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Dementia early

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  • 1. EARLY DIAGNOSIS OF Dementia By Abeer Mahmoud Ass.professor of psychiatry , institute of psychiatry, Ain shams University
  • 2. Early diagnosis of dementia
    • Many evidence suggest that whatever the level of disability, the majority of people with dementia live in their own home.
    • Other practioners is therefore the first point of contact with them and their families, as a result, half of dementia cases remain undiagnosed.
  • 3. Advantages of early diagnosis
    • Advantages to patients include:
      • Confirm the diagnosis
      • Excluding treatable causes (however rare)
      • Planning support and avoiding crises.
    • Advantages to Families:
      • Awareness of prognosis and the disease course, time to organize support and plan for the future.
      • Opportunities to make appropriate legal arrangements and time to consider genetic counselling.
      • Better quality of life through enhanced knowledge and anticipation of problems.
  • 4. Hazards of early diagnosis
    • Early recognition of dementia might lead to disclosing the diagnosis creating anxiety and provoking a depressive reaction .
    • Relatives could also experience shame , stigma , anxiety and isolation ; they might alter their relationship with the patient .
  • 5. Diagnostic Approach to Dementia
    • To make the diagnosis, the clinician must document evidence of intellectual and practical functional decline in:
    • 1. Cognitive function
    • Decline in short and long term memory and in at least one other area of cognitive function (attention, abstraction, language, praxis, visual-spatial relationships, judgment, and calculations) or personality changes.
    • Decline and/or interference with work, social and interpersonal activities, or with the ability to function within society.
    • The decline is not part of a delirium, acute confusional state, and cannot be accounted for by psychiatric illness
  • 6. Early Signs of Possible Dementia
    • Memory loss that affects home or job skills
    • More frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something's wrong.
    • Difficulty performing familiar tasks
    • All of us occasionally get distracted and leave something on the stove too long or don't remember to serve part of a meal. People with dementia might prepare a meal and not only forget to serve it but also forget they made it.
  • 7. Early Signs of Possible Dementia,cont,
    • Problems with language
    • People with dementia may forget simple words or substitute inappropriate words, making their sentences difficult to understand.
    • Disorientation to time and place
    • Occasional momentary forgetting of the day of the week is normal. People with dementia can become lost on their own street, not knowing where they are, how they got there, or how to get back home.
  • 8. Early Signs of Possible Dementia,cont ,
    • Poor or decreased judgment
    • People with dementia, however, may dress inappropriately in more noticeable ways, wearing a bathrobe to the store or several blouses on a hot day.
    • Problems with complex and abstract tasks
    • People with dementia may find recognizing numbers or performing basic calculation to be impossible.
  • 9. Early Signs of Possible Dementia,cont ,
    • Misplacing things
    • People with dementia may put things in inappropriate places — such as an iron in the freezer or a wristwatch in the sugar bowl — and then not recall how they got there.
    • Changes in mood or behavior
    • People with dementia tend to exhibit more rapid mood swings for no apparent reason.
  • 10. Early Signs of Possible Dementia,cont ,
    • Changes in personality
    • Personality may change as people age. People with dementia often exhibit dramatic, either sudden or over a period of time, personality changes.
    • Loss of initiative
    • All of us normally tire of housework, business activities, or social obligations. People with dementia may remain uninterested and uninvolved in many or all of their usual habits.
  • 11. Overlap with
    • Normal aging
    • Forgets parts of normal experience
    • Forgets words or names
    • Delayed recall of names
    • Able to follow written directions
    • Able to use notes & cues from environment
    • Able to follow a story in the book or TV.
    • Slower calculations
    • Able to maintain self-care
  • 12. Overlap with
    • Mild cognitive impairment
    • Subjective memory complaint
    • Detectable memory deficit abnormal for age.
    • Normal general cognitive functioning.
    • Normal activities of daily living
    • 40% of those aged above 65.
    • 4 fold greater risk of progression to AD
    • 80% progress to AD over a 10 year period
    • Early detection and follow up (SPECT,MRI)
    • Early intervention may lead to an improved prognosis
  • 13. The interface of depression & dementia
    • Depression in patients with dementia (10 – 40%).
    • Cognitive impairment in depressed patients.
    • Symptoms common to both:
        • Apathy
        • Anhedonia
        • Insomnia
        • Agitation
        • Memory loss
        • Difficulty in concentration
  • 14. Depression
    • Depression is perhaps the most common cause of "reversible" dementia in the geriatric population.
