The document provides an overview of dementia, including definitions of common terms like MCI, dementia, and amnesia. It discusses the classification of dementias and the most common causes, with Alzheimer's disease and vascular dementia accounting for about 70% of cases. Diagnosis involves taking a history, physical and neurological exam, and testing including imaging and lumbar puncture. Treatment depends on the underlying cause but may include medications to address behavioral issues, the pathophysiological process, or modifying vascular risk factors. The prognosis depends on factors like age, education level, and subtype of vascular dementia.

1. DEMENTIA – AN OVERVIEW
Dr. A.V. Srinivasan, Dr. S. Yogaraj, Dr. G. Sarala
Dr. A.V. Srinivasan
Addl. Prof. of Neurology
Institute of Neurology
Chennai – 600 003

2. GLOSSARY OF TERMS
1) MCI
2) Dementia
3) Amnesia
a) Retrograde Amnesia
b) Anterograde Amnesia
4) Amentia
5) Senescence (Benign forgetfulness )
Mind is the great level of all things;
human thought is the process by which human ends
are ultimately answered
- Daniel Webster

3. PHONE CALLS / HISTORY
• What is the patient’s predominant neurologic
condition? In addition to memory loss, is there
confusion, agitation, delirium or stupor?
• Is this new memory dysfunction or does the
patient have known dementia?
• How old is the patient?
• Does the patient have acute medical problems?
In all of us, even in good men, there is a
wild - beast nature which peers out in sleep

4. Elevator Thoughts / Walking Thoughts
V (vascular): Cerebral infarction, Multiple strokes
I (infectious): Syphilis, Chronic meningitis
T (traumatic): Subdural hematoma, head injury
A (autoimmune): CNS vasculitis, Multiple sclerosis
M (metabolic/toxic): Renal failure, Hepatic failure
I (idiopathic/inherited): TGA, Alzheimer’s disease
N (neoplastic): Brain tumour, Meningeal carcinomatosis
S (seizure, pSychiatric, structural): Complex partial seizure,
postictal state
Thinking is the hardest work there is, which is probable
reason why so few engage in it.
- Henry Ford

5. Selective Physical Examination
• HEENT
• Cardiopulmonary
• Abdomen
• Extremities
Success in life is a matter not so much of talent and opportunity
as of concentration and perseverance
- C.W. Wendte

6. Neurological Examination
1) Mental status
a) Alertness
b) Aphasia
1) Fluency
2) Naming
3) Auditory comprehension of single and
multi step commands
4) Repetition of unfamiliar phrases
5) Reading aloud
6) Writing
7) Listen for phonemic paraphasias
Habit is either the best of servants or worst of masters
- Nathaniel Emmons

7. Neurological Examination
c) Memory
d) Calculations
e) Hemineglect
f) Apraxia
g) Drawing
2) Motor
3) Coordination and gait
4) Frontal “release” signs
It is the disease of not listening, the malady of not marking,
that I am troubled withal
- Shakespeare

8. Classification of Dementia
1) Aetiological classification
2) According to localization of pathological
process
3) Brain structures involved (cortical and
subcortical dementias)
4) DSM & ICD multiaxial coding syste,
Of these, the etiological classification is the
most commonly used one
Memory, the daughter of attention ,
is the teeming mother of knowledge
- Martin Tupper

9. Classification of Dementia
• Alzheimer’s disease (AD)
• Vascular Dementia (VaD)
• Lewy Body Dementia
• Pick’s Disease
• Reversible Dementia
We possess by nature the factors out of which personality can be
made, and to organize them into effective personal life is every
man’s primary responsibility
- Harry Emerson Fosdick

10. Selected causes of potentially
Reversible Dementia
Metabolic disorders Thyroid disease
Electrolyte imbalance
Renal failure
Liver failure
Adverse drug reactions Sedative hypnotics
Barbiturates
Anticholinergics
Many others
Autoimmune disorders Vasculitis
Lupus erythematosus
Time and Wo rds canno t be re calle d - Fulle r

11. Selected causes of potentially
Reversible Dementia
Infections AIDS encephalopathy
Syphilis
Lyme encephalitis
Tumours Primary
Metastatic
Poisoning Heavy metals
Insecticides
alcohol
Discipline Weighs ounces Regret weighs Tons

