The document discusses dementia, including its various types, symptoms, diagnostic criteria, assessment methods, and treatment options. It defines dementia as the loss of cognitive and intellectual function without impairment of perception or consciousness. The five major types of dementia are Alzheimer's disease, cerebrovascular disease, Lewy body disease, frontotemporal dementia, and Parkinson's disease with dementia. Assessment involves interviews, examinations, and tests to evaluate cognition, function, and rule out other conditions. Treatment focuses on enhancing quality of life and includes both non-pharmacological and pharmacological approaches.

1. Dementia Arden L Aylor, MD Geriatrics Texas Tech University

2. Goals & Objectives Statistics Clinical Features Diagnostic Criteria Assessment Methods Treatment Methods

3. Normal vs. Abnormal Aging >40 year-old: Age Associated Memory Impairment Decline in Hepatic & Renal function Vision changes Hearing changes

4. Dementia Definition: The loss of cognitive and intellectual function, without impairment of perception or consciousness Characterized by disorientation, impaired memory, judgment, intellect and labile affect

5. Did you Know… Five major types of Dementia Alzheimer’s: 60-70% Cerebrovascular: 15-25% Lewybody: 5-8% Frontotemporal: 3-5% Parkinson's with Dementia: 1-3% Estimated by 2040, 120 million Arch Neuro, 2005

6. Did you Know… Prevalence: 6-8% 60 yrs and doubles every 5 years 80 yrs: 47-50% population suffer from some form of dementia www.aoa.dhhs.gov

7. Did you Know… 2006 - total cost world wide exceeded $220 billion acute care long-term care home health care lost productivity for caregivers www.aoa.dhhs.gov

8. Genetics The two major risk factors for dementia age family history Alzheimer’s: 50% penetrance in first degree relatives by age 80

9. Genetics Alzheimer’s (AD): before age 60 genetic mutations on chromosomes 1, 14, 21 Alzheimer’s (AD): after age 60 apolipoprotein E gene (APOE) on chromosome 19

10. Genetics APOE* 4/4 allele 6x increase risk in ( AD) APOE* 2 appears to be protective Other risk factors: head injury, education level, estrogen replacement after menopause, long-term NSAID’s

11. Clinical Features Memory Impairment Early Dementia: difficulty learning and retaining new information Late Dementia: inability to access distant memories, impaired judgment and executive function

12. Clinical Features Dementia has a profound effect on the patient’s daily life: ADL’S (eating, bathing, grooming) planning meals managing finances medications communication driving

13. Clinical Features Early behavior and mood changes are common: personality alterations irritability anxiety depression Late findings: Delusions, hallucinations, aggression and wandering

14. Clinical Features Dementia and depression often overlap Depressed patients usually exhibit intact language and motor skills 55% over 65 yrs with mild cognitive impairment + depression, progress to moderate to severe dementia within 5 yrs Arch Neuro, 2005

15. Clinical Features Dementia & Agitation undiagnosed medical problem pain depression/ anxiety delirium environmental changes

16. Six Diagnostic Criteria for Dementia 1. Multiple cognitive deficits a. Memory impairment b. One or more of the following: aphasia apraxia agnosia disturbance in executive function Core Geri, 2005

17. Six Diagnostic Criteria for Dementia 2. Cognitive deficits in 1a and 1b causing an impairment in social or occupational function which represents a significant decline from a previous level 3. Course is characterized by gradual onset and continued cognitive decline

18. Six Diagnostic Criteria for Dementia 4. Cognitive deficits in 1a and 1b are not due to any of the following: central nervous system condition causing progressive deficits in memory or cognition systemic condition substance-induced condition

19. Six Diagnostic Criteria for Dementia 5. Deficits do not occur exclusively during the course of a delirium 6. Disturbance is not better accounted for by another Axis I disorder (major depression, schizophrenia )

20. Mild Dementia Disorientation for dates Naming difficulties (anomia) Recent recall problems Difficulty copying figures Decreased insight Social withdrawal Irritability, mood changes Problems managing finances

