EVALUATION OF THE
PATIENT WITH DEMENTIA
Jonathan T. Stewart, MD
Professor in Psychiatry
University of South Florida Colleg...
DEMENTIA
 A syndrome characterized by acquired,
progressive cognitive impairment
 Affects 10% of individuals over 65
 C...
PRIMARY SYMPTOMS
 ATTENTION
 MEMORY
 POSTROLANDIC (“COGNITION”)
 EXECUTIVE (FRONTAL/SUBCORTICAL)
 INSIGHT
PRIMARY SYMPTOMS
 ATTENTION: clouded sensorium, delirium
 MEMORY: forgetfulness
 POSTROLANDIC: aphasia, apraxia, gettin...
TWO TYPES OF DEMENTIA
 Postrolandic
 Frontal/subcortical
POSTROLANDI
C
 Memory deficits
 Aphasia
 Apraxia
 Agnosia
 Personality more or
less preserved
 MMSE valid
FRONTAL/SU...
THE REST OF THE
HISTORY
 Time course
 Depressive symptoms
 Past medical history
 Medical and psychiatric conditions
 ...
THE REST OF THE EXAM
 Physical exam
 Neurologic exam
 Mental status exam
THE FOLSTEIN MMSE
 Most studied and used of the
standardized exams
 Quick and easy to administer
 Excellent inter-rater...
BEYOND THE MMSE
 ATTENTION: digit span or “DLROW”
 MEMORY: 3 word recall, orientation
 POSTROLANDIC: naming, praxis,
ca...
LURIA’S RECURSIVE
FIGURES
LURIA’S RECURSIVE
FIGURES
LURIA’S RECURSIVE
FIGURES
THE GERIATRIC
DEPRESSION SCALE (GDS)
 Good screen for most patients
 Easy to administer and score
 Face-valid, so patie...
THE REST OF THE WORK-
UP
 Basic labs
 Thyroid function tests
 B12 (methylmalonic acid and
homocysteine if borderline)
...
PLEASANT SURPRISES
 Depression
 Iatrogenic (anticholinergics, sedatives,
narcotics, H2 blockers, multiple meds)
 Hypoth...
POSTROLANDIC
DEMENTIAS
 Alzheimer’s disease
 Diffuse Lewy body disease
ALZHEIMER’S DISEASE
 Slowly, insidiously progressive
postrolandic dementia; executive sx’s
much later
 Neurologic exam, ...
ANTI-DEMENTIA DRUGS
 May improve cognitive function, ADL’s to a
modest extent; often ineffective
 Dechallenge if no mean...
A TYPICAL STUDY
BEWARE!
DIFFUSE LEWY BODY
DISEASE
 Second most common dementia in
autopsy studies
 Characterized by Lewy bodies
throughout the c...
CLINICAL FEATURES
 Postrolandic dementia
 More rapidly progressive than AD
 Fluctuation, episodes of “pseudodelirium” c...
FRONTAL/SUBCORTICAL
DEMENTIAS
 Vascular dementia
 Frontotemporal dementia and Pick’s disease
 Alcoholic dementia
 Hunt...
TYPES OF VASCULAR
DEMENTIA
 Multi-infarct dementia
 Small vessel disease
 Lacunar state (gray > white)
 Binswanger’s d...
SMALL VESSEL DISEASE
 At least 50% of all vascular dementia
 Often coexists with MID
 Usual vascular risk factors, espe...
FRONTOTEMPORAL DEMENTIA
 Relatively uncommon, non-familial
illness
 Prominent (macroscopic) atrophy of
frontal and anter...
MANAGEMENT
BEHAVIORAL PROBLEMS IN
DEMENTIA
 Present in 80% of cases
 Major source of caregiver stress,
institutionalization
 Commo...
WOOF.
MEDS OTHER
THREE BASIC PRINCIPLES
 Simplicity
 Limited goals
 The “no-fail” environment
“THE CUSTOMER
IS ALWAYS
RIGHT!”
DEPRESSION
 20-30% incidence in Alzheimer’s
disease, often early in the course of the
illness
 Most important treatable ...
ACUTE BEHAVIOR CHANGE
 I atrogenic
 I nfection
 I llness
 I njury
 I mpaction
 I nconsistency
 I s the patient depr...