12. Selected causes of potentially
Reversible Dementia
Nutritional Deficiencies Vitamin B6, B12
Thiamine
Folate
Psychiatric disorders Depression
Other Normal pressure hydrocephalus
Head trauma
“Character gets you out of bed commitment moves you to action
faith, hope and Discipline follow through to completion”

13. Frequency of causes of Dementia
pooled from 32 studies
Cause Occurrence (%)
Alzheimer’s disease (AD) 57
Vascular Dementia 13
Depression 4.5
Alcohol 4.2
Normal pressure hydrocephalus 1.6
Metabolic 1.5
Medication 1.5
Neoplasm 1.5

14. Frequency of causes of Dementia
pooled from 32 studies
Cause Occurrence (%)
Parkinson’s disease 1.2
Huntington’s disease 0.9
Mixed AD & VD 0.8
Infection 0.6
Subdural haematoma 0.4
Post-trauma 0.4
Others 7.1
Not demented 3.7

15. Management
• Check the vital signs
• Check the finger stick glucose level
• Order the following laboratories tests stat:
Complete blood count (RBC)
Chemistry panel
Erythrocyte sedimentation rate (ESR)
Electrocardiogram (ECG)
Chest X-Ray
Urinalysis
Toxicology screen and ethanol level (if indicated)
 If the patient is too agitated to examine, follow the algorithm
of delirium
Opinion is ultimately determined by the feelings
and not by the intellect

16. Selective History and Chart Review
• What was the time course of onset of the patient’s
memory dysfuncion?
• Has the patient started any new medication within the
time frame of the memory loss?
• Is there any underlying medical illness?
• Have there been other cognitive or behavioural
changes bedsides memory loss, such as difficulty
making change in the grocery store, change in reading
habits, or disorientation, particularly in the evening?
• Is there any history of head trauma?
The True Art of Memory is The Art of Attention
- S.Johnson

17. Medications that may be associated
with memory impairment
Corticosteroids Chlorpromazine
Isoniazid Anticonvulsants (overdose)
Benzodiazepines Interleukins
Barbiturates Methotrexate
Bromides Clioquinol (antifungal)
Success is a prize to be won. Action is the road to it.
Chance is what may lurk in the shadows at the road side.
- O. Henry

18. Management
Diagnostic Testing
1. Blood tests (Thyroid function tests, Venereal
Disease Research Laboratory (VDRL) test,
Vitamin B12 level, HIV testing (if indicated))
2. Imaging (CT, MRI, SPECT, PET, TGA)
3. Electroencephalogram (EEG)
4. Lumbar puncture
People of mediocre ability often achieve success
because they don’t know enough to quit
- Bernard Baruch

19. Treatment
Treatment of Behavioral Dysfunction
1. Agitation, delusions or hallucinations/
illusions
2. Insomnia
3. Anxiety
4. Depression
At twenty the will rules
At thirty the intellect
At forty the Judgment

20. Disease specific Treatment of the
Pathophysiologic Process
1. Alzheimer’s disease
2. Parkinson’s disease, Lewy body disease
and progressive supranuclear palsy
3. Normal pressure hydrocephalus
4. Huntington’s disease
5. AIDS dementia complex
6. Transient global amnesia
7. Wernicke-Korsakoff syndrome
Maintaining the right attitude is easier than
regaining the right mental attitude

22. Two diverging/converging pataways
associated with VaD
Risk factor CVD Ischemic Brain injury
MRI lesion Clinical syndrome
HTN
Arteriosclerosis 1. occlusion complete infarct
lacune  lacunnar state
Arteriosclerosis 2. Hypoperfusion incomplete
infarct WHSM  Bingswanger syndrome
Experience can be defined as
yesterday’s answer to today’s problems

23. Pathogenesis of dementia due to VaD
1. Lacunar hypothesis
2. Binswanger’s subtype of VaD
3. VaD with coexisting Alzheimer’s disease
Expert is one who think to his
chosen mode of ignorance

24. Clinical syndromes
1. Lacunar state --- 85%
2. Strategic infarct dementia(e.g. thalamic
dementia) --- unknown %
3. Binswanger’s syndrome --- 10 – 15%
Take time to think; it is the source of power
Take time to read; it is the foundation of wisdom
Take time to work; it is the price of success

