Medicine 5th year, 5th lecture (Dr. Asso Fariadoon Ali Amin)


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The lecture has been given on May 21st, 2011 by Dr. Asso Fariadoon Ali Amin.

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Medicine 5th year, 5th lecture (Dr. Asso Fariadoon Ali Amin)

  1. 1. Understanding Dementia Dr Asso Fariadoon Ali Amin MRCP(UK)
  2. 2. Why is Dementia Important? <ul><li>Dementia is an acquired decline in memory and other cognitive function (s) in an alert non delirious person that is sufficiently severe to affect daily life ( home, work, or social function). </li></ul><ul><li>There are about 820,000 people in the UK with dementia </li></ul><ul><li>The number is set to double by 2030 </li></ul><ul><li>Prevalence:- rare before the age of 65 , increase with age , 65-69 (1.4%), 70-74 ( 2.8%), 75-79 ( 5.6%), 80-84 (11.1%), more than 85 (23.6%) </li></ul><ul><li>There are about 18,500 people in the UK under 65 who have dementia </li></ul><ul><li>There is no cure </li></ul>
  3. 3. Prevalence of Alzheimer’s Disease <ul><li>Prevalence of Alzheimer’s disease in an aging population. </li></ul><ul><li>Prevalence increases dramatically with age and approaches 50% of those over 85 years old. (Adapted from Evans et al., 1989.) </li></ul>
  4. 4. Dementia - Diagnosis <ul><li>Diagnosis ICD-10 & DSM-IV: </li></ul><ul><li>Multiple cognitive defects which must include: </li></ul><ul><li>Amnesia </li></ul><ul><li>Functional impairment </li></ul><ul><li>Clear consciousness </li></ul><ul><li>Clear change from previous level </li></ul><ul><li>Long duration (>6 months) </li></ul>
  5. 5. Forms of Dementia <ul><li>Alzheimer’s disease </li></ul><ul><li>Vascular Dementia </li></ul><ul><li>Dementia in Parkinson’s & Dementia with Lewy Bodies </li></ul><ul><li>Frontotemporal Dementia </li></ul><ul><li>Reversible (<5%):- Subdural haematoma, normal pressure hydrocephalus, metabolic, drugs </li></ul><ul><li>Neurological dementias: </li></ul><ul><li>Cerebral Vasculitis </li></ul><ul><li>Corticobasal Degeneration </li></ul><ul><li>Dementia in MS </li></ul><ul><li>HIV/AIDS Dementia </li></ul><ul><li>Huntington’s Dementia </li></ul><ul><li>Lysosomal storage diseases </li></ul><ul><li>Prion Diseases – CJD </li></ul>
  6. 6. Prevalence of the forms of dementia Cause Percentage Alzheimer’s disease 55% Vascular dementia 20% Dementia with Lewy Bodies 15% Frontotemporal dementia 5% Rarer causes (all) 5%
  7. 7. Clinical Diagnosis <ul><li>History:- Take a careful history from the patient and the relative, concentrate mainly on the onset and progression of symptoms, , take careful drug history, social history. Deterioration of cognitive function is slow in Alzheimer disease within years , faster in vascular dementia, and very rapid in reversible like metabolic causes. </li></ul><ul><li>Deterioration occurs in :- </li></ul><ul><li>retention of new information like appointments, events, or working a new household appliance) </li></ul><ul><li>Managing complex tasks e.g. Paying bills , cooking a meal) </li></ul><ul><li>Language ( word finding difficulty) </li></ul><ul><li>Behaviour ;- become aggressive, irritability, poor motivation and wandering) </li></ul><ul><li>orientation getting lost in familiar places. </li></ul><ul><li>recognition:- failure to recognise people </li></ul><ul><li>Ability to self care :- bathing , dressing. </li></ul><ul><li>Reasoning:- poor judgement </li></ul>
  8. 8. Alzheimer’s – Diagnosis <ul><li>Fulfil criteria for dementia syndrome </li></ul><ul><li>Insidious onset </li></ul><ul><li>Gradual progression </li></ul><ul><li>No focal neurological signs </li></ul><ul><li>No evidence for a systemic or brain disease sufficient to cause dementia </li></ul>
