Dementia an overview

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Dementia an overview

  1. 1. DEMENTIA – AN OVERVIEWDr. A.V. Srinivasan, Dr. S. Yogaraj, Dr. G. Sarala Dr. A.V. Srinivasan Addl. Prof. of Neurology Institute of Neurology Chennai – 600 003
  2. 2. GLOSSARY OF TERMS1) MCI2) Dementia3) Amnesia a) Retrograde Amnesia b) Anterograde Amnesia4) Amentia5) Senescence (Benign forgetfulness ) Mind is the great level of all things;human thought is the process by which human ends are ultimately answered - Daniel Webster
  3. 3. PHONE CALLS / HISTORY• What is the patient’s predominant neurologic condition? In addition to memory loss, is there confusion, agitation, delirium or stupor?• Is this new memory dysfunction or does the patient have known dementia?• How old is the patient?• Does the patient have acute medical problems? In all of us, even in good men, there is a wild - beast nature which peers out in sleep
  4. 4. Elevator Thoughts / Walking ThoughtsV (vascular): Cerebral infarction, Multiple strokesI (infectious): Syphilis, Chronic meningitisT (traumatic): Subdural hematoma, head injuryA (autoimmune): CNS vasculitis, Multiple sclerosisM (metabolic/toxic): Renal failure, Hepatic failureI (idiopathic/inherited): TGA, Alzheimer’s diseaseN (neoplastic): Brain tumour, Meningeal carcinomatosisS (seizure, pSychiatric, structural): Complex partial seizure, postictal state Thinking is the hardest work there is, which is probable reason why so few engage in it. - Henry Ford
  5. 5. Selective Physical Examination • HEENT • Cardiopulmonary • Abdomen • ExtremitiesSuccess in life is a matter not so much of talent and opportunity as of concentration and perseverance - C.W. Wendte
  6. 6. Neurological Examination1) Mental status a) Alertness b) Aphasia 1) Fluency 2) Naming 3) Auditory comprehension of single and multi step commands 4) Repetition of unfamiliar phrases 5) Reading aloud 6) Writing 7) Listen for phonemic paraphasias Habit is either the best of servants or worst of masters - Nathaniel Emmons
  7. 7. Neurological Examination c) Memory d) Calculations e) Hemineglect f) Apraxia g) Drawing2) Motor3) Coordination and gait4) Frontal “release” signsIt is the disease of not listening, the malady of not marking, that I am troubled withal - Shakespeare
  8. 8. Classification of Dementia1) Aetiological classification2) According to localization of pathological process3) Brain structures involved (cortical and subcortical dementias)4) DSM & ICD multiaxial coding syste,Of these, the etiological classification is themost commonly used one Memory, the daughter of attention , is the teeming mother of knowledge - Martin Tupper
  9. 9. Classification of Dementia • Alzheimer’s disease (AD) • Vascular Dementia (VaD) • Lewy Body Dementia • Pick’s Disease • Reversible DementiaWe possess by nature the factors out of which personality can bemade, and to organize them into effective personal life is every man’s primary responsibility - Harry Emerson Fosdick
  10. 10. Selected causes of potentially Reversible DementiaMetabolic disorders Thyroid disease Electrolyte imbalance Renal failure Liver failureAdverse drug reactions Sedative hypnotics Barbiturates Anticholinergics Many othersAutoimmune disorders Vasculitis Lupus erythematosus Time and Wo rds canno t be re calle d - Fulle r
  11. 11. Selected causes of potentially Reversible DementiaInfections AIDS encephalopathy Syphilis Lyme encephalitisTumours Primary MetastaticPoisoning Heavy metals Insecticides alcohol Discipline Weighs ounces Regret weighs Tons
  12. 12. Selected causes of potentially Reversible Dementia Nutritional Deficiencies Vitamin B6, B12 Thiamine Folate Psychiatric disorders Depression Other Normal pressure hydrocephalus Head trauma“Character gets you out of bed commitment moves you to action faith, hope and Discipline follow through to completion”