21. Moderate Dementia Disoriented to date and place Comprehension difficulties Impaired new learning Getting lost in familiar areas Impaired calculating skills Delusions, agitation, aggression Stop cooking, shopping, banking Restless, anxious, depressed Problems with dressing, grooming

22. Severe Dementia Unintelligible speech Remote memory gone Inability to copy or write Loss of self care Incontinent

23. Clinical Features Alzheimer’s Dementia Age: 70-75 Cognition: Memory Impairment Behavioral: Apathy, Depression Neurological: Intact Prognosis: Death 8-10 years

24. Clinical Features Cerebrovascular Dementia Age: 70 Cognition: Language, Memory, Executive Function Impairment Behavioral: Agitation, Hallucinations, Depression Neurological: Frontal Release Signs, (+) Brain Imaging Studies Prognosis: Death 5-8 years

25. Clinical Features Lewybody Dementia Age: 65 Cognition: Memory, Executive Function & Orientation Impairment Behavioral: Visual Hallucinations, Depression Neurological: Parkinsonism Prognosis: Death 6-8 years

26. Clinical Features Frontotemporal Dementia Age: 65 Cognition: Executive Function Impairment Behavioral: Social Inhibition Neurological: Intact Prognosis: Death 6-8 years

27. Clinical Features Parkinson’s with Dementia Age: 70 Cognition: Memory, Executive Function, Language, Orientation Impairment Behavioral: Depression, Hallucinations Neurological: Parkinson’s Disease Prognosis: Death <5 years

28. Assessment Methods Informant interview and office evaluation are the most important diagnostic tools Functional Status: MMSE , Functional Activities Questionnaire (FAQ), Geriatric Depression Screening, Clock Drawing Test Laboratory: CBC, CMP, TSH, Serology for Syphilis, Vitamin B12, HIV Core Geri, 2005

29. Assessment Methods Brain Imaging (CT, MRI, PET) atrophy space-occupying lesions vascular disease whiter matter disease

31. Assessment Methods Imaging Studies Order if-- onset before 60 yrs post-acute illness less that 18 months neurologic finding are asymmetric gait disturbance incontinence unexplained

32. Treatment and Management Goal: Enhance quality of life, maximize function, improve cognition, mood and behavior non-pharmacological pharmacological

33. Nonpharmacologic Cognitive Enhancement reality orientation and memory training Individual and Group Therapy emotional orientated psychotherapy stimulation orientated therapy art and exercise

34. Other Nonpharmacologic Communication with family and caregiver Medical and legal Advance Directives Environmental Modifications moderate stimulation only memory measures clocks, calendars, to-do lists name tags, alert bracelets

35. Pharmacologic Individualized treatment Monitor renal clearance and hepatic metabolism Anticholinergic medications worsen cognitive impairment “ Start low and go slow” Avoid starting multiple medications

36. Pharmacologic Alzheimer’s Dementia Cholinesterase Inhibitors Donepezil (Aricept) Galantamine (Razadyne) Rivastigmine (Exelon) Memantine (Namenda) SSRI’s

37. Pharmacologic Cerebrovascular Dementia Cholinesterase Inhibitors Control lipids Stoke prevention SSRI’s Memantine Anticonvulsants Antipsychotics

38. Pharmacologic Frontotemporal Dementia No Cholinesterase Inhibitors SSRI’s Memantine Anticonvulsants Antipsychotics

39. Pharmacologic Lewybody Dementia (Pick’s disease) Cholinesterase Inhibitors SSRI’s Memantine Levodopa/ Carbidopa Antipsychotic

40. Pharmacologic Parkinson’s Disease with Dementia Treat the Parkinson’s disease No Cholinesterase Inhibitors SSRI’s Memantine Antipsychotic

41. Cholinesterase Inhibitors Donepezil (Aricept) Precautions : Nausea, vomiting, diarrhea, GI bleed, sick sinus syndrome, seizures Interactions : CYP2D6 (flecainide, metopropol, codeine) , used with NSAID 3-4x risk for GI bleed

