Assessment and Treatment of Dementia

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Assessment and Treatment of Dementia

  1. 1. Assessment and Treatment of Dementia <ul><li>Juan Francisco Rodriguez, M.D. </li></ul><ul><li>Adult and Geriatric Psychiatrist </li></ul><ul><li>Outpatient Mental Health Clinic </li></ul>
  2. 2. DSM-IV Criteria <ul><li>A- memory impairment (impaired ability to learn new information or to recall previously learned information) </li></ul><ul><ul><li>One (or more) of the following cognitive </li></ul></ul><ul><ul><li>disturbances: </li></ul></ul><ul><ul><li>aphasia </li></ul></ul><ul><ul><li>apraxia </li></ul></ul><ul><ul><li>agnosia </li></ul></ul><ul><ul><li>disturbance of executive functioning </li></ul></ul>
  3. 3. DSM-IV Criteria (cont) <ul><li>B- the cognitive deficits with significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. </li></ul><ul><li>C- the course is characterized by gradual onset and continuing cognitive decline </li></ul>
  4. 4. DSM-IV Criteria (cont) <ul><li>D- other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, parkinson’s disease, Huntington disease, subdural hematoma, NPH, brain tumor). </li></ul><ul><li>Systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B 12 or folic acid deficiency, neurosyphyllis, HIV infection, substance induced conditions </li></ul>
  5. 5. DSM-IV Criteria (cont) <ul><li>E- the deficits do not occur exclusively during the course of a delirium </li></ul><ul><li>F- the disturbance is not better accounted for by another axis 1 disorder </li></ul>
  6. 6. Signs and Symptoms of Dementia <ul><li>Personality changes </li></ul><ul><li>Difficulty coping with changes </li></ul><ul><li>Confusion </li></ul><ul><li>Repeating themselves (asking the same questions) </li></ul><ul><li>Difficulty reading quickly </li></ul><ul><li>Forgetfulness </li></ul><ul><li>Poor decision making </li></ul>
  7. 7. Assessment of Dementia <ul><li>Detailed history to identify dementia </li></ul><ul><li>Assessment of Mental Status </li></ul><ul><ul><li>MMSE </li></ul></ul><ul><ul><li>IADL’S </li></ul></ul><ul><ul><li>ADL’S </li></ul></ul><ul><li>Neuropsychological testing </li></ul>
  8. 8. Assessment of Dementia <ul><li>Blood tests </li></ul><ul><li>Brain imaging (CT, MRI, PET, SPECT of the head </li></ul><ul><li>EEG </li></ul><ul><li>Pittsburgh Compound </li></ul><ul><li>Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementia </li></ul><ul><li>UCLA Compound </li></ul>
  9. 9. Assessment of Dementia (cont) <ul><li>Medical condition </li></ul><ul><li>Medications </li></ul><ul><li>Neurological conditions causing dementia </li></ul><ul><li>Treatable conditions </li></ul>
  10. 10. Differential Diagnosis <ul><li>Primary Etiology </li></ul><ul><ul><li>Alzheimer’s dementia </li></ul></ul><ul><ul><li>Pick’s disease </li></ul></ul><ul><ul><li>Frontotemporal dementia </li></ul></ul><ul><ul><li>Lewy body dementia </li></ul></ul>
  11. 11. Differential Diagnosis <ul><li>Secondary Etiology </li></ul><ul><ul><li>Vascular dementia e.g. cva, tia </li></ul></ul><ul><ul><li>Infections e.g. Hiv, syphyllis </li></ul></ul><ul><ul><li>Inflammatory e.g. SLE </li></ul></ul><ul><ul><li>Traumatic e.g. head injury </li></ul></ul>
  12. 12. Differential Diagnosis <ul><li>Neurodegenerative </li></ul><ul><ul><li>Huntington’s Chorea </li></ul></ul><ul><ul><li>CJD (prion) </li></ul></ul><ul><ul><li>Parkinson’s Disease induced dementia </li></ul></ul><ul><ul><li>Multiple Sclerosis </li></ul></ul><ul><ul><li>Wilson’s Disease </li></ul></ul>
  13. 13. Vascular Dementias <ul><li>Hypertension </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Hyperlipedemia </li></ul><ul><li>Elevation of homocysteine level </li></ul>