  9. 9. Alzheimer’s Diagnosis DSM IV <ul><li>The development of multiple cognitive deficits manifested </li></ul><ul><li>by both: </li></ul><ul><li>Memory impairment and: </li></ul><ul><li>One or more of the following cognitive disturbances: </li></ul><ul><li>Aphasia </li></ul><ul><li>Apraxia </li></ul><ul><li>Agnosia </li></ul><ul><li>Disturbed executive function </li></ul>
  10. 10. Alzheimer’s Diagnosis DSM IV <ul><li>The cognitive impairments above lead to significant impairment in social or occupational functioning & are a decline from a previous level </li></ul><ul><li>The course is gradual in onset & shows continuous decline </li></ul><ul><li>The cognitive impairments are not due to: </li></ul><ul><li>Other CNS conditions that cause progressive deficits in memory & cognition </li></ul><ul><li>Systemic conditions that cause dementia </li></ul><ul><li>Substance induced conditions </li></ul><ul><li>The deficits do not occur during the course of delirium </li></ul>
  11. 11. Alzheimer’s - features <ul><li>Cognitive symptoms </li></ul><ul><li>Amnesia – early features are impaired new learning & recall, disorientation in time & place, late features include impaired semantic memory & visuospatial memory </li></ul><ul><li>Aphasia (dysphasia) – deficits in cortical language function – early features are nominal aphasia, verbal perseveration, late features include mutism & echolalia </li></ul><ul><li>Apraxia (dyspraxia) – common forms are: ideomotor dyspraxia (cannot carry out motor function to command), constructional dyspraxia (manifested by inability to copy intersecting pentagons or draw a clockface) </li></ul>
  12. 12. Cognitive Features <ul><li>Agnosia especially visual agnosia (inability to recognise objects) & prosopagnosia (inability to recognise faces) </li></ul><ul><li>Frontal-executive dysfunction – inflexible (concrete thinking). Difficulties with problem solving or planning, difficulty correctly sequencing behaviour. </li></ul><ul><li>Dyslexia </li></ul><ul><li>Dysgraphia </li></ul><ul><li>Acalculia </li></ul><ul><li>R/L disorientation </li></ul>
  13. 13. Non-cognitive symptoms <ul><li>Psychotic: Delusions often paranoid </li></ul><ul><li>Hallucinations: commonly visual </li></ul><ul><li>Mood: Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Euphoria </li></ul><ul><li>Behavioural: Apathy </li></ul><ul><li>Over activity </li></ul><ul><li>Aggression </li></ul>
  14. 14. Non-cognitive symptoms <ul><li>Neurovegetative Symptoms: </li></ul><ul><li>Sleep disturbance, day-night reversal in about 30% patients </li></ul><ul><li>Eating: poor oral intake or binge eating </li></ul><ul><li>Sexual disinhibition </li></ul><ul><li>Personality change </li></ul><ul><li>Physical Symptoms: </li></ul><ul><li>Primitive reflexes (grasp & palmomental reflexes) </li></ul><ul><li>Incontinence (often a late feature in AD) </li></ul><ul><li>Weight loss </li></ul><ul><li>Deterioration in gait </li></ul><ul><li>Falls </li></ul>
  15. 15. Vascular Dementia <ul><li>Evidence of dementia and </li></ul><ul><li>Cerebrovascular disease: focal signs on neurological testing & evidence of cerebrovascular disease on brain imaging (CT or MRI): multiple large infarcts, single infarct in the angular gyrus, thalamus, basal forebrain or PCA or ACA territories, or multiple basal ganglia & white matter lacunar infarcts or extensive periventricular white matter lesions or a combination of the above </li></ul><ul><li>A relationship between the onset of dementia & the presence of cerebrovascular disease: </li></ul><ul><ul><li>Onset of dementia within 3 months of a stroke </li></ul></ul><ul><ul><li>Abrupt deterioration in cognitive function or a fluctuating or stepwise deterioration </li></ul></ul>