42. Cholinesterase Inhibitors Galantamine (Razadyne) Precautions : AV block, seizures, bladder obstruction, renal and hepatic, GI bleed, GI upset Interactions : CYP3A4 (cholinergic agonist -bethanechol, ketoconazole, cimetidine, erythromycin)

43. Cholinesterase Inhibitors Rivastigmine (new q 24 Exelon Patch) Precautions : Nausea, vomiting, anoxia, GI bleed, sick sinus syndrome, seizures Interactions : CYP2D6 and CYP3A4, potentates muscle relaxants, used with NSAID 3-4x risk for GI bleed

44. NMDA [glutamate] antagonist Memantine (Namenda) Precautions : Dizziness, headache, alkalinized urine (ATN, UTI) seizures, GI upset Interactions : Other NMDA antagonists (amantadine, dextromethorphan), decreased by renally-excreted drugs (HCTZ)

45. Mild to Moderate Dementia Cholinesterase Inhibitors slow cognitive decline Meta Analysis - Delayed nursing home placement by 1.2 years NNT 9.6 www.aoa.dhhs.gov

46. Moderate to Severe Memantine: 1-3 year delay in progression of symptoms NNT 16.2 Memantine + Cholinesterase inhibitor No definitive data early combination may decrease progression from mild to severe dementia by 4-5 years Ann Intern Med , 2004

47. Research: What’s New Tramiprostate (Alzhemed) mechanism: Inhibits GAG & A β protein fibrillization reduces amyloid formation and accumulation Tarenflurbil (Flurizan) r-flurbiprofen mechanism: Selective Amyloid-Lowering Agent (SALA) inhibits A β 42 amyloid plaques cascade Alzheimer’s Vaccine

48. Research Other studies estrogen NSAIDS vitamin E (increase cardiac events) selective monoamine oxidase-B inhibitor ginko biloba prophylaxis cholinesterase treatment J Gerontol a Bio Sci Med , 2004

49. Antidepressants Guidelines (American & UK Geriatric Society) treating all patients with dementia and signs of depression/ anxiety with an SSRI or SNRI

50. All SSRI are not Equal Paroxetine (Paxil): Drug interaction, anti-cholinergic Fluoxetine (Prozac): Long half life, anorexia Sertraline (Zoloft): Good, sleepy Citalopram (Celexa): Good, mild hypotension Escitlopram (Lexapro): Good, mild hypotension

51. “ Sundowning” Mild Dementia late afternoon or evening confusion Severe Dementia agitation, irritability restlessness

52. “ Sundowning” Etiology: lack of clues from light/ dark cycling decrease sensory input environmental changes lack of a structure daily routine change in caregivers

53. “ Sundowning” Recommendations R/O occult medical problems infection medication changes avoid dramatic changes in living environment encourage familiar home surroundings

54. Key Points Interviews & office evaluations are the most important diagnostic tools Goal: Enhance quality of life, maximize function, improve cognition, mood and behavior Not all SSRI’s are equal Individualized treatment mild - moderate: cholinesterase inhibitors, SSRI’s moderate - severe: memantine, SSRI’s or combinations

55. References Cobb, Duthie, Murphy; Geriatric Review Syllabus: A Core curriculum in Geriatrics, 5th ed, 2005, 117-129 Peterson, Smith, Waring, Mild Cognitive Impairment, Arch Neurol ., 2005(3): 303-308 Royall, Chaiodo, Polk, Subclinical Cognitive Impairment, J Gerontol a Bio Sci Med , 2004;55 (9):M541-M546 Grifford, Holloway, Frankel, Improving adherence to dementia, A randomized Controlled Trial, Ann Intern Med , 2004;131(40):237-246 Governmental Administration on Aging & Research www.aoa.dhhs.gov Alzheimer Research Forum, www.alzhforum.org/drug

56. Assessment: PET Alzheimer's Disease Parietal & Temporal deficits with intact neurology Frontotemporal Frontal & Temporal deficits Parkinson’s with dementia Parietal deficits Vascular dementia Focal, asymmetric