remembering, thinking clearly and concentrating. Sometimes depression occurs in conjunction with dementia. In those cases emotional and intellectual deterioration can be especially severe.
  23. 23. There are 5 aspects to the management of dementias :  Treating any underlying disorder Vascular dementia  lifelong aspirin  Treating the cognitive deficits in patients with AD Anticholinergics (Tacrine; Donepezil)  Ameliorating associated behavioral disturbances  Reducing the consequences of disability  Addressing the needs of the caregivers
  24. 24. Tier 1 No dementia, management is prevention Tier 2 Dementia with no BPSD, Management : selected prevention Teir 3 Dementia with mild BPSD eg. Wandering, sleep problem Depression, apathy, repetition Management : Primary health workers
  25. 25. Tier 4 Dementia with moderate BPSD Management:Specialist in PHC Tier 5 Dementia with severe BPSD Management:Dementia-nursing homes / case managers Tier 6 Dementia with very severe BPSD Management:Psychogeriatric/ neurobehavioral units
  26. 26.  HMG Co-A Reductase Inhibitors (lipid-lowering agents) found to reduce the risk of dementia  High Homocysteine Levels May Double Risk of Dementia, Alzheimer’s Disease, New Report Suggests ( Feb 2002)  Rates of dementia increase among older women on combination hormonal therapy

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