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An overview of dementia

An overview of dementia gives an introduction to epidemiology, causes, clinical features, investigations, diagnosis, and management of dementia. Also a short description of related topics like difference between cortical and sub cortical dementia, psuedo dementia, mild cognitive impairment and reversible causes of dementia is also included.

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An overview of dementia

  1. 1. An overview of dementia Dr. Cijo Alex MD SR in Psychiatry SMVMCH
  2. 2. An overview of dementia 2
  3. 3. September 21 – World Alzheimer’s day September 21st was selected as world Alzheimer’s day as it marked the tenth anniversary of Alzheimer's Disease International, back in 1994. ADI is an international association based in London, UK which is active in the field of Alzheimer’s dementia. An overview of dementia 3
  4. 4. Contents 1. Introduction 2. Epidemiology and global burden 3. Causes 4. Clinical features 5. Investigations 6. Treatment 7. Prognosis 8. Others a) Cortical and sub cortical dementia b) Dementia and delirium c) Pseudo dementia d) Mild cognitive impairment An overview of dementia 4
  5. 5. Introduction Dementia literally means ‘to depart from mind’ in Latin. It was the German Psychiatrist Emil Kraepelin who first used the term ‘dementia praecox’ to describe the modern day schizophrenia. Later, it was from 1920’s that the term dementia was started to be used in the modern day meaning. An overview of dementia 5
  6. 6. Introduction contd... What is dementia ? Dementia is syndrome due to disease of the brain, usually chronic and progressive, in which there is disturbance in multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, language, learning ability, and judgment. – ICD 10 by WHO An overview of dementia 6
  7. 7. Introduction contd... - Dementia is a syndrome - Dementia is more than just amnesia - Dementia is often chronic, progressive and irreversible An overview of dementia 7
  8. 8. Epidemiology and global burden An overview of dementia 8
  9. 9. Causes of dementia Generally, Alzheimer’s disease is considered the most common cause of dementia worldwide (60%) and vascular dementia as the second commonest (30%). Other less common types constitute up to 10% of dementias. However, there is marked regional variation in the prevalence. We have convincing evidence to state that vascular dementia is more common in our part of the world. Study by Shaji et al from Trichur states AD:VD = 1.6:1.5 An overview of dementia 9
  10. 10. Causes of dementia Parenchymatous brain disease Alzheimer’s disease, Picks disease, Huntington disease, Parkinson’s disease, Progressive supranuclear palsy Vascular Multi-infarct dementia, Single infarct dementia, Binswagners disease, Specific vascular syndromes Infections* Creutzfeldt Jacob disease, AIDS dementia, Neurosyphilis, Chronic meningitis , Encephalitis, Whipples disease, Lyme disease, Sarcoidosis Metabolic* Wilsons Disease, Hepatic encephalopathy, Uremic encephalopathy Endocrine* Thyroid , Parathyroid , Pituitary or Adrenal dysfunction Deficiencies* Vitamin B1, B3, B6 or B12 deficiency Toxic causes* Heavy metals, CO, Alcohol, Drugs like antiepileptics, benzodiazepines and analgesics , Dialysis dementia (Aluminium toxicity) Other Causes* Chronic subdural haematoma, Normal pressure hydrocephalus, Dementia Pugilistica aka punch drunk syndrome, neoplasm’s and other SOL. * Generally considered reversible causes of dementia An overview of dementia 10
  11. 11. Clinical features Disturbances are seen in multiple higher cortical functions like memory, thinking, orientation, comprehension, calculations, learning, language and judgment. Recent memory is first impaired followed by impairment of remote memory. Immediate memory, ie attention and concentration is usually intact and consciousness is clear. Symptoms specific to the cause of dementia are also noted. An overview of dementia 11
  12. 12. Investigations in dementia Investigations in dementia are of two broad categories, 1. To confirm / diagnose dementia and 2. To diagnose the cause of dementia An overview of dementia 12
  13. 13. Investigations contd.. 1.Investigations to diagnose dementia. After we clinically suspect dementia in a patient, scales are often used to assess memory and other cognitive functions. 2.Investigations to diagnose the cause of dementia Once dementia is diagnosed, we need to do a battery of tests to identify the cause of dementia. An overview of dementia 13
  14. 14. Investigations contd… SCALES USED IN DEMENTIA Cognition Mini Mental Status Examination (MMSE), Modified MMSE (3MMSE), Hindi MMSE - Indian version of MMSE (English and Hindi) Clock drawing test , Trail marking Test, Addembrook’s cognitive examination, Alzheimer’s disease assessment scale for cognition (ADAS Cog), Montreal Cognitive Assessment Global function Barthel index, Bristol ADL scale General An overview of dementia 14