  13. 13. Frequency of causes of Dementia pooled from 32 studies Cause Occurrence (%)Alzheimer’s disease (AD) 57Vascular Dementia 13Depression 4.5Alcohol 4.2Normal pressure hydrocephalus 1.6Metabolic 1.5Medication 1.5Neoplasm 1.5
  14. 14. Frequency of causes of Dementia pooled from 32 studies Cause Occurrence (%)Parkinson’s disease 1.2Huntington’s disease 0.9Mixed AD & VD 0.8Infection 0.6Subdural haematoma 0.4Post-trauma 0.4Others 7.1Not demented 3.7
  15. 15. Management• Check the vital signs• Check the finger stick glucose level• Order the following laboratories tests stat: Complete blood count (RBC) Chemistry panel Erythrocyte sedimentation rate (ESR) Electrocardiogram (ECG) Chest X-Ray Urinalysis Toxicology screen and ethanol level (if indicated) If the patient is too agitated to examine, follow the algorithm of delirium Opinion is ultimately determined by the feelings and not by the intellect
  16. 16. Selective History and Chart Review• What was the time course of onset of the patient’s memory dysfuncion?• Has the patient started any new medication within the time frame of the memory loss?• Is there any underlying medical illness?• Have there been other cognitive or behavioural changes bedsides memory loss, such as difficulty making change in the grocery store, change in reading habits, or disorientation, particularly in the evening?• Is there any history of head trauma? The True Art of Memory is The Art of Attention - S.Johnson
  17. 17. Medications that may be associated with memory impairment Corticosteroids Chlorpromazine Isoniazid Anticonvulsants (overdose) Benzodiazepines Interleukins Barbiturates Methotrexate Bromides Clioquinol (antifungal) Success is a prize to be won. Action is the road to it.Chance is what may lurk in the shadows at the road side. - O. Henry
  18. 18. ManagementDiagnostic Testing1. Blood tests (Thyroid function tests, Venereal Disease Research Laboratory (VDRL) test, Vitamin B12 level, HIV testing (if indicated))2. Imaging (CT, MRI, SPECT, PET, TGA)3. Electroencephalogram (EEG)4. Lumbar puncture People of mediocre ability often achieve success because they don’t know enough to quit - Bernard Baruch
  19. 19. TreatmentTreatment of Behavioral Dysfunction1. Agitation, delusions or hallucinations/ illusions2. Insomnia3. Anxiety4. Depression At twenty the will rules At thirty the intellect At forty the Judgment
  20. 20. Disease specific Treatment of the Pathophysiologic Process1. Alzheimer’s disease2. Parkinson’s disease, Lewy body disease and progressive supranuclear palsy3. Normal pressure hydrocephalus4. Huntington’s disease5. AIDS dementia complex6. Transient global amnesia7. Wernicke-Korsakoff syndrome Maintaining the right attitude is easier than regaining the right mental attitude
  21. 21. Two diverging/converging pataways associated with VaDRisk factor CVD Ischemic Brain injury MRI lesion Clinical syndromeHTNArteriosclerosis 1. occlusion complete infarct lacune  lacunnar stateArteriosclerosis 2. Hypoperfusion incomplete infarct WHSM  Bingswanger syndrome Experience can be defined as yesterday’s answer to today’s problems
  22. 22. Pathogenesis of dementia due to VaD 1. Lacunar hypothesis 2. Binswanger’s subtype of VaD 3. VaD with coexisting Alzheimer’s disease Expert is one who think to his chosen mode of ignorance
  23. 23. Clinical syndromes1. Lacunar state --- 85%2. Strategic infarct dementia(e.g. thalamic dementia) --- unknown %3. Binswanger’s syndrome --- 10 – 15% Take time to think; it is the source of power Take time to read; it is the foundation of wisdom Take time to work; it is the price of success
  24. 24. Features suggestive of vascular dementiaFrom the history Onset associated with a stroke Improvement following acute event Abrupt onsetFrom the exam Findings typical of stroke e.g., hemiparesis, hemianopiaFrom imaging Infarct(s) above the tentorium Every thing should be made as simple as possible; but not simpler