  16. 16. Vascular Dementia <ul><li>Other features which may be associated: </li></ul><ul><li>Early gait disturbance: </li></ul><ul><li>‘ Marche a petit pas’, Parkinsonian (lower limbs), apraxic-ataxic </li></ul><ul><li>History of unsteadiness or frequent falls </li></ul><ul><li>Early urinary symptoms not explained by urological disease </li></ul><ul><li>Pseudobulbar palsy, depression, psychomotor retardation & abnormal executive function </li></ul>
  17. 17. Dementia with Lewy Bodies (DLB) (Consensus Criteria) <ul><li>(1) Evidence of dementia with: </li></ul><ul><li>(2) Two of the following core features are essential in </li></ul><ul><li>order to diagnose possible DLB: </li></ul><ul><ul><ul><li>fluctuations with pronounced variations in alertness & attention </li></ul></ul></ul><ul><ul><ul><li>recurrent visual hallucinations that are typically well formed & detailed </li></ul></ul></ul><ul><ul><ul><li>spontaneous features of parkinsonism e.g. rigidity, bradykinesia, tremor </li></ul></ul></ul><ul><li>(3) Other supportive features: </li></ul><ul><li>Repeated falls, syncope, </li></ul><ul><li>systematised delusions, hallucinations in modalities other </li></ul><ul><li>than vision </li></ul>
  18. 18. Parkinson's disease Dementia <ul><li>Elderly with Parkinson's are more likely to develop dementia. </li></ul><ul><li>Motor symptoms proceed by at least one year. Then followed by cognitive function deterioration </li></ul><ul><li>No hallucination. </li></ul>
  19. 19. Frontal Lobe Dementia <ul><li>Neurodegenerative disease with insidious onset and low progression. </li></ul><ul><li>Onset is often early ( 35-75), and either behavioural or language symptoms dominate the clinical picture. Forgetfulness is mild, insight is lost early. Difficulties at work may be the first sign. </li></ul><ul><li>Using MMSE can miss the diagnosis ( require FLT) </li></ul><ul><li>Behavioural problems include disinhibition, mental rigidity, inflexibility, impairment of executive function, decrease personal care and repetitive behaviours. </li></ul><ul><li>Language dysfunction:- include word finding difficulties, problem with naming or understanding words. Lack of spontaneous conversation. </li></ul><ul><li>Neuroimaging usually demonstrate frontal/temporal atrophy </li></ul><ul><li>50% positive FH </li></ul><ul><li>FLD include many spectrum like FL Degenration, Picks disease, MND with dementia </li></ul>
  20. 20. Normal Pressure Hydrocephalus <ul><li>Wide gate (gate disturbance) </li></ul><ul><li>Urinary incontinence </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>CT large ventricle disproportional to cerebral atrophy </li></ul><ul><li>MMSE and gait assessment before LP </li></ul><ul><li>LP is diagnostic and therapeutic ( normal pressure, remove 20-30ml and re-assess gait and cognitive function) </li></ul><ul><li>Some improve with ventricular-peritoneal shunt. Gait is more likely to improve. Complication infection and SDH </li></ul>
  21. 21. Differential Diagnosis Causes of memory problems / confusion that are not dementia Delirium Depression ‘pseudo-dementia’ Mild cognitive impairment or benign cognitive impairment of aging Learning difficulties Previous brain injury
  22. 22. Memory Complaints in Aging, Depression & Dementia Aging Depression Dementia Complaint May report a mild or subtle memory problem More likely to complain about their memory Expresses variable, non-specific memory problems or may be unaware Functional Interference No interference with daily functioning Minimal interference- functional problems more likely due to mood disorder Clearly interferes with daily functioning: missing appointments, unpaid bills, medication compliance Cognitive Status Onset of problem unclear. Cognition is normal on testing Onset may be reported as sudden, subtle deficits on testing only Gradual onset & progression Cognition impaired on testing Mood Not associated with depression or anxiety Associated with a depressed or anxious mood May be associated with fluctuating or blunted affect
