12. DSM ā IV Criteria for Dementia
Memory Impairment plus
ā¢ APHASIA (Deterioration of Language function)
ā¢ APRAXIA (inability to Execute Motor function)
ā¢ AGNOSIA
(inability to Recognise or Naming of Object)
Disturbance in executive functioning
with
ā¢ Impairment in occupational or social functioning
13. 70% of dementia is Alzheimerās
10-15% is Vascular dementia
10-15% Lewy Body dementias
5-10% Others
Overall Situation:
Alzheimerās disease 70 %
Vacular Dementia 15-20%
Lewy Body Dementia 10-15 %
Others 5 %
15. Psudodementia
A group of disease due to functional disease
rather than organic dementia
ā¢ Depression
ā¢ Hysterical Dementia
ā¢ Psychogenic amnesia
16. Causes of Dementia
Primary Degenerative Dementia:
ā¢Alzheimerās Disease
ā¢Frontotemporal dementia
ā¢Dementia with Lewy Body
23. Depression Dementia:
Little effort on tasks Struggles to complete tasks
Donāt know answers Attempts answers, but incorrect
Absence of Dyspraxia, Have Dyspraxias, Agnosias,
No language problem Language problem
27. Is it Dementia??
Is it
Depression
or Dementia
Is it Delirium
or Dementia
Is it
Alzheimerās??
IsThere any
Reversable
Cause??
If not Alzheimerās
What is it??
42. Alzheimerās
Pathology (Gross) :
ļ§ Every part of cerebral
cortex is involved with
relative sparing of
occipital pole
ļ§ Marked Atrophy.
ļ§ Widened Sulci
ļ§ Shrinkage of Gyri
ļ§ Ventricular Dilatation
49. Cholinergic deficit
ā progressive loss of cholinergic
neurones
ā progressive decrease in
available ACh
ā impairment in ADL, behaviour
and cognition
Hippocampus
Cortex
N. basalis Meynert
Pathophysiology of AD (Biochemical)
50.
51.
52. ALZHEIMERāS VASCULAR
Onset Incidious Sudden
Risk factors Family history CVD risks
Mental status Recent Memory Psychomotor
slowing
Neuro exam No Focal neuro deficit
Behavioral Delusion,
Poor insight
Apathy,
Depression
MRI Diffuse /
Temporal atrophy
Stroke
53.
54.
55.
56.
57.
58. ALZHEIMERāS VASCULAR LBD FTD
Short term
Memory Loss
Personality
change
Parkinsonism Prominent
Behavior
change
Dysphasia
Dyspraxia
Labile Mood Fluctuating
Alertness
Expressive
Dysphasia
Wandering Preserved
Insight
Visual
Hallucination
Early loss of
insight
59. DEMENTIA:
Common diagnostic strategies:
ļ§ Clinical :
ļŗ History (from patient, family)
ļŗ Bedside Examination (e.g. MMSE)
ļŗ Physical Examination
ļ§ Neuropsychological Assessment.
ļ§ Imaging.
ļ§ Lab Screening for other causes.
60. History :
ļ§ Nature of the problem
ļŗ Memory?
ļŗ Behavioral
ļŗ Emotional
ļ§ Who perceives the
problem?
ļŗ Patient?
ļŗ Family?
ļ§ Tempo of the illness
ļŗ Gradual
ļŗ Fast
ļŗ Stepwise
ļ§ Family history
ļ§ Other medical
problems
ļŗ Neurological (e.g.
movement disorder)
ļŗ Systemic (e.g.
thyroid disease,
vascular disease)
63. COGNITIVE
FUNCTION
BEHAVIOUR &
PSYCHOLOGICAL
FEATURES
ACTIVITY OF
DAILY LIVING
DEPRESSION
MMSE Neuropsychiatric
inventory
Bristol Scale Cornel Scale
Clock Drawing
Test
Behave AD AD functional
Assesment scale
Geriatric
Depression
Scale
Seven Minute
Screen
Cohen Mansfield
Aggression
Inventory
Disability
Assesment
Dementia
MentalTest
Score
64. ļ§Mini Mental State
Examiation :
ļ§ Staging of Disease by MMSE
Normal 27-30
Mild 25-26
Mild- Moderate 10-24
Moderate- Severe 6-9
Very Severe <6
65.