AGITATION
 Present in up to 80% of patients
 Up to 34% of patients are combative
 Few predictors
 Probably a very hete...
EMPIRICALLY EFFECTIVE
MEDS FOR AGITATION
 Atypical neuroleptics (best when agitation is
clearly related to delusions or h...
THE BEST NUMBER OF
MEDICATIONS TO USE IS
ZERO (or sometimes one)
WHEN IN DOUBT, GET RID OF
MEDICATIONS!
DON’T FORGET SAFETY
ISSUES!
 DRIVING
 FIREARMS
 POWER TOOLS
 SMOKING IN BED
 POISONS, MEDICATIONS
 FALL RISK
WOOF!
MEDS OTHER
GOOD LUCK!
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Evaluation of the Patient with Dementia

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Evaluation of the Patient with Dementia

  1. 1. EVALUATION OF THE PATIENT WITH DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center
  2. 2. DEMENTIA  A syndrome characterized by acquired, progressive cognitive impairment  Affects 10% of individuals over 65  Caused by at least 80 different diseases, many reversible  Unfortunately, the most common diseases (85 – 90%) are irreversible  Diagnosis will have prognostic and treatment implications  All demented patients need a work-up  …and it’s mostly a good history
  3. 3. PRIMARY SYMPTOMS  ATTENTION  MEMORY  POSTROLANDIC (“COGNITION”)  EXECUTIVE (FRONTAL/SUBCORTICAL)  INSIGHT
  4. 4. PRIMARY SYMPTOMS  ATTENTION: clouded sensorium, delirium  MEMORY: forgetfulness  POSTROLANDIC: aphasia, apraxia, getting lost  EXECUTIVE: poor judgment, disinhibition, abulia, urge incontinence  INSIGHT: anosognosia, catastrophic reactions
  5. 5. TWO TYPES OF DEMENTIA  Postrolandic  Frontal/subcortical
  6. 6. POSTROLANDI C  Memory deficits  Aphasia  Apraxia  Agnosia  Personality more or less preserved  MMSE valid FRONTAL/SUBCORTI CAL  Memory deficits  Loss of behavioral plasticity and adaptability, judgment  Personality changes  Disinhibition  Abulia  Urge incontinence  MMSE useless
  7. 7. THE REST OF THE HISTORY  Time course  Depressive symptoms  Past medical history  Medical and psychiatric conditions  Family Hx  EtOH  Medications (including OTC, OPM)
  8. 8. THE REST OF THE EXAM  Physical exam  Neurologic exam  Mental status exam
  9. 9. THE FOLSTEIN MMSE  Most studied and used of the standardized exams  Quick and easy to administer  Excellent inter-rater reliability  Accurately measures the severity and progression of Alzheimer’s disease  Does not detect executive deficits at all
  10. 10. BEYOND THE MMSE  ATTENTION: digit span or “DLROW”  MEMORY: 3 word recall, orientation  POSTROLANDIC: naming, praxis, calculations, intersecting pentagons  EXECUTIVE: contrasting programs, Luria figures, go-no go, controlled word fluency, frontal release signs
  11. 11. LURIA’S RECURSIVE FIGURES
  12. 12. LURIA’S RECURSIVE FIGURES
  13. 13. LURIA’S RECURSIVE FIGURES
  14. 14. THE GERIATRIC DEPRESSION SCALE (GDS)  Good screen for most patients  Easy to administer and score  Face-valid, so patients can “fake good” or “fake bad”  Valid for demented patients with an MMSE above about 12  Use DMAS or Cornell scale for severely demented patients
  15. 15. THE REST OF THE WORK- UP  Basic labs  Thyroid function tests  B12 (methylmalonic acid and homocysteine if borderline)  Serology  HIV, drug screen, others, as indicated  Neuroimaging study, usually  LP or EEG, rarely
  16. 16. PLEASANT SURPRISES  Depression  Iatrogenic (anticholinergics, sedatives, narcotics, H2 blockers, multiple meds)  Hypothyroidism  B12 deficiency  Neurosyphilis  Alcoholic dementia  Normal pressure hydrocephalus  Subdural hematoma  Others
  17. 17. POSTROLANDIC DEMENTIAS  Alzheimer’s disease  Diffuse Lewy body disease
  18. 18. ALZHEIMER’S DISEASE  Slowly, insidiously progressive postrolandic dementia; executive sx’s much later  Neurologic exam, labs, neuroimaging studies unremarkable  Often familial, especially in younger patients
  19. 19. ANTI-DEMENTIA DRUGS  May improve cognitive function, ADL’s to a modest extent; often ineffective  Dechallenge if no meaningful benefit  Possibly delay nursing home placement  Cholinesterase inhibitors may cause nausea, diarrhea, weight loss  Memantine occasionally causes agitation  THESE AGENTS DO NOT SLOW THE RATE OF DECLINE
  20. 20. A TYPICAL STUDY
  21. 21. BEWARE!