  23. 23. Assessment <ul><li>Important points in the history: </li></ul><ul><li>Duration, fluctuation, progression </li></ul><ul><li>Forgetfulness, repetitiveness </li></ul><ul><li>Misplacing or losing things </li></ul><ul><li>Judgement – ability to manage finances </li></ul><ul><li>Safety concerns </li></ul><ul><li>Changes in personality or behaviour </li></ul><ul><li>Loss of hygiene </li></ul><ul><li>Falls </li></ul><ul><li>Insight </li></ul><ul><li>PMH </li></ul><ul><li>Medications and compliance </li></ul>
  24. 24. Assessment II <ul><li>Mental state examination </li></ul><ul><li>Appearance & behaviour </li></ul><ul><li>Speech </li></ul><ul><li>Mood </li></ul><ul><li>Delusions </li></ul><ul><li>Hallucinations </li></ul><ul><li>Personality – past & present </li></ul><ul><li>Insight </li></ul><ul><li>Cognition </li></ul>
  25. 25. Assessment III <ul><li>Cognitive Assessment </li></ul><ul><li>MMSE & Frontal Lobe Score </li></ul><ul><li>MMSE & Clock Drawing Test </li></ul><ul><li>Addenbrooke’s Cognitive Examination – Revised (ACE-R) </li></ul><ul><li>Alzheimer’s Disease Assessment Scale for Cognition (ADAS-Cog) </li></ul><ul><li>Assessment of Mood </li></ul><ul><li>Geriatric Depression Score </li></ul><ul><li>Hospital Anxiety & Depression Score </li></ul>
  26. 26. Assessment IV <ul><li>Physical Assessment </li></ul><ul><li>Focal neurological weakness </li></ul><ul><li>Evidence of Parkinsonism </li></ul><ul><li>Evidence of intercurrent illness causing a delirium </li></ul><ul><li>Evidence of significant anaemia or hypothyroidism </li></ul><ul><li>Evidence of dyspraxia </li></ul>
  27. 27. Investigations <ul><li>All patients should have FBC, U&E’s, LFT’s, Ca, glucose to look for systemic causes of confusion </li></ul><ul><li>B12, Folate, TFT’s </li></ul><ul><li>VDRL if clinically suspect syphilis </li></ul><ul><li>Cranial imaging to confirm / exclude : </li></ul><ul><li>Cerebral tumours, Normal Pressure Hydrocephalus, subdural haematoma & to assess degree of vascular insufficiency </li></ul><ul><li>DaTSCAN (Ioflupane SPECT) for clinically difficult to diagnose Dementia with Lewy Bodies </li></ul><ul><li>EEG – not generally indicated but is abnormal in sporadic CJD </li></ul>
  28. 28. DaTSCAN in DLB Normal DaTSCAN DaTSCAN in PD & DLB – Decreased dopaminergic neurones in the striatal area
  29. 29. Management in Dementia - General <ul><li>Assess for physical illness & depression </li></ul><ul><li>Establish functional abilities & any risks </li></ul><ul><li>Capacity assessment </li></ul><ul><li>Carer assessment </li></ul><ul><li>Education of carers </li></ul><ul><li>Assess social care needs & support required </li></ul><ul><li>Planning for future care: advance directives, power of attorney </li></ul><ul><li>Cholinesterase inhibitors </li></ul><ul><li>Management of behavioural problems </li></ul><ul><li>Terminal care </li></ul>
  30. 30. Mild Dementia (Mild symptoms or MMSE 20-24) <ul><li>Appropriate counseling around the diagnosis </li></ul><ul><li>Advice on how to maintain health & well-being </li></ul><ul><li>Ensuring the individual has care to meet their needs prior to discharge </li></ul><ul><li>Written information about dementia – leaflets produced by the Alzheimer’s Society </li></ul><ul><li>Advice on Power of Attorney & how to plan for the future </li></ul><ul><li>Details of how to contact the Alzheimer’s Society for ongoing support </li></ul><ul><li>Convey the diagnosis to the GP so they can arrange follow up & refer to memory clinic if & when appropriate </li></ul>
