The document discusses the approach to dementia. It begins with definitions of dementia and mild cognitive impairment. There is impairment in neuropsychological abilities, behavior, activities of daily living, and quality of life in dementia patients. A thorough history, physical and neurological examination is essential to determine the type and cause of dementia. Investigations including blood tests, imaging and cognitive assessment scales help arrive at a confirmed diagnosis and identify any reversible causes. The most common types of dementia like Alzheimer's, vascular dementia, frontotemporal dementia and Lewy body dementia present with varying initial symptoms, mental status, neuropsychiatric and neurological features.

1. Approach to Dementia
Dr. Aminur Rahman
FCPS (Med), MD(Neuro) ,FINR (Switzerland), FACP (USA)
Fellow Interventional Neuroradiology (Thailand)
Assistant Professor
Department of Neurology
Sir Salimullah Medical College

2. Dementia
Definition:
• Dementia is defined as an acquired deterioration in
cognitive abilities that impairs the successful
performance of activities of daily living (ADL).

3. Mildcognitive impairment (MCI)
• MCI is a state intermediate between normal
cognition and dementia, with essentially
preserved functional abilities.

4. Domain of impairment
A. Neuropsychological
B. Behavioural
C. Activities of daily living (ADL)
D. Quality of life (QOL)

5. Neuropsychological problems- 80%
1. General intelligence (verbal & nonverbal)
2. Memory (verbal and visual)
3. Language
4. Orientation
5. Visuospatial perception
6. Frontal lobe (executive) function

6. Behavioral disturbances
1. Agitation
2. Personality changes
3. Abnormal eating
behaviours
4. Wandering
5. Affective disorders/mood
disorders
6. Incontinence
7. Anxiety, phobias, fears
8. Delusions
9. Restlessness
11. Demanding/critical behaviour
12. hallucinations
13. Illusions
14. Shouting/screaming
15. Rage/violence
16. Disinhibition
17. Sleep-wake disturbances
18. Sexual behabiours
19. Compulsive/ritualistic
behaviours

7. ADL
A. Baseline self-care abilities
1. Eating, drinking
2. Toileting, washing
3. Walking
4. Dressing
B. Complex everyday activities
1. Shopping
2. Food preparation
3. House keeping
4. Finances
5. responsibilities

8. In Dementia, there is-
• Neuropsychological problems
• Behavioural disturbances
• Impaired ADL
Leading to-
• Reduced QOL

9. Approach to Dementia
A. Determine presence of Dementia -Decision is
solely & essentially clinical
B. Determine primary degenerative/other potential
treatable causes of dementia
C. Co-morbid medical illness. Treatment of an
intervening illness may reverse a worsening of
dementia
Key points:

10. A. History of Present illness :Obtain a meticulous history
(with temporal profile)
A. Rate of intellectual decline
B. Impairment of social function
C. General health & relevant disorders-stroke, head injury
B. History of past illness
C. Nutritional status
D. Drug history
E. Personal history
F. Family history of dementia
G. Occupational history - toxins
Approach to Dementia- History

11. A. History of present illness:
I. Age
-Younger: Secondary cases
-Older: AD/other primary dementia
II. Sex:
– More women are affected by dementia than men.
– Worldwide, women with dementia outnumber men
2 to 1.
Approach to Dementia - History (Contd.)
Evaluation:

12. Approach to Dementia - History (Contd.)
III. Meticulous history from
-Patient
-Independent informate
-Spouse
1. Patient difficulties:
• Difficulties patient having
• Family member notice

13. EN MID CZD NPH, AD
Approach to Dementia - History (Contd.)
2. Time course & progression
Weeks Months Years

14. Approach to Dementia - History (Contd.)
a) Onset:
i) Early onset e.g.. CADASIL
Deficiency states
Postencephalitic
SSPE
Wilson’s Disease
Leukodystrophy
ii) Late onset e.g.. Alzheimer’s disease (AD)

15. Approach to Dementia - History (Contd.)
b) Duration:
i) Long duration – AD
ii) Short duration – Chronic subdural haematoma,
Creutzfeldt-Jakob disease (CJD)
c) Temporal progression:
i) Slowly progressive – AD
ii) Relentlessly progressive – CJD, Huntington’s disease,
other infections

16. 3. Function of the patient
a) At work
b) At home
c) Performance of basic activities of daily life
4. Issue of safety
 Driving
- accident, traffic violation, lost in driving
Danger
- to patient/others
Approach to Dementia- History (Contd.)

17. 5. Etiologically directed history:
a) Vascular disease-Risk factors
b) Infections/toxic/metabolic/trauma
c) Psychiatric-depression, insomnia, agitation
Approach to Dementia- History (Contd.)

