Dementia

Geriatric Psychiatry:
A Review & Update
Dementia DefinitionDementia Definition
 Multiple Cognitive Deficits:Multiple Cognitive Deficits:
 Memory dysfunctionMemory dysfunction
 At least one additional cognitive deficitAt least one additional cognitive deficit
 Cognitive Disturbances:Cognitive Disturbances:
 Sufficiently severe to cause impairment ofSufficiently severe to cause impairment of
occupational or social functioning andoccupational or social functioning and
 Must represent a decline from a previous level ofMust represent a decline from a previous level of
functioningfunctioning

A Review & Update
Differential Diagnosis: Top TenDifferential Diagnosis: Top Ten
1.1. AAlzheimer Disease (pure ~40%, + mixed~70%)lzheimer Disease (pure ~40%, + mixed~70%)
2.2. VVascular Disease, MID (5-20%)ascular Disease, MID (5-20%)
3.3. DDrugs,rugs, DDepression,epression, DDeliriumelirium
4.4. EEthanolthanol (5-15%)(5-15%)
5.5. MMedical /edical / MMetabolic Systemsetabolic Systems
6.6. EEndocrine (thyroid, diabetes),ndocrine (thyroid, diabetes), EEars,ars, EEyes,yes, EEnviron.nviron.
7.7. NNeurologic (other primary degenerations, etc.)eurologic (other primary degenerations, etc.)
8.8. TTumor,umor, TToxin,oxin, TTraumarauma
9.9. IInfection,nfection, IIdiopathic,diopathic, IImmunologicmmunologic
10.10. AAmnesia,mnesia, AAutoimmune,utoimmune, AApnea,pnea, AAAMIAMI

A Review & Update
Diagnostic Criteria For Dementia Of TheDiagnostic Criteria For Dementia Of The
Alzheimer TypeAlzheimer Type
A.A. Multiple Cognitive DeficitsMultiple Cognitive Deficits
1. Memory Impairment1. Memory Impairment
2. Other Cognitive Impairment2. Other Cognitive Impairment
B. Deficits Impair Social/OccupationalB. Deficits Impair Social/Occupational
C.C. Course Shows Gradual Onset And DeclineCourse Shows Gradual Onset And Decline
D.D. Deficits Are Not Due to:Deficits Are Not Due to:
1. Other CNS Conditions1. Other CNS Conditions
2. Substance Induced Conditions2. Substance Induced Conditions
E. Do Not Occur Exclusively during DeliriumE. Do Not Occur Exclusively during Delirium
F. Not Due to Another Psychiatric DisorderF. Not Due to Another Psychiatric Disorder

A Review & Update

CausesCauses
 Reduced synthesis of the neurotransmitterReduced synthesis of the neurotransmitter
acetylcholine.acetylcholine.
 Aggregation of amyloid* leading to generalizedAggregation of amyloid* leading to generalized
neuroinflammation.neuroinflammation.
 Plaques– deposits of the protein beta-amyloid*Plaques– deposits of the protein beta-amyloid*
that accumulate in the spaces between nervethat accumulate in the spaces between nerve
cellscells
 Tangles – deposits of the protein tau thatTangles – deposits of the protein tau that
accumulate inside of nerve cellsaccumulate inside of nerve cells
A Review & Update

TaupathyTaupathy
 Abnormal aggregation of theAbnormal aggregation of the tau proteintau protein. Every. Every
neuron has aneuron has a cytoskeletoncytoskeleton, called, called microtubulesmicrotubules..
 A protein calledA protein called tautau stabilizes the microtubulesstabilizes the microtubules
whenwhen phosphorylatedphosphorylated, and is therefore called a, and is therefore called a
microtubule-associated proteinmicrotubule-associated protein..
 In AD, tau undergoes chemical changes,In AD, tau undergoes chemical changes,
becomingbecoming hyperphosphorylatedhyperphosphorylated; it then begins to; it then begins to
pair with other threads, creating neurofibrillarypair with other threads, creating neurofibrillary
tangles and disintegrating the neuron's system.tangles and disintegrating the neuron's system.
A Review & Update