  15. 15. Investigations contd… INVESTIGATIONS IN DEMENTIA Blood CBC LFT – Hepatic Encephalopathy, RFT – Uremic Encephalopathy, TFT – Hypothyroidism VDRL – Neurosyphilis or GPI, ELISA for HIV – AIDS Dementia Complex Urine Wilsons disease Structural imaging Diffuse Cortical Atrophy with flattened sulci and ventricular enlargement in AD. In research, Hippocampal atrophy is considered a biomarker of AD. Infarct, Chronic SDH and Other SOL may be visible. Functional imaging SPECT or PET in atypical cases – FTD EEG CJD shows triphasic waves Lumbar Puncture NPH, Chronic meningitis Genetic mapping Huntingtons chorea An overview of dementia 15
  16. 16. Treatment Treatment of dementia will largely depend on the etiology. AD is often treated with cholinesterase inhibitors like Donapezil and NMDA antagonists like Memantine. Ginkobilobo and NSAIDS may have a role. Insomnia and psychotic or mood symptoms need appropriate care. An overview of dementia 16
  17. 17. Treatment contd... Dementia is a chronic and devastating illness which takes away the identity of the person. By the terminal stages, patients often become empty shells of their former selves. Realizing this can be fatal to them. Following non pharmacological approaches are of great help – Insight oriented psychotherapy, Assistance in grieving, Maximizing any areas of intact functioning, Activity scheduling and day structuring, Cognitive skills training, Family psycho education, Care giver stress and burn out management. An overview of dementia 17
  18. 18. Prognosis Prognosis of dementia will largely depend on the etiology. AD often has an insidious onset with chronic and progressive course. VD typically has an acute onset and step ladder pattern of progression. Reversible causes of dementia show a good prognosis. An overview of dementia 18
  19. 19. Other topics related to dementia a) Cortical and sub cortical dementia b) Dementia and delirium c) Pseudo dementia d) Mild cognitive impairment An overview of dementia 19
  20. 20. Cortical and sub cortical dementia Dementias are often classified into two broad categories of cortical and sub cortical based on the area of brain affected and the resulting clinical features. This division is not very sharp as clinical features often overlap. As a general rule, cortical dementia exhibits more cognitive dysfunction while sub cortical dementia has more motor symptoms. An overview of dementia 20
  21. 21. Cortical and sub cortical dementia contd… CORTICAL AND SUBCORTICAL DEMENTIA Feature Cortical dementia Sub cortical dementia Site of brain Outer cortex Sub cortical grey matter Examples AD, Picks HD , PD , WD , PSP , HIV D Motor symptoms Rare Usual Memory symptoms Common Less marked Language Aphasia +, Dysarthria - Aphasia - , Dysarthria + Calculation Acalculia + Acalculia - Co ordination Preserved Impaired Posture Upright Bowed or extended An overview of dementia 21
  22. 22. Dementia and delirium Delirium is an etiologically nonspecific syndrome characterized by disturbances in consciousness, cognition, psychomotor activity, sleep wake cycle and emotions. It is aka acute confusional state, acute brain syndrome, ICU psychosis etc. Delirium has a potential to get confused with dementia, especially if no history is available regarding the onset. Further, they both can exist together complicating the clinical picture. An overview of dementia 22
  23. 23. DEMENTIA VS DELIRIUM Feature Delirium Dementia Onset Acute Insidious Course Fluctuating Progressive Duration Weeks Chronic, often life long Attention and concentration Impaired Intact Orientation Impaired Intact, Impaired in later stages Memory Impaired immediate and recent Impaired recent. Remote memory imaired in late stages Perception Hallucinations and illusions common Variable Thought Delusions common Variable Diurnal variation (+) Sun downing (-) Floccilation (+) (-) An overview of dementia 23
  24. 24. Psuedo dementia Psuedo dementia (PDEM) is a word coined by Kiloh. PDEM often occurs in depression where patients show some cognitive dysfunction and has the potential to be mistaken for dementia. Differentiating dementia and psuedo dementia is important in clinical practice. An overview of dementia 24
  25. 25. DEMENTIA VS PSUEDODEMENTIA Dementia Psuedo dementia History Onset not clear Onset is somewhat clear Slower progression Rapid progression of symptoms Pt may even refuse medical help Pt wanting medical help Past psychiatric dysfunction rare Past h/o depression common Clinical features Pt highlights achievements Pt highlights failures Pt struggle to perform Little effort to perform Pt may appear unconcerned Pt appears deeply concerned Confabulation present Absent An overview of dementia 25
  26. 26. MCI Mild cognitive impairment (MCI) MCI primarily identifies a person with deteriorating cognitive impairment, but not severe enough to be diagnosed as dementia. European Consortium Task Force guidelines for MCI includes, 1) Complaints about cognitive impairment, 2) Cognitive impairment on clinical examination, 3) Cognitive impairment not severe to interfere with ADL, 4) No dementia. Management of MCI may include COX II inhibitors, Tocopherol and antioxidants. MCI conversion to Dementia of 2 – 30% per year is reported by Lishman. An overview of dementia 26
  27. 27. Thank you An overview of dementia 27