    • With abrupt onset and short duration.
    • Previous psychiatric history may present.
    • Presence of other depressive symptoms
    • Elderly depressed patients may present with cognitive impairment, i.e., confusion, memory disturbance, attention deficits, all of which can be mistaken for dementia.
    • Memory disturbance equal for recent and remote one.
    • Depression may also coexist with dementia and worsen the problem.
  • 15. Delirium
    • Abrupt onset
    • Short duration
    • Reversible
    • Early disorientation and altered consciousness
    • Fluctuating course
    • Prominent physiological changes
    • Marked psychomotor changes.
  • 16. Alzheimer's disease
    • Alzheimer's is the most common cause of dementia (50-60%).
    • Alzheimer's disease (AD) is gradual progressive, neurodegenerative disorder
    • The clinical symptoms include memory loss, language disorders, visual-spatial impairment, and behavioral disturbances.
    • AD may present with a variety of symptoms, but difficulties with memory are common to all.
    • For a diagnosis of probable AD, the criteria are:
    • a. Dementia established by examination and objective testing
    • b. Deficits in two or more cognitive areas
    • c. Progressive worsening of memory and other cognitive functions
    • d. No disturbance in consciousness
    • e. Absence of systemic disorders or other brain diseases, which could account for the deficits in memory and cognition
  • 17. Vascular dementia
    • Vascular dementia (VaD) may arise as a sequel to any form of cerebrovascular disease.
    • VaD is responsible for approximately 20 percent of dementia cases.
    • As a co-morbid condition , VaD may worsen the dementia of Alzheimer's disease.
    • Diagnosis of probable vascular dementia is supported from the following criteria:
    • a. sudden onset of dysfunction in one or more cognitive domains
    • b. Stepwise deteriorating course
    • c. presence of focal signs on neurological examination .
    • d. History of previous strokes
    • e. Evidence of stroke risk factors and of systemic vascular disease.
    • f. Evidence of relevant CVD by brain imaging,
  • 18. Treatable and comorbid conditions
    • 13% of all dementias are potentially reversible.
    • Treatable causes of dementia occur in 21% of those under 65 and 5% of those over 65 %.
    • The clinician must identify the coexisting medical conditions which may worsen the dementia. "co-morbidity."
    • Undetected or untreated comorbid conditions may exacerbate an already existing cognitive impairment.
    • The most common comorbid conditions affecting demented patients are: Parkinson's disease, depression, infections (particularly urinary tract, congestive heart failure, and chronic obstructive pulmonary disease.
  • 19. Comprehensive patient evaluation includes:
    • A complete medical history and physical examination
    • Neurological and mental status assessments
    • Neuropsychological assessment
    • Investigations: blood and urine, electrocardiogram, electroencephalogram (EEG), lumbar puncture, imaging exam (CT or MRI).
  • 20. Investigations Lab Work a. CBC, electrolytes and calcium, renal function, VDRL , Thyroid function studies, B12 level, level of oxygenation. b. Consider HIV testing, drug screening, toxin screen, collagen-vascular studies, general biochemical screens Imaging Study a. Duration of cognitive complaints less than 6 months b. Symptom onset before the age of 60 c. Focal signs, focal symptoms, or papilledema d. Diagnosis of a seizure by history, or usual gait abnormalities (e.g.. ataxia or apraxic gait)
  • 21. Medication-induced dementia
    • Medication-induced dementia is the most frequent cause of "reversible" dementia.
    • Alterations in pharmacokinetics and pharmacodynamics, together with the presence of concomitant illnesses (especially renal, hepatic, and cardiac) and the number of prescribed medications taken, all make older people more vulnerable to this.
  • 22. Metabolic/endocrine/nutritional/ systemic disorders
    • Metabolic/endocrine/nutritional/systemic disorders (e.g., hypothyroidism, B12 deficiency, and systemic infections) are additional causes of "reversible" dementias.
    • Diagnose with routine laboratory tests.
  • 23. Other Conditions
    • HIV dementia.
    • The most common of the structural brain lesions, presenting with dementia.
    • Normal pressure hydrocephalus (dementia, gait disturbance, and incontinence).
    • Brain tumors, and subdural hematoma .
  • 24. Behavioral Symptoms Associated with Dementia
    • Behavioral problems may appear slowly and change as dementia progresses. The most common problematic behaviors are: agitation; aggression , suspiciousness/paranoia; delusions; hallucinations; insomnia; and wandering
  • 25.  
  • 26.
    • Thank you