A Review & Update
Vascular DementiaVascular Dementia
A.A. Multiple Cogntive ImpairmentsMultiple Cogntive Impairments
B.B. Deficits Impair Social/OccupationalDeficits Impair Social/Occupational
C.C. Focal Neurological Signs and Symptoms orFocal Neurological Signs and Symptoms or
Laboratory Evidence IndicatingLaboratory Evidence Indicating
Cerebrovascular Disease Etiologically RelatedCerebrovascular Disease Etiologically Related
to the Deficitsto the Deficits
D.D. Not Due to DeliriumNot Due to Delirium

A Review & Update
Factors Associated with Multi-infarct DementiaFactors Associated with Multi-infarct Dementia
 History of stroke (especially in Nursing Home)History of stroke (especially in Nursing Home)
 Step-wise deteriorationStep-wise deterioration
 Cardiovascular disease – HTD & Atrial FibCardiovascular disease – HTD & Atrial Fib
 Depression (left anterior strokes), personality changeDepression (left anterior strokes), personality change
 More gait problems than in ADMore gait problems than in AD
 Binswanger’s disease*Binswanger’s disease*
 SPECT / PET show focal areas of dysfunctionSPECT / PET show focal areas of dysfunction
 Neuropsychological dysfunctions are patchyNeuropsychological dysfunctions are patchy

Binswanger's diseaseBinswanger's disease
 Also known as subcortical leukoencephalopathy,Also known as subcortical leukoencephalopathy,
is a form of small vessel vascular dementiais a form of small vessel vascular dementia
caused by damage to the white brain matter.caused by damage to the white brain matter.
White matter atrophy can be caused by manyWhite matter atrophy can be caused by many
circumstances including chronic hypertension ascircumstances including chronic hypertension as
well as old agewell as old age
A Review & Update

A Review & Update
Post-Cardiac SurgeryPost-Cardiac Surgery
 53% post-surgical confusion at discharge (delirium)53% post-surgical confusion at discharge (delirium)
 42% impaired 5 years later42% impaired 5 years later
 May be related to anoxic brain injury, apneaMay be related to anoxic brain injury, apnea
 May be related to narcotic/other medicationMay be related to narcotic/other medication
 May occur in those patients who would haveMay occur in those patients who would have
developed dementia anyway (? genetic risk)developed dementia anyway (? genetic risk)
 Cardio-vascular disease and stress may startCardio-vascular disease and stress may start
Alzheimer pathologyAlzheimer pathology
 Any surgery may have a similar effect related to peri-op orAny surgery may have a similar effect related to peri-op or
post-op anoxia or vascular stresspost-op anoxia or vascular stress
Newman et al., 2001, NEJMNewman et al., 2001, NEJM

A Review & Update
Drug InteractionsDrug Interactions
 Anticholinergics: amitriptyline, atropine,Anticholinergics: amitriptyline, atropine,
benztropine, scopolamine, hyoscyamine,benztropine, scopolamine, hyoscyamine,
oxybutynin, diphenhydramine, chlorpheniramine,oxybutynin, diphenhydramine, chlorpheniramine,
many anti-histaminicsmany anti-histaminics
 May aggravate Alzheimer pathologyMay aggravate Alzheimer pathology
 GABA agonists: benzodiazepines, barbiturates,GABA agonists: benzodiazepines, barbiturates,
ethanol, anti-convulsantsethanol, anti-convulsants
 Beta-blockers: propranololBeta-blockers: propranolol
 Dopaminergics: l-dopa, alpha-methyl-dopaDopaminergics: l-dopa, alpha-methyl-dopa
 Narcotics: may contribute to dementiaNarcotics: may contribute to dementia

A Review & Update
Delirium DefinitionDelirium Definition
 Disturbance of consciousnessDisturbance of consciousness
 i.e., reduced clarity of awareness of thei.e., reduced clarity of awareness of the
environment with reduced ability to focus, sustain,environment with reduced ability to focus, sustain,
or shift attentionor shift attention
 Change in cognition (memory, orientation,Change in cognition (memory, orientation,
language, perception)language, perception)
 Development over a short period (hours toDevelopment over a short period (hours to
days), tends to fluctuatedays), tends to fluctuate
 Evidence of medical etiologyEvidence of medical etiology