25. Features suggestive of
vascular dementia
From the history
Onset associated with a stroke
Improvement following acute event
Abrupt onset
From the exam
Findings typical of stroke e.g., hemiparesis,
hemianopia
From imaging
Infarct(s) above the tentorium
Every thing should be made as simple as
possible; but not simpler

26. Patterns of blood supply to the
cerebral hemispheres
Vascular Arterial supply Collateral supply
distribution
Cortex shorter
Corpus callosum Shorter
Sub cortical U fibers Intermediate Inter digitating
External / extreme Intermediate
capsules
Basal Ganglia Long
Centrum semiovale /
PVWM Long
Medical School can be a tool of torture or an
Instrument of Inspiration”

27. Categories of vascular Dementia
Category Clinical presentation
Lacunar infarctions Progressive dementia, focal deficits, or apathetic,
frontal-lobe-like syndrome, may have no stroke history
Single strategic infarctions Sudden onset aphasia, agnosia, anterograde amnesia,
frontal lobe syndrome
Multiple infarctions Step-wise appearance of cognitive & motor deficits
Mixed AD – VaD Progressive dementia with remote or concurrent history
of stroke
White matter infarctions Dementia, apathy, agitation, bilateral cortico-
(Binswanger’s disease) spinal/bulbar signs
Character gets you out of bed commitment moves you to action
faith, hope and Discipline follow through to completion

28. Diagnosis
Vascular Mechanism of Pathological
distribution Brain injury phenotype
“Infarct”
Single artery Acute ischemia Multiple lacunar
Small arteriole infarcts
Single artery Acute ischemia Single strategically
placed lacunar
infarct
Border zone Chronic White matter
Small arteriole hypo perfusion demyelination and
axonal loss
It is the providence of the knowledge to speak and it is the
privilege of the wisdom to listen - Hodly’s

29. Diagnostic criteria
1. Hachinski’s ischemic score
2. DSM IV criteria
3. ADDTC criteria
4. NINDS – AIREN criteria
5. Binswanger’s criteria
Give us the GR ACE to acce pt with se re nity the thing s that
canno t be chang e d the COUR AGE to chang e the thing s that
sho uld be chang e d and the WISDOM to kno w the diffe re nce

30. Short comings
1. Not interchangeable hence four fold rise in
frequency
2. DSM IV R most liberal
3. NINDS- AIREN criteria conservative
4. Gold standard for VaD (pathological definition
difficult)
5. Most of the criteria failed to distinguish between
small and large vessel subtypes
“HealthyMind and Healthyexpression of
Emotion go hand in Hand”

31. Diagnosis of Dementia after stroke
4 sets of criteria are used Sens Spec
1.Hachinski ischemic score 89% 89%
< 4 AD / 18, > 7 MID / 18
2. DSM IV 43% 95%
3. NINDS – AIREN 50% 98%
4. ADDTC criteria 50% 90%
Every discovery contains an irrational element or
4 creative intuition
Khrl Popper

32. Clinical characteristics of Neuro
behavioral syndrome of VaD
• Mental changes of dementia with single
brain lesion
• Sub cortical infarcts
• Multi Infarct Dementia: -
• Sub cortical arteriosclerotic
leukoencephalopathy
A great many people think they are thinking when
they are merely re arranging their prejudices
W. James

33. AD Vs VaD
AD VaD
Neuro transmitter defect Hemodynamic defect
Female predominance Male predominance
Gradual onset Abrupt onset
Steady deterioration Stepwise deterioration,
fluctuating course
BP normal Hypertension
No history of stroke History of stroke
Global decline in cognitive function Focal neurological symptoms and
signs
Unlikely to respond to treatment May respond to a drug which modifies
microcirculation and enhance cerebral
tissue perfusion
T T
he ruth is fear and immorality are two of the greatest
inhibitors of Performance to progress

34. Prognosis
1. Risk factors
• Advanced age
• Education
Develops dementia
• Lacunar subtype following ischemic
• Lt. Hemisphere CVA stroke
• Non white
“ Fools Adm but of m of sense approve”
ire en
- A. Pope

35. Prognosis contd….
2. In Lacunar stroke - Leukoariosis is
a poor prognosis
3. Recurrence of stroke
Hence
• Atrophy
• cognitive impairment
• WMSH are inter related in VaD
“ Social Isolation is in itself a pathogenic
Factor for disease production”

