This presentation gives overviews of approach to dementia diagnosis.

1. APPROACH TO
DEMENTIA
Moderater : Asst. Prof. Dr. Bhupendra Shah
Presenter: Dr. Manoj Subedi

3. How big is the problem?
 The number of people living with dementia worldwide in
2015 was estimated at 47.47 million, reaching 75.63
million in 2030 and 135.46 million in 2050
 37% in High income countries vs. 63% in low income
countries
 10% of population aged >70yr
1/13/2019
3
Epidemiology and impact of dementia: WHO report, 2015

4. WHAT ARE WE DISCUSSING ?
 Memory and its type
 Introduction to dementia
 Types
 Assessment tool
 How to Approach

5. WHAT WE ARE NOT DISCUSSING ?
 Complex Pathophysiology of memory/circuits
 Detailed clinical features
 Investigations
 Treatment

6.  What is the capital of Nepal ?
 What journal did we discussed on 1st week of June in
morning seminar?
 How many of you, can ride a motorcycle ?

7. MEMORY

8. DEMENTIA: WHEN TO SUSPECT ?
 Dementia (Latin: dement-out of one’s mind)
 An acquired deterioration in cognitive abilities that
impairs the successful performance of activities of daily
living
 Elderly with slowly progressive memory loss over years
 Initial cues: Difficulty in managing money, shopping,
following instructions, finding words or navigating

9. BENIGN FORGETFULLNESS OF
ELDERLY
 Age associated memory loss
 Thought to be an extreme of normal aging
 Subtle cumulative decline in episodic memory
 Doesn't interfere with Activities of daily living
 Not a precursor of pathological aging

10. MILD COGNITIVE IMPAIRMENT vs.
DEMENTIA
 A measurable cognitive problem that does not seriously
disrupt daily activities is often referred to as mild
cognitive impairment (MCI)
 Search for factors that help in progression of MCI to
Dementia
 Prominent memory defecit
 Family history
 Apolipoprotein e4 allele
 Small hippocampal volume

11. IS IT DEPRESSION OR NOT ?
Symptom Dementia Depression
Cognition Lack of concern or denial about
symptoms
Amplification of
&preoccupation with deficits
Mood Normal most of time Subacute onset of
pervasively sad mood
Concentration and
thinking
Uncommon, impaired in late
dementia
Subacute loss of
concentration and focus
Guilt, worthlessness Uncommon Common
Eating behavior Gradual loss of weight over
months to year
Subacute changes[week] in
appetite, increase or
decrease in weight
Energy Normal energy level, but
reduced activity due to poor
initiation
Subacute decrease in
energy and increase
complaints of fatigue
Interest , Initiative Gradual loss of interest or
apathy
Subacute loss with low
mood and affect,
hopelessness
The Canadian Review of Alzheimer’s Disease and Other Dementias,
September 2009
HOW SEVERE IS YOUR DEMENTIA?

12. ABBREVIATED MENTAL TEST
SCORE(AMTS)
Score 8 or less at the time of testing indicate cognitive impairment and requires
further evaluation

13. MINI MENTAL STATE EXAMINATION

15. MMSE LIMITATIONS
 Age and Education
 Only screening, rather then diagnostic
 Visual and auditory impairment
 Not able to differentiate type of dementia

16. OTHER TOOLS
 Montreal Cognitive Assessment [ MOCA]
 ADAS-cog
 ADCS-ADL scale
 NPI
 CRD-SB

17. COGNITIVE TEST IN ILLETERATE
 Literacy Independent Cognitive Assessment(LICA)
 Montreal Cognitive Assessment [ MOCA]

18. CLUES FOR THE LOCATION

19. CORTICAL VS SUBCORTICAL
DEMENTIA
 CORTICAL DEMENTIA
 Symptoms: changes in memory, Language deficits,
perceptual deficits, praxis disturbances, lack of
extrapyramidal features
 Affected area: Temporal cortex, parietal cortex, frontal
lobe cortex
 Examples: AD,DLB,FTD, Vascular dementia

20. CORTICAL VS SUBCORTICAL
DEMENTIA
 SUBCORTICAL DEMENTIA
 Symptoms: Behavioral change, impaired mood and
affect, motor slowing, executive dysfunction,
extrapyramidal findings
 Affected areas: Thalamus, Straitum, Midbrain and
straitofrontal projections
 Examples: PDD, NPH, HD, CJD, Chronic meningitis