A Review & Update
EthanolEthanol
 Accidents, Head InjuryAccidents, Head Injury
 Dietary DeficiencyDietary Deficiency
 Thiamine – Wernicke-Korsakoff syndromeThiamine – Wernicke-Korsakoff syndrome
 Hepatic EncephalopathyHepatic Encephalopathy
 Withdrawal Damage (seizures) Delayed AlcoholWithdrawal Damage (seizures) Delayed Alcohol
WithdrawalWithdrawal
 Watch for in hospitalized patientsWatch for in hospitalized patients
 Chronic NeurodegenerationChronic Neurodegeneration
 Cerebellum, gray matter nucleiCerebellum, gray matter nuclei

A Review & Update
Medical / EndocrineMedical / Endocrine
 Thyroid dysfunctionThyroid dysfunction
 Hypothyoidism – elevated TSHHypothyoidism – elevated TSH
 Compensated hypothyroidism may have normal T4, FTICompensated hypothyroidism may have normal T4, FTI
 HyperthyroidismHyperthyroidism
 Apathetic, with anorexia, fatigue, weight loss, increased T4Apathetic, with anorexia, fatigue, weight loss, increased T4
 DiabetesDiabetes
 HypoglycemiaHypoglycemia (loss of recent memory since episode)(loss of recent memory since episode)
 HyperglycemiaHyperglycemia
 HypercalcemiaHypercalcemia
 Nephropathy, UremiaNephropathy, Uremia
 Hepatic dysfunction (Wilson’s disease)Hepatic dysfunction (Wilson’s disease)
 Vitamin Deficiency (B12, thiamine, niacin)Vitamin Deficiency (B12, thiamine, niacin)
 Pernicious anemia – B12 deficiency, ?homocysteinePernicious anemia – B12 deficiency, ?homocysteine

A Review & Update
Eyes, Ears, EnvironmentEyes, Ears, Environment
 Must consider sensory deficits might contribute to theMust consider sensory deficits might contribute to the
appearance of the patient being dementedappearance of the patient being demented
 Central Auditory Processing Deficits (CAPD)Central Auditory Processing Deficits (CAPD)
 Hearing problems are socially isolatingHearing problems are socially isolating
 Environmental stress factors can predispose to aEnvironmental stress factors can predispose to a
variety of conditionsvariety of conditions
 Nutritional deficiencies (tea & toast syndrome)Nutritional deficiencies (tea & toast syndrome)

A Review & Update
Neurological ConditionsNeurological Conditions
 Primary Neurodegenerative DiseasePrimary Neurodegenerative Disease
 Diffuse Lewy Body Dementia (? 7 - 50%)Diffuse Lewy Body Dementia (? 7 - 50%)
 Fronto-temporal dementia (tau gene)Fronto-temporal dementia (tau gene)
 Focal cortical atrophyFocal cortical atrophy
 Primary progressive aphasia (many causes)Primary progressive aphasia (many causes)
 Unilateral atrophy, hypofunction on EEG, SPECT, PETUnilateral atrophy, hypofunction on EEG, SPECT, PET
 Normal pressure hydrocephalusNormal pressure hydrocephalus
 Dementia with gait impairment, incontinenceDementia with gait impairment, incontinence
 Suggested on CT, MRI; need tap, ventriculographySuggested on CT, MRI; need tap, ventriculography
 Other Neurologic ConditionsOther Neurologic Conditions

A Review & Update
 TumorTumor
 ToxinsToxins
 TraumaTrauma

A Review & Update
Infectious ConditionsInfectious Conditions
Affecting the BrainAffecting the Brain
 HIVHIV
 NeurosyphilisNeurosyphilis
 Viral encephalitis (herpes)Viral encephalitis (herpes)
 Bacterial meningitisBacterial meningitis
 Fungal (cryptococcus)Fungal (cryptococcus)
 Prion (Creutzfeldt-Jakob disease); (mad cow disease)Prion (Creutzfeldt-Jakob disease); (mad cow disease)

A Review & Update
Amnesic DisordersAmnesic Disorders
 AmnesiaAmnesia
 Dissociative: localized, selective, generalizedDissociative: localized, selective, generalized
 Organic - damage to hippocampusOrganic - damage to hippocampus
 thiamine deficiency (WKE), hypoglycemia, hypoxiathiamine deficiency (WKE), hypoglycemia, hypoxia
 Epileptic eventsEpileptic events
 Partial complex seizuresPartial complex seizures
 Specific brain diseasesSpecific brain diseases
 Transient global amnesiaTransient global amnesia
 Multiple sclerosisMultiple sclerosis

