A presentation I did in the psychiatry course. Disclaimer: The context are of medical students levels and are rather theoretical than clinical.

1. Dementia
Hanan Musa

2. Objectives:
Definition
Signs and symptoms
Etiology and causes
Criteria for Dementia diagnosis
Assessment and investigation
Treatment

3. Definition
One of the neurocognitive disorders, a chronic, progressive
disorder of a global impairment of cognitive functions of the
brain with clear conciousness e.g. langauge skills, behaviour,
memory and personality.
It is primarily a syndrome of the elderly
{> 65 years = senile dementia}
{< 65 years = presenile dementia}

4. Features
Early stages
• Cognitive impairment may not be apparent
• Mild memory impairment
• Subtle changes in personality
• A decrease in range of interest and enthusiasm
• Shallow affect lability of affect and agitation
• Multiple somatic complaints and vague psychiatric
symptoms
• A gradual loss of social and intellectual skills ( first
noticed in work setting where high performance is
required

5. Features con.
Late stages
• Increasing memory impairment (esp. recent memory)
• Attention impairment
• Disorientation
• Language vague and imprecise
• Impaired judgment
• Potential aggression (verbal and physical)
• Psychotic features (Hallucinations visuals, auditory)
• Emotional lability
• Catastrophic reaction

6. Risk factors
• Aging
• Cardiovascular disease
• Diabetes
• Genetics
• Family history
• Head injury

7. Etiology
Reversible
Irreversible

8. Reversible
•Vascular dementia
•Normal pressure hydrocephalus
• Metabolic causes
•Chronic infection of the brain e.g. TB
•Alcoholic dementia

9. Etiology
Reversible
Irreversible

10. Irreversible
•Alzheimer disease (most common)
•Pick’s disorder/ frontotemporal
•Huntington’s chorea
•AIDS dementia
•Creutz-Fledt Jacob’s disease

12. Alzheimer disease
• Alzheimer’s disease (50 to 60% of dementias): Progressive downhill
deterioration of intellectual functioning due to a degenerative process
affecting the whole cortex, especially cholinergic neurons.
• It affects women three times more than men, and its presence in one
first-degree relative increases the risk fourfolds; genetics play a role.
• These patients have a a decrease in acetylcholine due to a loss of
neurons in the basal ceruleus and low choline acetyltransferase
(required for acetylcholine synthesis)

13. MRI:
• Cortical atrophy
• Enlarged
ventricles

14. Vascular Dementia
• Vascular dementia is the second most common form of
dementia. It is caused by microvascular disease in the
brain that produces multiple small infarcts. A substantial
infarct burden must accumulate before dementia
develops.
• (10 to 25% of dementias): Declining stepwise deterioration
of intellectual functioning due to multiple infarcts of
varying sizes or arteriosclerosis in the main intracranial
vessels. It usually occurs in patients with hypertension or
diabetes. Stepwise course (multiple drops) .
• Onset: after stroke, its sudden onset may resemble
delirium. Some cases follow a stationary course.

15. MRI:
• Multiple hyperintense
Infarcts/lesions

16. Differential diagnosis
• Psychiatric: Depression, delirium, malingering.
• Structural: Benign forgetfulness of normal aging, Parkinson's disease,
Huntington disease, Down syndrome, head trauma, brain tumor,
normal pressure hydrocephalus, multiple sclerosis, subdural
hematoma.
• Metabolic: Hypothyroidism, hypoxia, malnutrition (B12, folate, or
thiamine deficiency), Wilson disease, lead toxicity.
• Infectious: Lyme disease, Creutzfeldt-Jakob disease, neurosyphilis,
meningitis, encephalitis.
• Drugs: Alcohol (chronic and acute), anticholinergic, sedatives

17. Management

18. Diagnosis
Longitudinal
Detailed
History
Physical
examination
Labs and
imagings
Mental
state
Exam.

19. DSM IV dementia crieteria
A. The development of multiple cognitive deficits manifested by both:
1. Memory impairment (impaired ability to learn new information or to
recall previously learned information)
2.One (or more) of the following cognitive disturbances:
• Aphasia (language disturbance)
• Apraxia (impaired ability to carry out motor activities despite
intact motor function)
• Agnosia (failure to recognize or identify objects despite intact
sensory function)
• Disturbance in executive functioning (ie, planning, organizing,
sequencing, abstracting)
B. The cognitive deficits in criteria Al and A2 each cause significant
impairment in social or occupational functioning and represent a
significant decline from a previous level of functioning.
C. The course is characterized by gradual onset and continuing cognitive
decline.
D. The deficits do not occur exclusively during the course of a delirium..
E. The disturbance is not better accounted for by another Axis I disorder
(e.g., major depressive disorder, schizophrenia

20. Mini Mental
State Exam.

21. Investigations
To identify any reversible cause of the condition and to confirm
diagnosis
• Thyroid function test
• Blood study: B12 and folate blood levels
• Imaging: brain CT Scan, MRI
• Liver function test
• Lumbar puncture
• Rapid plasma reagent

22. Treatment
1. Identify and correct any treatable or controllable condition e.g. :
hypothyroidism, vitamin B12 deficiency, hypertension, diabetes.
2. Supportive measures:
• provide good physical care (meals, hygiene, ...)
• encourage the family’s involvement.
• support the care giver.
• keep in familiar settings if possible to avoid accidents, wandering
away,...etc.
3. Specific measures: Most of the disorders are untreatable, for so, slowing
of the progressive nature of the disease is the target. Symptomatic
treatment:
• Antiactylecholinestrase inhibitor or NMDA antagonist e.g. memantine in
severe to moderate Alzheimer patients.
• depression: small doses of antidepressants (serotonin reuptake
inhibitors or tricyclics).
• agitation, aggression: small doses of antipsychotics.
• insomnia: a sedative antidepressant or antipsychotic in small doses. (e.g.
thioridazine 25 mg. p.o.).

23. Summary
• The diagnosis of dementia requires both memory impairment and
another cognitive deficit.
• The MMSE is a very sensitive screening tool for diagnosing
dementia.
• Alzheimer disease is the most common form of dementia; vascular
disease is the next most common.
• Most dementias have a slow rate of onset, are irreversible, and are
progressive.
• Dementia is a chronic, neurocognitive disorder with clear
conciousneess.

25. References:
1. First Aid Psychiatry book
2. Case files Psychiatry book
3. Medscape
4. Basics of psychiatry book

26. Thank
you