  25. 25. Patterns of blood supply to the cerebral hemispheres Vascular Arterial supply Collateral supply distributionCortex shorterCorpus callosum ShorterSub cortical U fibers Intermediate Inter digitatingExternal / extreme IntermediatecapsulesBasal Ganglia LongCentrum semiovale /PVWM Long Medical School can be a tool of torture or an Instrument of Inspiration”
  26. 26. Categories of vascular Dementia Category Clinical presentationLacunar infarctions Progressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke historySingle strategic infarctions Sudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndromeMultiple infarctions Step-wise appearance of cognitive & motor deficitsMixed AD – VaD Progressive dementia with remote or concurrent history of strokeWhite matter infarctions Dementia, apathy, agitation, bilateral cortico-(Binswanger’s disease) spinal/bulbar signs Character gets you out of bed commitment moves you to action faith, hope and Discipline follow through to completion
  27. 27. Diagnosis Vascular Mechanism of Pathological distribution Brain injury phenotype “Infarct”Single artery Acute ischemia Multiple lacunarSmall arteriole infarctsSingle artery Acute ischemia Single strategically placed lacunar infarctBorder zone Chronic White matterSmall arteriole hypo perfusion demyelination and axonal loss It is the providence of the knowledge to speak and it is the privilege of the wisdom to listen - Hodly’s
  28. 28. Diagnostic criteria1. Hachinski’s ischemic score2. DSM IV criteria3. ADDTC criteria4. NINDS – AIREN criteria5. Binswanger’s criteria Give us the GR ACE to acce pt with se re nity the thing s that canno t be chang e d the COUR AGE to chang e the thing s that sho uld be chang e d and the WISDOM to kno w the diffe re nce
  29. 29. Short comings1. Not interchangeable hence four fold rise in frequency2. DSM IV R most liberal3. NINDS- AIREN criteria conservative4. Gold standard for VaD (pathological definition difficult)5. Most of the criteria failed to distinguish between small and large vessel subtypes “HealthyMind and Healthyexpression of Emotion go hand in Hand”
  30. 30. Diagnosis of Dementia after stroke4 sets of criteria are used Sens Spec1.Hachinski ischemic score 89% 89%< 4 AD / 18, > 7 MID / 182. DSM IV 43% 95%3. NINDS – AIREN 50% 98%4. ADDTC criteria 50% 90%Every discovery contains an irrational element or 4 creative intuition Khrl Popper
  31. 31. Clinical characteristics of Neuro behavioral syndrome of VaD • Mental changes of dementia with single brain lesion • Sub cortical infarcts • Multi Infarct Dementia: - • Sub cortical arteriosclerotic leukoencephalopathyA great many people think they are thinking when they are merely re arranging their prejudices W. James
  32. 32. AD Vs VaD AD VaDNeuro transmitter defect Hemodynamic defectFemale predominance Male predominanceGradual onset Abrupt onsetSteady deterioration Stepwise deterioration, fluctuating courseBP normal HypertensionNo history of stroke History of strokeGlobal decline in cognitive function Focal neurological symptoms and signsUnlikely to respond to treatment May respond to a drug which modifies microcirculation and enhance cerebral tissue perfusion T T he ruth is fear and immorality are two of the greatest inhibitors of Performance to progress
  33. 33. Prognosis1. Risk factors• Advanced age• Education Develops dementia• Lacunar subtype following ischemic• Lt. Hemisphere CVA stroke• Non white “ Fools Adm but of m of sense approve” ire en - A. Pope
  34. 34. Prognosis contd….2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHence• Atrophy• cognitive impairment• WMSH are inter related in VaD “ Social Isolation is in itself a pathogenic Factor for disease production”