A Review & Update
Age-Associated Memory ImpairmentAge-Associated Memory Impairment
vsvs
Mild Cognitive ImpairmentMild Cognitive Impairment
 Memory declines with ageMemory declines with age
 Age - related memory decline corresponds with atrophyAge - related memory decline corresponds with atrophy
of the hippocampusof the hippocampus
 Older individuals remember more complex items andOlder individuals remember more complex items and
relationshipsrelationships
 Older individuals are slower to respondOlder individuals are slower to respond
 Memory problems predispose to development ofMemory problems predispose to development of
Alzheimer’s diseaseAlzheimer’s disease

Advances in Alzheimer’sAdvances in Alzheimer’s
DiseaseDisease
 Uncovering etiologyUncovering etiology
 Understanding pathophysiologyUnderstanding pathophysiology
 Better screening toolsBetter screening tools
 Improved diagnosisImproved diagnosis
 Developing interventionsDeveloping interventions

A Review & Update
EtiologyEtiology
 Age - therefore - design and stressAge - therefore - design and stress
 Genetics (amyloid related)Genetics (amyloid related)
 Relation to vascular factors, cholesterol, BPRelation to vascular factors, cholesterol, BP
 Education (? design vs protection)Education (? design vs protection)
 Environment -Environment - diet, exercise, smokingdiet, exercise, smoking

A Review & Update
Neuropathology of ADNeuropathology of AD
 Senile plaquesSenile plaques
 Neurofibrillary tanglesNeurofibrillary tangles
 Neurotransmitter lossesNeurotransmitter losses
 Inflammatory responsesInflammatory responses
New Neuropath MechanismsNew Neuropath Mechanisms
 Amyloid PreProtein (APP - ch21)Amyloid PreProtein (APP - ch21)
 Tau phosphorylation (relation to dementia)Tau phosphorylation (relation to dementia)

A Review & Update
Biopsychosocial SystemsBiopsychosocial Systems
Affected by ADAffected by AD
(all related to neuroplasticity)(all related to neuroplasticity)
 Social SystemsSocial Systems
 Basic ADLs - LateBasic ADLs - Late
 Psychological SystemsPsychological Systems
 Primary Loss Of MemoryPrimary Loss Of Memory
 Later Loss Of Learned SkillsLater Loss Of Learned Skills
 Neuronal Memory SystemsNeuronal Memory Systems
 Cortical Glutamatergic StorageCortical Glutamatergic Storage
 Subcortical (acetylcholine, norepi, serotonin)Subcortical (acetylcholine, norepi, serotonin)
 Cellular Plastic ProcessesCellular Plastic Processes
 APP metabolism – early, broad cortical distributionAPP metabolism – early, broad cortical distribution
 TAU hyperphosphorylation – late, focal effect, dementia relatedTAU hyperphosphorylation – late, focal effect, dementia related

A Review & Update
Why Diagnose AD Early?Why Diagnose AD Early?
 Safety (driving, compliance, cooking, etc.)Safety (driving, compliance, cooking, etc.)
 Family stress and misunderstanding (blame, denial)Family stress and misunderstanding (blame, denial)
 Early education of caregivers of how to handleEarly education of caregivers of how to handle
patient (choices, getting started)patient (choices, getting started)
 Advance planning while patient is competent (will,Advance planning while patient is competent (will,
proxy, power of attorney, advance directives)proxy, power of attorney, advance directives)
 Patient’s and Family’s right to knowPatient’s and Family’s right to know
 Specific treatments now available, may delaySpecific treatments now available, may delay
nursing home placement longer if started earliernursing home placement longer if started earlier