  22. 22. DIFFUSE LEWY BODY DISEASE  Second most common dementia in autopsy studies  Characterized by Lewy bodies throughout the cortex  Non-familial  2:1 male:female ratio
  23. 23. CLINICAL FEATURES  Postrolandic dementia  More rapidly progressive than AD  Fluctuation, episodes of “pseudodelirium” common  Mild parkinsonism  Tremor often absent  Poor response to antiparkinsonian meds  Shy-Drager sx’s common  Prominent psychotic sx’s, esp visual hallucinations  SEVERE NEUROLEPTIC INTOLERANCE
  24. 24. FRONTAL/SUBCORTICAL DEMENTIAS  Vascular dementia  Frontotemporal dementia and Pick’s disease  Alcoholic dementia  Huntington’s disease, Wilson’s disease, progressive supranuclear palsy, late Parkinson’s disease  AIDS dementia complex, neurosyphilis, Lyme disease  Normal pressure hydrocephalus  Most head injuries  Anoxia, carbon monoxide  Multiple sclerosis  Tumors  ANY ADVANCED DEMENTIA
  25. 25. TYPES OF VASCULAR DEMENTIA  Multi-infarct dementia  Small vessel disease  Lacunar state (gray > white)  Binswanger’s disease (white)  Hemorrhagic vascular dementia  Strategic infarct dementia  Dementia due to hypoperfusion
  26. 26. SMALL VESSEL DISEASE  At least 50% of all vascular dementia  Often coexists with MID  Usual vascular risk factors, especially HPT  Steady, not step-wise deterioration  Relatively more abulia than disinhibition
  27. 27. FRONTOTEMPORAL DEMENTIA  Relatively uncommon, non-familial illness  Prominent (macroscopic) atrophy of frontal and anterior temporal cortex  Symptoms include executive deficits, Klüver-Bucy syndrome  About 25% of pts have Pick bodies
  28. 28. MANAGEMENT
  29. 29. BEHAVIORAL PROBLEMS IN DEMENTIA  Present in 80% of cases  Major source of caregiver stress, institutionalization  Common at all stages of the disease  Much more treatable than the underlying dementia  Poorly described in the literature
  30. 30. WOOF. MEDS OTHER
  31. 31. THREE BASIC PRINCIPLES  Simplicity  Limited goals  The “no-fail” environment
  32. 32. “THE CUSTOMER IS ALWAYS RIGHT!”
  33. 33. DEPRESSION  20-30% incidence in Alzheimer’s disease, often early in the course of the illness  Most important treatable cause of excess disability  Responds very well to treatment
  34. 34. ACUTE BEHAVIOR CHANGE  I atrogenic  I nfection  I llness  I njury  I mpaction  I nconsistency  I s the patient depressed?
  35. 35. AGITATION  Present in up to 80% of patients  Up to 34% of patients are combative  Few predictors  Probably a very heterogeneous problem  Cornerstone of treatment is nonpharmacologic
  36. 36. EMPIRICALLY EFFECTIVE MEDS FOR AGITATION  Atypical neuroleptics (best when agitation is clearly related to delusions or hallucinations)  Anticonvulsants  Trazodone  Beta-blockers  Buspirone  Benzodiazepines  Others
  37. 37. THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one) WHEN IN DOUBT, GET RID OF MEDICATIONS!
  38. 38. DON’T FORGET SAFETY ISSUES!  DRIVING  FIREARMS  POWER TOOLS  SMOKING IN BED  POISONS, MEDICATIONS  FALL RISK
  39. 39. WOOF! MEDS OTHER GOOD LUCK!
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