18. Approach to Dementia – History (Contd.)
B. Past illness:
Gastric surgery – vit. B12 deficiency
Chancre – Neurosyphilis
C. Nutritional status :
– Malnutrition has been associated with more severe
symptoms of dementia
D. Drugs – sedatives, tranquilizers
E. Personal history:
Alcohol – thiamine deficiency
I.V. drug users – HIV infection

19. Approach to Dementia - History(Contd.)
F. Occupational history:
Working in chemical factory – lead, mercury etc.
G. Family history:
– HD
– AD
– Frontotemporal Dementia (FTD)
– Wilson’s Disease
– CADASIL
– Some Hereditary Ataxias etc.

20. A. Problem with intellect-
1. Memory impairment & judgment
2. Abstract thinking
B. Orientation problem-
1. Time (Day)
2. Place (Where)
3. Person (Who)
C. Difficulties with language
D. Change in personality
1. Anxiety
2. Agitation
3. irritability
Approach to Dementia – clinical features

21. Approach to Dementia – clinical features
A. Poor memory : Persistent complaint(recent > remote)
B. Disturbed behaviour :
1. Personality
2. Mood
3. PerceptioN
4. Attention and Concentration
C. As dementia worsens:
1. Less able to self care
2. Neglect social connection
3. Disoriented
4. Slowing of thought
5. Behaviour aimless, stereotypic mannerism
6. Persecutory delusion
7. Mute

22. Table: Dementia associated prominent behavioral features
Major Types Dementias Associated behavioral disturbances
A. Alzheimer disease  Depression,
 Irritability & Anxiety,
 Apathy,
 Delusions,
 Paranoia &Psychosis
A. Lewy body dementia  Fluctuating confusion,
 Hallucinations, Delusions,
 Depression &
 Rapid eye movement behavior disorder (RBD)
A. Vascular dementia  Depression, Apathy, Psychosis
A. Frontotemporal
dementia
 Early impaired judgment,
 Disinhibition,
 Apathy,
 Depression,
 Delusions &
 Psychosis.
A. Parkinson’s disease  Depression,
 Anxiety,
 Drug associated hallucinations and Psychosis &
 RBD.
A. Corticobasal
degeneration
 Depression,
 Irritability,
 RBD and Alien hand syndrome.

23. Neurological examination:
1.Mental state:
Difficulties in assessing in
I. Lethargic
II.Inattentive
III.Aphasic
IV.Agitation: Evening disorientation & agitation is called
Sun downing occurs in Primary Dementia
a. Alertness/ attentiveness:
 Depends on education level
 Serial 7s
 Count back words
Approach to Dementia – Physical Examination

24. b. Memory:
Immediate recall
Short term/long term memory
c. Aphasia:
Fluency
-Non fluent speech
-Loss of grammar/syntax
-Word finding difficulties
Naming
-Anomia- Non specific
Auditory comprehension of single & multi step
commends
-Single step: Show two fingers
-Multi step: With your eyes closed tap your right knee
with two fingers of your left hand
Approach to Dementia – Examination

25.  Repetition of unfamiliar phrases
 Reading aloud
 Writing
-Name
-Directed sentences
-Spontaneous sentences
 Listen for paraphasic error
-Phonemic: tadle for table
-Semantic: door for window
d. Calculations:
 Educational level
-Two digit addition/multiplication
Approach to Dementia – Examination
Contd.

26. e. Hemineglect:
 Target cancellation
- Circle all letters
- Look for left right asymmetry
- Bisect horizontal line
f. Apraxia:
 Impairment of the execution of a learned/
imitated movement in absence of weakness/sensory
loss/ Incoordination
 Opening a look with key
 Ideometer
 ideational
g. Drawing
 Copy a complex figures
Approach to Dementia – Examination
Contd.

27. Approach to Dementia - examinations (contd.)
So “ A thorough examination is essential” is mandatory
 AD: Does not affect motor system untill late stage
 VaD: Hemiparesis, pseudobulbar palsy or other deficits.
 FTD: Axial rigidity, supranuclear gaze palsy
 Dementia with Lewy body (DLB): Parkinsonian features
 PSP: Unexplained falls, Axial rigidity
 CBD: Dystonia, asymmetric motor deficit, alien hand, myoclonus

28. Approach to Dementia - examinations (contd.)
 B12 deficiency: Myelopathy, peripheral neuropathy
 Other vit. Deficiency and heavy metal poisoning: Peripheral
neuropathy
 Hypothyroidism: Dry cool skin, hair loss, bradycardia
 HD: Chorea
 CRF: Anemia, HTN
 CLD: Features of portal hypertension, palmar erythema,
gynaecomastia etc.
 Paraneoplastic eg Carcinoma bronchus – clubbing

29. Korsakoff’s syndrome: ophthalmoplegia,
confabulation,
Neurosyphilis: Argyll Robertson pupil
HIV infection: Opportunistic infections, Kaposi's
sarcoma
Chronic lead poisoning: Blue lines in gums
Arsenicosis: Mee’s lines
Wilson’s disease: K. F. Ring
Approach to Dementia - examinations (contd.)