A Review & Update
Need for Better ScreeningNeed for Better Screening
and Assessment Toolsand Assessment Tools
 Genetic vulnerability testingGenetic vulnerability testing
 Early recognition (10 warning signs)Early recognition (10 warning signs)
 Screening tools (6th vital sign in elderly)Screening tools (6th vital sign in elderly)
 Positive diagnostic testsPositive diagnostic tests
 CSF – tau levels elevated, amyloid levels lowCSF – tau levels elevated, amyloid levels low
 Brain scan – PET – DDNP, Congo-red derivativesBrain scan – PET – DDNP, Congo-red derivatives
 Dementia severity assessmentsDementia severity assessments
 Tracking progression rate, prediction of changeTracking progression rate, prediction of change

A Review & Update
Alzheimer Warning SignsAlzheimer Warning Signs
Top TenTop Ten
Alzheimer AssociationAlzheimer Association
1. Recent memory loss affecting job1. Recent memory loss affecting job
2. Difficulty performing familiar tasks2. Difficulty performing familiar tasks
3. Problems with language3. Problems with language
4. Disorientation to time or place4. Disorientation to time or place
5. Poor or decreased judgment5. Poor or decreased judgment
6. Problems with abstract thinking6. Problems with abstract thinking
7. Misplacing things7. Misplacing things
8. Changes in mood or behavior8. Changes in mood or behavior
9. Changes in personality9. Changes in personality
10. Loss of initiative10. Loss of initiative

A Review & Update
AssessmentAssessment
 History Of The Development Of TheHistory Of The Development Of The
DementiaDementia
 Physical ExaminationPhysical Examination
 Neurological ExaminationNeurological Examination

A Review & Update
Neurological ExamNeurological Exam
 Cranial NervesCranial Nerves
 Sensory DeficitsSensory Deficits
 MotorMotor
 Deep tendonDeep tendon
 PathologicalPathological

A Review & Update
Laboratory TestsLaboratory Tests
ROUTINEROUTINE
 Routine – Blood tests & UrinalysisRoutine – Blood tests & Urinalysis
 EKGEKG
 Chest X-RayChest X-Ray
 Anatomical Brain Scan – CT (cheapest), MRIAnatomical Brain Scan – CT (cheapest), MRI
SPECIALSPECIAL
 Functional Brain Imaging (SPECT, PET)Functional Brain Imaging (SPECT, PET)
 EEG, Evoked Potentials (P300)EEG, Evoked Potentials (P300)
 Reaction TimesReaction Times
 CSF Analysis - Routine StudiesCSF Analysis - Routine Studies
 Heavy Metal Screen (24 hr urine)Heavy Metal Screen (24 hr urine)
 GenotypingGenotyping

A Review & Update
Justification for Brain Scan inJustification for Brain Scan in
Dementia DiagnosisDementia Diagnosis
 Differential Diagnosis: Tumor, Stroke, SubduralDifferential Diagnosis: Tumor, Stroke, Subdural
Hematoma, Normal Pressure Hydrocephalus,Hematoma, Normal Pressure Hydrocephalus,
EncephalomalaciaEncephalomalacia
 Confirmation of atrophy patternConfirmation of atrophy pattern
 Estimation of severity of brain atrophyEstimation of severity of brain atrophy
 MRI shows T2 white matter changesMRI shows T2 white matter changes
 Periventricular, basal ganglia, focal vs confluentPeriventricular, basal ganglia, focal vs confluent
 These may indicate vascular pathologyThese may indicate vascular pathology
 SPECT, PET - estimation of regions of physiologicSPECT, PET - estimation of regions of physiologic
dysfunction, areas of infarctiondysfunction, areas of infarction
 Helps family to visualize problemHelps family to visualize problem

A Review & Update
INTERVENTIONSINTERVENTIONS
 Only successful intervention –Only successful intervention –
 Cholinesterase InhibitionCholinesterase Inhibition
(1st double blind study - Ashford et al., 1981)(1st double blind study - Ashford et al., 1981)
 Available Interventions –Available Interventions –
 Not yet proven or unconvincing effectsNot yet proven or unconvincing effects
 Promising InterventionsPromising Interventions

A Review & Update
Other Medical ConditionsOther Medical Conditions
 Chronic pain syndromeChronic pain syndrome
 Medical consultation-liaisonMedical consultation-liaison
Other Neurological ConditionsOther Neurological Conditions
 Parkinson’s diseaseParkinson’s disease
 Guillan Barre syndromeGuillan Barre syndrome
 Huntington’s diseaseHuntington’s disease
 Seizure disorders – partial complex seizuresSeizure disorders – partial complex seizures