36. Prognosis contd..,
Neuro imaging phenotype
• CT lucency (lacunes and leukoariosis)
• MRI hyper intensity (lacunes and WMSH)
A true com itm is a heart felt prom to
m ent ise
yourself fromwhich y will not back down -
ou
D. Mcnally

37. Prevention and Treatment of
vascular dementia
I. Brain at risk stage
The aged
Hypertensive
Smokers
Diabetics
Atrial fibrillators
Cardiac patients
Serious, sincere, systematic studies,
surely secure supreme success

38. II. Pre-dementia stage
Patients with TIA
Patients with stroke
Patients with subtle cognitive infarctions
Patients with silent cerebral infarctions
“Men of Genius Adm ired:
Men of W ealth envied
wom of power feared but only
en
wom of character are trusted”
en
A- Friedman

39. III. Dementia stage
Cardiac embolism
Atherosclerotic cerebrovascular disease
Hypertensive cerebrovascular disease
“Motivation is the Spark that lights
the Fire of Knowledge and
fuels the engine of Accomplishment”

40. Potential therapies of
vascular dementia
1. Brain at risk stage
Smoking cessation
Exercise (prevention and management of diabetes)
Diet (control of diabetes, hyperlipidemias, obesity)
Antihypertensives (ACE inhibitors and ca++ channel-
blockers maybe particularly suitable)
Lipid lowering agents
Anticoagulants (for atrial fibrillation)
Aspirin (for selected patients at high risk)
“Peace Rules the day where reason Rules the mind”
Colling

41. 2. Pre-dementia stage
Carotid endarterectomy (symptomatic patients with
-carotid stenosis of 70-99%)
Anticoagulants
Aspirin
Ticlopidine
Agents that interfere with amyloid deposition vessels
Ca++ channel blockers (pre treatment to attenuate
-effect of infarcts)
“ByNature All Men/W en are alike but
om
byEducation widelydifferent”
- Chinese

42. 3. Dementia stage
Antidepressents
Antihypertensives – 6 mm of Hg reduction in systolic or diastolic
BP -reduces the risk of stroke by 40%
Cholinergics - Tacrine, Galantamine, rivastigmine, donepezil
NMDA antagonist – Memantine
Aspirin
Ticlopidine
The Truth is fear and im oralityare two of the greatest
m
inhibitors of P erformance too progress

43. Prevention & Treatment
Anti dementia drug trials (not based on subtype of VaD)
Alkaloid derivatives
(hydergine or nicergoline)
Pentoxyfylline
Piracetam Modest benefit
Memantine
Donepezil
Gingko biloba
“ He who cannot forgive others destroy the bridge
s
over which he him m pass” - Annoy
self ust

44. Role of RIVASTIGMINE in VaD
No.of patients : 15
Age group : 50 – 80 years
Female : 6
Male : 9
Most of them had diabetes and hypertension
Not based on subtype of VaD
30% showed remarkable improvement in cognitive, curative
and affective functions of the brain
Future study needed in pre dementia and dementia stages
Thought is the labour of the intellect
Reverie is its pleasure

45. Strategies to prevent –
STROKE-TO-DEMENTIA
TEN-STEP APPROACH
1. Treat hypertension optimally
2. Treat diabetes
3. Control hyperlipidaemia, use dietary control for
diabetes, obesity and hyperlipidaemia
4. Persuade patients to cease smoking and decrease
alcohol intake
5. Prescribe anticoagulants for atrial fibrillation
6. Provide antiplatelet therapy for high risk patients
A open foe may prove a curse ; but
a pretended friend is worse

46. Strategies to prevent –
STROKE-TO-DEMENTIA contd…
7. Perform carotid endarterectomy for severe (>70%) carotid stenosis
8. Recommend lifestyle changes (e.g., weight loss, exercise, reduce
stress, decrease salt intake)
9. N-methyl-D-aspartate receptor antagonists, antioxidants)
10. Intervene early for stroke and transient ischemic attacks with
neuroprotective agents (e.g., propentofylline, calcium channel
antagosists, - ? Rivastigmine
It is a great misfortune not to possess sufficient wit to speak well
nor sufficient judgment to keep silent
La Broyers character

47. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU
“My Opinions are founded on knowledge
but modified by experience”