  31. 31. Moderate Dementia (Moderate symptoms or MMSE 10-20) <ul><li>As for mild dementia plus: </li></ul><ul><li>Assess eligibility for memory clinic & cholinesterase inhibitors </li></ul><ul><li>Discussions should take place about how someone would wish to be treated in the future: ceilings of treatment, palliative care if appropriate on the ward </li></ul>
  32. 32. Severe Dementia <ul><li>If the patient has a clinical picture of dementia with severe symptoms with or without an MMSE of <10: </li></ul><ul><li>As for mild to moderate dementia </li></ul><ul><li>Consider stopping cholinesterase inhibitor </li></ul><ul><li>Discussions should take place about how someone would wish to be treated in the future: ceilings of treatment, palliative care, where the individual would wish to die. </li></ul>
  33. 33. Anti-dementia drugs <ul><li>Cholinesterase inhibitors : </li></ul><ul><li>Donepezil : A reversible inhibitor of acetyl cholinesterase </li></ul><ul><li>Galantamine : As for Donepezil + nicotinic receptor agonist </li></ul><ul><li>Rivastigmine : Non-competitive inhibitor of acetyl cholinesterase, </li></ul><ul><li>Licensed for dementia in PD & DLB </li></ul><ul><li>N-methyl-D- aspartate (NMDA) receptor antagonist : </li></ul><ul><li>Memantine : Some evidence it is effective in more advanced </li></ul><ul><li>dementia, & beneficial in behaviourally disturbed AD in </li></ul><ul><li>conjunction with a cholinesterase inhibitor </li></ul><ul><li>PDD,DLB,ALZ have greatest cholinergic deficit </li></ul>
  34. 34. What do NICE say? (November 2006) <ul><li>The cholinesterase inhibitors can be prescribed for clinically moderate AD or those with an MMSE 10-20 </li></ul><ul><li>NMDA receptor antagonists to be prescribed ‘de novo’ only in recognised clinical trials </li></ul><ul><li>Only specialists in Old Age Psychiatry or those geriatricians with specific expertise may start therapy </li></ul><ul><li>Patients need to be reviewed at 3/12 & then 6/12 intervals to assess response with an MMSE score, a global functional & behavioural assessment & carer views to be considered </li></ul><ul><li>If benefit noted they may continue on therapy until the MMSE<10 </li></ul>
  35. 35. Management of Behavioural Problems <ul><li>Non-Pharmacological intervention </li></ul><ul><li>Assess for intercurrent illnesses, pain ,constipation, urinary retention etc </li></ul><ul><li>Ensure environment is appropriate for their needs: </li></ul><ul><li>Lighting levels appropriate for the time of day </li></ul><ul><li>Regular (at least 3xday) cues to orientate </li></ul><ul><li>Use of clocks & calendars </li></ul><ul><li>Hearing aids & glasses available & functioning </li></ul><ul><li>Continuity of care from nursing staff </li></ul><ul><li>Encouragement of mobility & engagement in activities </li></ul><ul><li>Approach & handle gently, explain who you are, what you are going to do & why </li></ul>
  36. 36. Non-pharmacological measures <ul><li>Elimination of unexpected & irritating noise </li></ul><ul><li>Good pain control </li></ul><ul><li>Encourage visits from family & friends especially at meal times </li></ul><ul><li>Ensure adequate fluid & dietary intake </li></ul><ul><li>Adequate CNS oxygen delivery </li></ul><ul><li>Monitor bowels – avoid constipation </li></ul><ul><li>Encourage a good sleep pattern </li></ul><ul><li>Avoid inter & intra ward transfers </li></ul><ul><li>Avoid catheters where possible </li></ul>
  37. 37. Pharmacological interventions <ul><li>Indications for sedation: </li></ul><ul><li>In order to carry out essential investigations or treatment </li></ul><ul><li>To prevent a patient endangering themselves or others </li></ul><ul><li>To relieve distress in a highly agitated or hallucinating patient, after assessing whether there is a physical cause for that distress </li></ul>