21. • Episodic memory initiallyMemory
• Language, Visuospatial and Praxis
• Judgment
• Problem solving abilities
Mental faculties
• Depression, apathy and anxiety
• Delusion, hallucinations
• Agitation, insomnia sleep disturbances
• Sleep disturbances, disinhibition
Neuropsychiatric
and social deficits
IMPACT OF DEMENTIA

22. ETIOLOGY

23. Reversible
• Hypothyroidism
• Thiamine
deficiency
• Vitamin B12
deficiency
• NPH
• SDH
• Chronic
infection
• Brain tumor
• Drug
intoxication
• Autoimmune
encephalopathy
Irreversible/
Degenerative
• Alzheimer’s
disease
• Frontotemporal
dementia
• Huntington’s
dementia
• Dementia with
Lewy body
• Vascular
• Leukoencephalo
pathies
• Parkinson's
Psychiatric
• Depression
• Schizophrenia
• Conversion
reaction

24. HOW TO PROCEED
 Clinical history and Symptom analysis
 Physical and neurological examination
 Cognitive and Neuropsychiatric examination
 Laboratory tests

25. 3 QUESTIONS TO BE IN MIND?
1. What is the best fit for clinical diagnosis?
2. What component of dementia syndrome is treatable or
reversible?
3. Can the physician help to alleviate the burden on
caregiver?

26. HISTORY
 Onset, Duration and temporal of progression
 Acute or subacute onset of confusion: delirium
 Infection, Intoxication or Metabolic derangement]

27. ALZHEIMERS DISEASE
 Elderly with slowly progressive memory loss over years
 Initial cues:
 Difficulty in managing money,
 Shopping, following instructions,
 Finding words
 Navigating

28. FRONTOTEMPORAL DEMENTIA
 Personality change, disinhibition and weight gain
because of compulsive eating
 Prominent apathy, compulsivity, loss of empathy for
others, loss of speech fluency
 Relative sparing of memory and Visuospatial abilities

29. DEMENTIA OF LEWY BODY
 Early visual hallucinations
 Parkinsonism
 Proneness to delirium
 Rapid eye movement behavior disorder-RBD
 Capgras syndrome

30. VASCULAR DEMENTIA
 History of stroke
 Irregular stepwise progression
 Look for HTN, AF, PVD, DM

31. LABORATORY TESTS
 CBC
 TSH
 Vitamin B12
 Electrolytes
 CT/MRI
 CXR
 LP
 LFT
 RFT
 HIV,VDRL or RPR
 Apolipoprotein E
 EEG,PTH, Adrenal function, urine heavy metals,
Angiogram, PET, SPECT, Autoantibody
 Brain Biopsy

32. SEARCH FOR REVERSIBLE CAUSES
 Alcohol-malnutrition and thiamine deficiency
 B12 deficiency: veganism, bowel irradiation, h/o gastric
surgery
 Occupation: Battery or chemical factory-heavy metal
intoxication
 Search for depression related cognitive impairment

33. IMAGING

34. MRI FINDING IN FTD

35. CLINICAL VINGETTES
 Case 1:
 A 55 yr male, non smoker, alcohol consumer for last
year[30unit/day], without any prior co morbidities
presented with the complaints of irrelevant behavior and
slurred speech for 6 months
 No FND
 MMSE: 19/30
 CT Head: diffuse brain atrophy

36. ANY CLUE
?

37.  Case 2
 26 yr male, non smoker, non alcohol consumer w/o prior
co morbidities presented with abnormal, purposeless
body movement of UL and LL for year 3 year, and
irrelevant behavior for 6 months
 All metabolic parameter-Normal
 MMSE: 21/30
 CT –normal
 MRI

38. WHAT DID YOU SEE ?

40. TAKE HOME MESSAGE
 Dementia is decline in cognitive function with impairment
of daily activities
 Memory and its type
 Mild cognitive impairment and depression should be
differentiated
 MMSE as a screening tool
 Different imaging finding

41. REFERENCES
 Harrisons principle of medicine, 19th edition
 Dementia: Clinical review, BMJ,2009
 Epidemiology and impact of dementia: WHO report,
2015
 The Canadian Review of Alzheimer’s Disease and Other
Dementias, September 2009
 Dementia: role of MRI, Alzheimer Centre and Image
Analysis Centre,2012