A Review & Update
Parkinson’s DiseaseParkinson’s Disease
 Increases steadily after 50 years of ageIncreases steadily after 50 years of age
 PathophysiologyPathophysiology
 Concomitant conditionsConcomitant conditions
 Parkinson signsParkinson signs
 Symptomatic treatmentSymptomatic treatment

A Review & Update
Behavioral Problems InBehavioral Problems In
Dementia PatientsDementia Patients
 Mood Disorders – depression – early in ADMood Disorders – depression – early in AD
 Psychotic DisordersPsychotic Disorders
 Particularly paranoia, e.g, people stealing thingsParticularly paranoia, e.g, people stealing things
 AgitationAgitation
 Meal Time BehaviorsMeal Time Behaviors
 Sleep DisordersSleep Disorders

A Review & Update
Neuropsychiatric TreatmentsNeuropsychiatric Treatments
 First treat medical problemsFirst treat medical problems
 Second environmental interventionsSecond environmental interventions
 Third neuropsychiatric medicationsThird neuropsychiatric medications

Dementia with Lewy BodiesDementia with Lewy Bodies
 clinically defined by the presence of dementia,clinically defined by the presence of dementia,
prominent hallucinations and delusions (yet sensitive toprominent hallucinations and delusions (yet sensitive to
antipsychotic medications), fluctuations in alertness,antipsychotic medications), fluctuations in alertness,
and gait/balance disorderand gait/balance disorder (McKeith et al., Neurology 1996;47:1113-(McKeith et al., Neurology 1996;47:1113-
1124)1124)
 Accounts for up to 20-30% of degenerative dementiasAccounts for up to 20-30% of degenerative dementias
(Hansen et al., Neurology 1990;40:1-8)(Hansen et al., Neurology 1990;40:1-8)
Second in occurrence behind ADSecond in occurrence behind AD
A Review & Update

 Abnormal clumps of a protein called alpha-Abnormal clumps of a protein called alpha-
synuclein. These clumps, called Lewy bodies, aresynuclein. These clumps, called Lewy bodies, are
found in nerve cells throughout the outer layerfound in nerve cells throughout the outer layer
of the brain (the cerebral cortex) and deep insideof the brain (the cerebral cortex) and deep inside
the midbrain and brainstem.the midbrain and brainstem.
A Review & Update

 cases presenting for autopsy have Lewy Bodiescases presenting for autopsy have Lewy Bodies
(LB) in neocortex and brainstem(LB) in neocortex and brainstem
 Most also AD changesMost also AD changes
 Typically include pure dementia cases withTypically include pure dementia cases with
cortical Lewy Bodies and those those withcortical Lewy Bodies and those those with
AD+LB under Dementia with Lewy BodiesAD+LB under Dementia with Lewy Bodies
A Review & Update

CoreCore
 Has two of the following core features forHas two of the following core features for
probable and one for possible DLBprobable and one for possible DLB
 Fluctuating cognition with pronouncedFluctuating cognition with pronounced
variations in attention and alertnessvariations in attention and alertness
 Occurs in 80-90% of DLB, only 20% of ADOccurs in 80-90% of DLB, only 20% of AD
 Recurrent visual hallucinations that are typicallyRecurrent visual hallucinations that are typically
well formed and detailedwell formed and detailed
 Spontaneous motor features of parkinsonismSpontaneous motor features of parkinsonism
A Review & Update

Features supportive of theFeatures supportive of the
diagnosisdiagnosis
 Repeated fallsRepeated falls
 SyncopeSyncope
 Transient loss of consciousnessTransient loss of consciousness
 Neuroleptic sensitivityNeuroleptic sensitivity
 Systematized delusionsSystematized delusions
 Hallucinations in other modalitiesHallucinations in other modalities
A Review & Update

 motor symptoms- Nonpharmacologicmotor symptoms- Nonpharmacologic
interventions, including physical, occupationalinterventions, including physical, occupational
and speech therapy, community resources andand speech therapy, community resources and
assistance with home care treated withassistance with home care treated with
dopaminergic therapies. These medications aredopaminergic therapies. These medications are
usually helpful in decreasing the severity ofusually helpful in decreasing the severity of
motor symptoms..motor symptoms..
A Review & Update