  38. 38. <ul><li>Acutely: Haloperidol, Olanzapine, trazodone 50mg nocte to 300mg max. and Lorazepam </li></ul><ul><li>are the drugs of choice </li></ul><ul><li>Do not use Haloperidol in patients with </li></ul><ul><li>Parkinson’s disease or Dementia with Lewy </li></ul><ul><li>Bodies </li></ul><ul><li>Medium term : Haloperidol or atypical antipsychotics: </li></ul><ul><li>(up to 6 weeks) Amisulpiride, Quetiapine, Olanzapine, </li></ul><ul><li>Risperidone (caution in cerebrovascular disease) </li></ul><ul><li>Longer term: Cholinesterase inhibitors, NMDA Receptor </li></ul><ul><li>antagonists </li></ul>Pharmacological intervention
  39. 39. Prevention of Dementia <ul><li>Life style </li></ul><ul><li>Physical activity </li></ul><ul><li>Cognitive activity </li></ul><ul><li>Diet:- fish oil </li></ul><ul><li>Medication </li></ul><ul><li>HRT </li></ul><ul><li>NSAID </li></ul><ul><li>Antioxidant Vitamin E&C </li></ul><ul><li>Antihypertensive </li></ul><ul><li>Statin </li></ul>
  40. 40. <ul><li>Give 3 key features of dementia </li></ul><ul><li>How long should symptoms have been present for to diagnose dementia? </li></ul><ul><li>Give 3 different types of dementia. </li></ul><ul><li>Which blood tests should be done routinely in a possible dementia patient? </li></ul><ul><li>Why? </li></ul><ul><li>Give 3 differential diagnoses for cognitive dysfunction. </li></ul><ul><li>Name 3 assessments of cognitive function. </li></ul><ul><li>Name a treatment for dementia? What class of drug are these? </li></ul><ul><li>What are the standard criteria for eligibility for this drug? </li></ul><ul><li>Give one key clinical feature of Alzheimer’s dementia. </li></ul><ul><li>Give one key clinical feature of vascular dementia. </li></ul>Dementia Questionnaire
  41. 41. Dementia Questionnaire <ul><li>An 82 year old lady presents having had recurrent falls, she doesn’t know why she is in hospital, her niece reports that she was fully able to look after herself and was driving 4 weeks ago. She is covered in bruises and her obs/WCC/urine dipstix/chest X-ray are normal. What is the most likely diagnosis? </li></ul><ul><li>You are asked to review a 79year old surgical patient with “confusion” He has been confused since admission and looks thin and unkempt. He does not know where he is but is GCS 15. His son tells you he has stopped being able to cook meals, and does not recognise his grandchildren anymore. This has been going on for over a year. What is the likely diagnosis? </li></ul>
  42. 42. Dementia Questionnaire <ul><li>An 86 year old lady is brought in with dehydration, apart from a raised urea her other investigations are normal. She reports having a memory problem which she is very anxious about, on testing her cognitive function is just below normal. She has trouble concentrating on the test. On the ward she is able to wash and dress herself, but keeps to herself. What is the likely diagnosis? </li></ul><ul><li>You are called to the ward at night because a patient is threatening the nurses with his Zimmer frame. The nurses report that he is usually a “lovely old man” but today he has been more agitated. He is currently being treated for a UTI. What is the likely diagnosis? </li></ul>
  43. 43. <ul><li>www.Alzheimer’ </li></ul><ul><li>Bournemouth Office: </li></ul><ul><li>Alzheimer’s Society </li></ul><ul><li>c/o King’s Park Community Hospital </li></ul><ul><li>Gloucester Road </li></ul><ul><li>Bournemouth </li></ul><ul><li>BH7 6JE </li></ul><ul><li>Telephone: 01202 309084 </li></ul>
  44. 44. Thank you for listening