  14. 14. Management Strategies <ul><li>Carefully plan relocation </li></ul><ul><ul><li>Temporal and long term </li></ul></ul><ul><li>Discuss with family health care by proxy or advanced directives, DNR </li></ul><ul><li>Discuss the use of psychotropic medications </li></ul>
  15. 15. Management Strategies <ul><li>Discuss ethical issues </li></ul><ul><li>Discuss management of behavioral </li></ul><ul><ul><li>disruption and functional deficits </li></ul></ul><ul><li>Discuss psychosocial issues </li></ul><ul><li>Management and discuss quality of the issues and progression of the illness </li></ul><ul><li>Discuss management of Tx plan including medications </li></ul>
  16. 16. Management of Dementia <ul><li>Non pharmacological </li></ul><ul><li>Pharmacological </li></ul>
  17. 17. Pharmacological Management <ul><li>Cholinesterase inhibitors </li></ul><ul><li>NMDA (memantine) </li></ul><ul><li>AMOI (eldepryl) </li></ul><ul><li>Medications for disruptive behavior </li></ul><ul><li>Antidepressants for comorbid disorders </li></ul>
  18. 18. Cholinesterase Inhibitors <ul><li>Cognex (tacrine) </li></ul><ul><li>Rivastagmine (Exelon) Patch </li></ul><ul><li>Donepezil (Aricept) </li></ul><ul><li>Galantamine </li></ul><ul><li>Galantamine (Razadyne ER) </li></ul>
  19. 19. Question <ul><li>65 yo wf with hx of dementia develops frightening visual hallucinations. Pt was started on low dosage of risperidone, days after the patient develops severe bradykenesia, tremor, rigidity, and gait disturbance. Side effects/adverse reaction suggests which type of dementia? </li></ul>
  20. 20. Question (cont) <ul><li>a- Alzheimer’s Dementia </li></ul><ul><li>b- Frontotemporal Dementia </li></ul><ul><li>c- Diffuse Lewy Body Dementia </li></ul><ul><li>d- Progressive Supranuclear Palsy </li></ul><ul><li>e- Normal Pressure Hydrocephalus </li></ul><ul><li>f- Parkinson’s Induced Dementia </li></ul>
  21. 21. Question <ul><li>Which of the following are not considered as </li></ul><ul><li>part of the routine dementia work-up? </li></ul><ul><li>a- VDRL </li></ul><ul><li>b- Neurological exam </li></ul><ul><li>c- Chest xray </li></ul><ul><li>d- Vitamin B 12 level </li></ul><ul><li>e- CT or MRI of the head </li></ul>
  22. 22. Question <ul><li>A 70 yo wm with history of AD was first prescribed Exelon patch x 2 years without good results, he then was changed to galantamine oral bid. Family complains that patient’s cognition continues to deteriorate. Which of the following is the most likely approach in treatment? </li></ul>
  23. 23. Question (cont) <ul><li>a- Re-start Exelon </li></ul><ul><li>b- Continue galantamine </li></ul><ul><li>c- Start Razadyine </li></ul><ul><li>d- Start Tacrine </li></ul><ul><li>e- Start Aricept 5mg po qhs x 30 days then 10mg po qhs </li></ul>
  24. 24. Question <ul><li>75 yo patient with history of AD with </li></ul><ul><li>behavioral disturbance, he scores 15/30 in the </li></ul><ul><li>mmse, he has occasional visual hallucinations, </li></ul><ul><li>illusions and delusions. Patient has been taking </li></ul><ul><li>Aricept 10mg po qhs, he suddenly develops </li></ul><ul><li>stomach upset, which his pcp thinks is related </li></ul><ul><li>to his cholinesterase inhibitor, what is the next </li></ul><ul><li>step in treatment? </li></ul>
  25. 25. Question (cont) <ul><li>a- Continue Aricept po qhs </li></ul><ul><li> b- Change Aricept to po qam </li></ul><ul><li>c- D/C Aricept </li></ul><ul><li>d- Start rivastagmine </li></ul><ul><li>e- Start galantamine </li></ul><ul><li>f- Start Namenda </li></ul>

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