Cognitive symptomsCognitive symptoms
 treated with cholinesterase inhibitors (e.g.,treated with cholinesterase inhibitors (e.g.,
Rivastigmine®, Aricept®). These medicationsRivastigmine®, Aricept®). These medications
can improve the attention deficits, cognitivecan improve the attention deficits, cognitive
fluctuations, neuropsychiatric symptoms (e.g.,fluctuations, neuropsychiatric symptoms (e.g.,
hallucinations, apathy, anxiety), and sleephallucinations, apathy, anxiety), and sleep
disturbances by boosting acetylcholine in thedisturbances by boosting acetylcholine in the
brain, a neurotransmitter that is severely reducedbrain, a neurotransmitter that is severely reduced
by these diseases. Memantine has also been triedby these diseases. Memantine has also been tried
for treatment of cognitive impairment in Lewyfor treatment of cognitive impairment in Lewy
body dementias.body dementias.Geriatric Psychiatry:
A Review & Update

 Depression is very common in Lewy bodyDepression is very common in Lewy body
dementias and can be treated withdementias and can be treated with
antidepressant medications.antidepressant medications.
A Review & Update

psychotic symptomspsychotic symptoms
 If non-responsive to psychosocial interventionsIf non-responsive to psychosocial interventions
(e.g., making changes in the patient’s(e.g., making changes in the patient’s
environment) or cholinesterase inhibitorenvironment) or cholinesterase inhibitor
treatment, atypical second generationtreatment, atypical second generation
antipsychotic medications such as risperidoneantipsychotic medications such as risperidone
(Risperdol®) and quetiapine (Seroquel®) can be(Risperdol®) and quetiapine (Seroquel®) can be
tried but must be used cautiously due to the risktried but must be used cautiously due to the risk
of motor and cognitive side effects.of motor and cognitive side effects.
A Review & Update

 Older, first generation antipsychotic drugs suchOlder, first generation antipsychotic drugs such
as haloperidol or chlorpromazine should beas haloperidol or chlorpromazine should be
avoided because of ??avoided because of ??
A Review & Update

FRONTO-TEMPORALFRONTO-TEMPORAL
clinicopathologic condition consisting ofclinicopathologic condition consisting of
deterioration of personality and cognition assoc.deterioration of personality and cognition assoc.
with prominent frontal and temporal lobewith prominent frontal and temporal lobe
atrophyatrophy
Accounts for up to 3-20% of dementiasAccounts for up to 3-20% of dementias
Third behind AD and Lewy Body Dementia inThird behind AD and Lewy Body Dementia in
neurodegenerative dementing illnessesneurodegenerative dementing illnesses
A Review & Update

Core featuresCore features
 Insidious onset and slow progressionInsidious onset and slow progression
 Early decline ofEarly decline of
 Social interpersonal conductSocial interpersonal conduct
 Regulation of personal conductRegulation of personal conduct
 InsightInsight
 Early emotional bluntingEarly emotional blunting
A Review & Update

Supportive featuresSupportive features
 Decline in personal hygiene and groomingDecline in personal hygiene and grooming
 Mental rigidity and inflexibilityMental rigidity and inflexibility
 Distractibility and impersistenceDistractibility and impersistence
 HyperoralityHyperorality
 Perseverative behaviorPerseverative behavior
 Speech and languageSpeech and language
A Review & Update

TreatmentTreatment
 Options for pharmacotherapy are limited. TheOptions for pharmacotherapy are limited. The
available evidence is derived largely from small,available evidence is derived largely from small,
open label studies or case reports. Open labelopen label studies or case reports. Open label
studies have shown no clear symptomaticstudies have shown no clear symptomatic
benefit for cholinesterase inhibitors orbenefit for cholinesterase inhibitors or
memantine.*memantine.*
A Review & Update

ReferenceReference
 Seltman RE, Matthews BR. FrontotemporalSeltman RE, Matthews BR. Frontotemporal
lobar degeneration: epidemiology, pathology,lobar degeneration: epidemiology, pathology,
diagnosis and management. CNSdiagnosis and management. CNS
Drugs2012;26:841-70.Drugs2012;26:841-70.
A Review & Update

Dementia

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