30. Assessment Scales
1. Mini mental scale (MMS)
2. Clinical dementia rating (CDR)
3. Geriatric mental state (GMS)
4. Cambridge evaluation for mental disorders (CAMDEX)
5. Community screening instrument for dementia (CISD)

31. Assessment Scales of Cognitive and Neuropsychiatric
examinations
Mini – Mental Status Examination (MMSE) is important for:
A. Diagnosis
B. Prognosis
C. Treatment

32. Assessment Scales of Cognitive and Neuropsychiatric
examinations (contd.)
Mini – Mental Status Examination (MMSE):
Points
 Orientation:
Name – season/date/day/month/year – 5 (1 for each)
Name – hospital/floor/town/state/country – ` 5 (do)
 Registration:
Identify three objects by name and ask patient to repeat –
3 (do)
 Attention and calculation :
Serial 7s, substract from 100 –------- 5 (do)
 Recall:
Recall the three objects presented – 3 (do)
Earlier

33. Assessment Scales of Cognitive and Neuropsychiatric
examinations(contd.)
Mini – Mental Status Examination (MMSE-contd.):
Points
 Language :
Name pencil and watch – 2 (1 for each)
Repeat “no ifs, ands or buts – 1
Follow a 3 step command (eg. Take this paper, fold it in half and place it on the
table) – 3 (1 for each)
 Write “ close your eyes” and ask patient to obey written command –
1
 Ask patient to write a sentence – 1
 Ask patient to copy a design - 1
Total 30
• Note: score 24 or below indicates cognitive impairment

34. Stages of the disease by MMS
A. 27-30 = Normal
B. 25-26 = Possible
C. 10-24 = Mild-moderate
D. 6-9 =Mod-severe
E. <6 = Severe

35. 1. Motor:
a. Focal weakness/neurological sign:
 Structure brain disease
- MID, SDH, ICSOL
b. Adventitial movements :
 Tremor, chorea, myoclonus
- degenerative dementia, sub cortical
c. Co-ordination & gait:
 Slow settling- PD/PD plus
 Ataxia- Wernick-korsakoff
NPH
Approach to Dementia – Examination
Contd.

36. d. Primitive reflexes / Frontal release signs:
I. Palmar grasp: Baby naturally grabs objects placed in palm.
II. Palmomental reflex: stroking on the thenar eminence of the hand
causes contraction of sub mental muscles .
III. Rooting reflex: Baby finds breast to suckle.
IV. Sucking reflex: Baby sucks breast / bottle / teat to get milk.
V. Snout reflex: Involved in suckling.
VI. Glabellar reflex: May protect eyes in certain situations.
 Selected physical examination
 Secondary reversible cause
 Factors for deteriorating, Intercurrent infection,
Electrolyte imbalance
Approach to Dementia – Examination
Contd.

37. Primitive reflexes / Frontal release signs

38. Primitive reflexes / Frontal release signs

39. Clinical differentiationof Major Dementias
Disease Initial
symptom
Mental
status
Neuropsy-
chiatry
Neurology Imaging
AD Memory loss Episodic
memory
loss
Initially
normal
Initially normal Entorhinal
&
hippocam-
pal
atrophy
Vascular
(VaD)
Often
sudden,
variable initial
symptoms,
focal lesions
Frontal/exec
-utive
cognitive
slowing, can
spare
memory
Apathy,
delusions,
anxiety
Usually motor
slowing,
spasticity, can
be normal
Cortical or
subcortical
infarctions
etc.
FTD Apathy,
reduced
judgment,/insi
ght/speech/
language,
hyperorality
Frontal/
executive,
language,sp
are drawing
Apathy,
euphoria,
depression
Vertical gaze
palsy,axial
rigidity,
dystonia
Frontal &
or
temporal
lobe
atrophy

40. Disease Initial
symptom
Mental
status
Neuropsyc-
hiatry
Neurol
-ogy
Imaging
DLB Visual
hallucination,
REM sleep
disorder,
delirium,Parkins-
onism, Capgras
syndrome
Frontal/
executive,
spares
memory
Visual
hallucinations
, depression,
delusions
Parkins-
onism
Posterior
parietal ,
hippocampus --
larger than in AD
PRION Dementia, mood
change, anxiety,
movement
disorder
Variable,
frontal/ex-
ecutive,
memory
Depression,
anxiety
Myoclon
-us,
rigidity,
Parkins-
onism
Cortical
ribboning, basal
ganglia
hyperintensities
on FLAIR MRI
Clinical differentiationof Major Dementias( Contd.)