  35. 35. Prognosis contd..,Neuro imaging phenotype• CT lucency (lacunes and leukoariosis)• MRI hyper intensity (lacunes and WMSH) A true com itm is a heart felt prom to m ent ise yourself fromwhich y will not back down - ou D. Mcnally
  36. 36. Prevention and Treatment of vascular dementiaI. Brain at risk stage The aged Hypertensive Smokers Diabetics Atrial fibrillators Cardiac patients Serious, sincere, systematic studies, surely secure supreme success
  37. 37. II. Pre-dementia stage Patients with TIA Patients with stroke Patients with subtle cognitive infarctions Patients with silent cerebral infarctions “Men of Genius Adm ired: Men of W ealth envied wom of power feared but only en wom of character are trusted” en A- Friedman
  38. 38. III. Dementia stage Cardiac embolism Atherosclerotic cerebrovascular disease Hypertensive cerebrovascular disease “Motivation is the Spark that lights the Fire of Knowledge and fuels the engine of Accomplishment”
  39. 39. Potential therapies of vascular dementia1. Brain at risk stageSmoking cessationExercise (prevention and management of diabetes)Diet (control of diabetes, hyperlipidemias, obesity)Antihypertensives (ACE inhibitors and ca++ channel- blockers maybe particularly suitable)Lipid lowering agentsAnticoagulants (for atrial fibrillation)Aspirin (for selected patients at high risk)“Peace Rules the day where reason Rules the mind” Colling
  40. 40. 2. Pre-dementia stageCarotid endarterectomy (symptomatic patients with -carotid stenosis of 70-99%)AnticoagulantsAspirinTiclopidineAgents that interfere with amyloid deposition vesselsCa++ channel blockers (pre treatment to attenuate -effect of infarcts) “ByNature All Men/W en are alike but om byEducation widelydifferent” - Chinese
  41. 41. 3. Dementia stageAntidepressentsAntihypertensives – 6 mm of Hg reduction in systolic or diastolic BP -reduces the risk of stroke by 40%Cholinergics - Tacrine, Galantamine, rivastigmine, donepezilNMDA antagonist – MemantineAspirinTiclopidineThe Truth is fear and im oralityare two of the greatest m inhibitors of P erformance too progress
  42. 42. Prevention & TreatmentAnti dementia drug trials (not based on subtype of VaD)Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetam Modest benefitMemantineDonepezilGingko biloba “ He who cannot forgive others destroy the bridge s over which he him m pass” - Annoy self ust
  43. 43. Role of RIVASTIGMINE in VaDNo.of patients : 15Age group : 50 – 80 yearsFemale : 6Male : 9Most of them had diabetes and hypertensionNot based on subtype of VaD30% showed remarkable improvement in cognitive, curative and affective functions of the brainFuture study needed in pre dementia and dementia stages Thought is the labour of the intellect Reverie is its pleasure
  44. 44. Strategies to prevent – STROKE-TO-DEMENTIA TEN-STEP APPROACH1. Treat hypertension optimally2. Treat diabetes3. Control hyperlipidaemia, use dietary control for diabetes, obesity and hyperlipidaemia4. Persuade patients to cease smoking and decrease alcohol intake5. Prescribe anticoagulants for atrial fibrillation6. Provide antiplatelet therapy for high risk patients A open foe may prove a curse ; but a pretended friend is worse
  45. 45. Strategies to prevent – STROKE-TO-DEMENTIA contd…7. Perform carotid endarterectomy for severe (>70%) carotid stenosis8. Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake)9. N-methyl-D-aspartate receptor antagonists, antioxidants)10. Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists, - ? Rivastigmine It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent La Broyers character
  46. 46. READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDERTHANK YOU“My Opinions are founded on knowledge but modified by experience”

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