66.
67. Clock Drawing
ļ§ āDraw a clock and set the hands to ten
minutes to twoā
ļ§ Marked out of ten e.g.
Perfect 10
Noticable palcement errors of the hand 8
Numbers & clock face not conected 3
uninterruptable 1
68.
69.
70. Imaging :
ļ§ Structural imaging (CT or MRI )
ļŗ Exclusion of structural abnormalities
ļŗ Volumetric studies
ļ§ Functional imaging
ļŗ PET
ļŗ SPECT
71.
72.
73. In A, MRI shows cortical atrophy
and ventricular enlargement.
In B, PET scan shows reduced glucose metabolism in
the parietal lobes bilaterally (blue green) as
compared with more normal metabolism in other
cortical areas (yellow)
Probable Alzheimerās Disease
74.
75.
76.
77.
78. BASELINE TESTS:
Baseline investigations for
Dementia:
CBC, ESR S. Electrolytes
Calcium, Phosphate Syphilis
Chest X ray HIV
CT, MRI Thyroid Function test
B12, Folate Liver function tests
EEG, ECG Renal FunctionTests
79.
80. Diagnosis Flow Chart:
History
Memory =
Activity in
Daily Living
Cognitive
ScreeningTest
MMSE +
CLOCK Drawing
Exclede Reversable causes
by BaselineTests
Neuroimaging
88. Management of Dementia
ļ§ Supportive treatment
ļŗ Non-pharmacological
ļŗ Pharmacological
ļ§ Treatment of complications &
co-morbidities
89.
90. Symptomatic Treatment of AD
. The mainstay of symptomatic treatment of AD, so far, is
the cholinergic treatment strategies and most widely
used, till now, are the Cholinesterase (ChE) inhibitors.
.
These agents
ā¢Reduce the metabolism of acetylcholine
ā¢Prolonging its action at cholinergic synapses.
91. Cholinesterase inhibitors:
two classes exist for the treatment of
Dementia
Class Inhibit
Dual ChE inhibitors
ā Rivastigmine Both AChE
ā Tacrine and BuChE
Single ChE inhibitors
ā Donepezil AChE
ā Galantamine
Weinstock, 1999
99. ALZEIMERāS VASCULAR FRONTO
TEMPORAL
LEWY BODY
DONEPEZIL ChE Inhibitors No ChE
inhibitors
ChE inhibitors
RIVASTIGMIE HMG CoA SSRI SSRI
GALANTAMINE Stroke Prevent Antipsychotics Memantine
MEMANTINE Memantine Memantine Levadopa
SSRI Antipsychotic
101. Transdermal Patch Technology:
Reservoir versus Matrix
Nitti VW, et al Urology. 2006;67:657ā64
Drug contained in adhesive layer along
with polymer
Smaller and thinner than reservoir patches
Reservoir
Matrix
Drug contained in separate layer,
with a rate-controlling membrane
Matrix Diffusion
Controlled Patch
Release Liner
Drug + Polymer
+ Adhesive
Backing
Rate-Controlled
Reservoir/Membrane Patch
Dermal Layer
Backing
Drug
Reservoir
Release Liner Adhesive Layer
103. Where to Apply Exelon Patch
ļ§Apply to:
ļŗ Upper and lower back
ļŗ Upper arm
ļŗ Chest
ļ§The skin should be clean, dry
and hairless before the patch
is applied
ļ§Normal daily activities, such
as bathing, are permitted
104. Exelon Transdermal Patch:
Smooth Continuous Delivery Through the Skin
Exelon 6 mg BID capsule
Exelon 9.5 mg/24 h patch
Plasmaconcentration(ng/mL)
Exelon 9.5 mg/24 h patch delivered comparable average concentrations (AUC)
to those provided by an oral dose of 6 mg BID (12 mg/day)*
* Model-predicted analysis based on actual patient data corrected for body weight.
0
5
10
15
20
25
0 6 12 18 24
Time (hours)
108. When to Refer to SPECIALIST:
ā¢Early Onset
ā¢Presentation Atypical
ā¢Severe Parkinsonism
ā¢Focal Finding
ā¢Behaviors seeming to be Untreatable