41. Investigations for Dementia
Objectives:
• To arrive to a confirmed diagnosis in collaboration with history
and clinical findings
• To find out the reversible types of Dementia.

42. Investigations for Dementia (contd.)
A. Routine:
1. Thyroid function test: eg. Hypothyroidism
2. Serum Vit. B12 Assay- Pernicious Anaemia
3. Complete blood count (may give a clue):
 Vitamin deficiency states
 Organ failure
 Endocrinopathies
 neoplastic conditions
 Toxic causes. eg, Basophilic Stippling of RBC in
lead poisoning
 Vacuolated lymphocytes in Niemann-Pick disease
4. Electrolytes:
 Eg. Increased K+ inCRF, Addison’s Disease

43. Investigationsin Dementia (contd.)
A. Routine (contd.):
5. VDRL: Neurosyphilis, False positive in SLE
6. CT/MRI of brain (MRI preferable in most cases)
Brain atrophy in different topography in different conditions
Stroke, Binswanger’s disease
CNS infections
ICSOL
Hydrocephalus
Leukodystrophies
Wilson’s Disease
Hallervorden-Spatz Disease

44. Neuroimaging findings in different Dementias

45. Fig: Vascular dementia- Infract
Neuroimaging findings in different Dementias

46. Fig: FTD
Neuroimaging findings in different Dementias

47. Fig: DLB/ AD
Neuroimaging findings in different Dementias

48. Investigations for Dementia (contd.)
B. Optional Focused Tests:
1. Chest Skiagram:-
 Cardiomegaly- Stroke, Hypothyroidism, Anaemia,
Alcoholism, Etc.
 Ca- Bronchus
 Pulmonary Tuberculosis
 Vasculitis- SLE, Wegener’s Granulomatosis
 Sarcoidosis
2. CSF Study:
 CNS INFECTIONS. Eg. HIV, Neurosyphilis
 Decreased Aß42-Amyloid & increased tau protein in AD-
Not diagnostic

49. Investigations for Dementia (contd.)
B. Optional Focused Tests (contd.) :
3. Liver Function tests
4. Renal function tests
5. Urine toxin screen. Eg. Lead, Arsenic, Mercury
6. Apolipoprotein- E genotyping- in “AD”
7. DNA testing for Presenilin -1 (ps-1)-in “AD”

51. Alzheimer's disease

52. 1. Alzheimer's disease is the commonest form of
dementia. In this brain, the gross appearance of the
brain reveals marked atrophy.
2. The brain weighs lighter and there is atrophy of the
gyral convolutions with widening of the sulcal spaces.
Alzheimer'sdisease

53. Alzheimer's disease

54. Alzheimer's disease

55. Alzheimer's disease

56. 1. Neurofibrillary tangles are twisted, disfigured cytoplasmic
filaments found in cortical neurons.
2. They contains altered intermediate filaments. They can be
demonstrated by special silver staining methods.
3. Together with neuritic plaques, they constitute the
histological substrates of Alzheimer's disease.
Neurofibrillary tangles in Alzheimer's disease

57. Investigations for Dementia (contd.)
B. Optional Focused Tests (contd.):
8. DNA repeat expansion (CAG) OF Gene encoding Huntingtin
on chromosome-4 Diagnostic for HD.
9. Decreased transkeltolase activity in Korsakoff’s syndrome
10. Measurement of PrPsc in CJD------------ Diagnostic

58. Investigations in Dementia (contd.)
C. Occasionally helpful:
1. EEG:-
 Repetitive bursts of diffuse high voltage sharp waves
in CJD
 Non-convulsive seizure
 Encephalopathies
2.Parathyroid function
3. Adrenocortical function
4. ESR: Vasculitis, CNS infections, Malignancy

59. Investigations in Dementia (contd.)
C. Occasionally helpful (contd.):
5. Angiogram: Specially isolated CNS vasculitis
6. Brain & Meningeal biopsy:
Not routine
Isolated CNS vasculitis
Potentially treatable neoplasm
Young persons where diagnosis is uncertain
7.SPECT:
Not routine
In atypical “AD”- Hypometabolism & hypoperfusion in
posterior temporo-parietal cortex
8.PET:- Almost exclusively a research tool

60. Conclusion
 Proper diagnosis of Dementia is essential for therapeutic &
prognostic purposes.
 Thorough history & clinical examination are indispensable. In
many situations, these two can produce the confirmed
diagnosis even without laboratory investigations.
 A patient of Alzheimer’s disease may have stroke without
Dementia & vice- versa.
 In many situations, laboratory investigations are adjunctive, not
diagnostic.
 In some situations, laboratory investigations are confirmatory.
Eg. CNS infections, ICSOL, Wilson’s disease, toxic conditions, HD,
etc.

61. Thank you