This is a presentation on the science behind diagnosis of dementias (inc alzheimer's, FTD, lewy body). The take home message is that our clinical accuracy is modest. Includes images from several sources. Delivered to MRCPsych Leicester 2009
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
Edith Pomarol-Clotet, Unidad de Psicosis e Investigación de Complejo Asistencial en Salud Mental Benito Menni.
"Esquizofrenia, cerebro y neuroimagen, lo que todavía no sabemos"
Evento: El papel de los investigadores ante los grandes retos de la innovación en salud.
Madrid, 23 de marzo de 2012
This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference, that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada
Anatomical plasticity of adult brain is titrated by nogo receptor 1 (06 March...Loki Stormbringer
Experience rearranges anatomical connectivity in the brain, but such plasticity is suppressed in adulthood. We examined the turnover of dendritic spines and axonal varicosities in the somatosensory cortex of mice lacking Nogo Receptor 1 (NgR1). Through adolescence, the anatomy and plasticity of ngr1 null mice are indistinguishable from control, but suppression of turnover after age 26 days fails to occur in ngr1−/− mice. Adolescent anatomical plasticity can be restored to 1-year-old mice by conditional deletion of ngr1. Suppression of anatomical dynamics by NgR1 is cell autonomous and is phenocopied by deletion of Nogo-A ligand. Whisker removal deprives the somatosensory cortex of experience-dependent input and reduces dendritic spine turnover in adult ngr1−/− mice to control levels, while an acutely enriched environment increases dendritic spine dynamics in control mice to the level of ngr1−/− mice in a standard environment. Thus, NgR1 determines the low set point for synaptic turnover in adult cerebral cortex.
Diagnosis and Management of Special Populations 2010Dominick Maino
Diagnosis and Management of Special Populations presents the latest in the assessment and treatment of those with physical, cognitive, and behavioral abnormalities. Up to date information concerning the etiology, prevalence/incidence and physical/cognitive findings of individuals with developmental/acauired disabilities (Cerebral palsy, Down syndrome, Fragile X syndrome, autism, acquired/traumatic brain injury) will be discussed. New diagnostic and treatment techniques are reviewed. The eye care practitioner will be able to confidently provide eye and vision care for those with disability at the end of this presentation.
May marks the recognition of National Brain Tumor Awareness Month. Since its establishment in 2008, community organizations and support groups celebrate this month with increased efforts to raise awareness of brain tumors, increase funding for research and educate the public on symptoms and treatment options.
Edith Pomarol-Clotet, Unidad de Psicosis e Investigación de Complejo Asistencial en Salud Mental Benito Menni.
"Esquizofrenia, cerebro y neuroimagen, lo que todavía no sabemos"
Evento: El papel de los investigadores ante los grandes retos de la innovación en salud.
Madrid, 23 de marzo de 2012
This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference, that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada
Anatomical plasticity of adult brain is titrated by nogo receptor 1 (06 March...Loki Stormbringer
Experience rearranges anatomical connectivity in the brain, but such plasticity is suppressed in adulthood. We examined the turnover of dendritic spines and axonal varicosities in the somatosensory cortex of mice lacking Nogo Receptor 1 (NgR1). Through adolescence, the anatomy and plasticity of ngr1 null mice are indistinguishable from control, but suppression of turnover after age 26 days fails to occur in ngr1−/− mice. Adolescent anatomical plasticity can be restored to 1-year-old mice by conditional deletion of ngr1. Suppression of anatomical dynamics by NgR1 is cell autonomous and is phenocopied by deletion of Nogo-A ligand. Whisker removal deprives the somatosensory cortex of experience-dependent input and reduces dendritic spine turnover in adult ngr1−/− mice to control levels, while an acutely enriched environment increases dendritic spine dynamics in control mice to the level of ngr1−/− mice in a standard environment. Thus, NgR1 determines the low set point for synaptic turnover in adult cerebral cortex.
Diagnosis and Management of Special Populations 2010Dominick Maino
Diagnosis and Management of Special Populations presents the latest in the assessment and treatment of those with physical, cognitive, and behavioral abnormalities. Up to date information concerning the etiology, prevalence/incidence and physical/cognitive findings of individuals with developmental/acauired disabilities (Cerebral palsy, Down syndrome, Fragile X syndrome, autism, acquired/traumatic brain injury) will be discussed. New diagnostic and treatment techniques are reviewed. The eye care practitioner will be able to confidently provide eye and vision care for those with disability at the end of this presentation.
Dementia is an umbrella term that can affect even young individuals. This presentation investigates causes, assessment, diagnosis, and treatment options.
This Slide describes progression of alzheimer disease and the changes that occurs in alzheimer disease. Also it describes how the disease progress to different parts of brain and which different part of brain are involved in it. It is made by Gopal Agarwal, Ph.D Research Scholar, NIPER-Ahmedabad
Similar to MCRPsych09 - Evidence Based Diagnosis of Dementias (Nov09) (20)
Alex J Mitchell Alcohol Detection by Clinician (Aug2012)Alex J Mitchell
Powerpoint slides on detection and identification of alcohol problems (alcohol use disorder) by clinicians.
See related paper:
http://bjp.rcpsych.org/content/201/2/93.abstract
Royalty free for personal use, but please cite with credit to AJMitchell (Leicester)
Here are the most anticipated time-trial (triathlon) bikes of 2012. Carbon fibre masterpieces designed to go fast in a straight line. Image resolution 1600x1000 approx.
Illustration of Mental Health Clustering Calculator ajmitchellAlex J Mitchell
Our team has created a clustering calculator for mental health diagnoses. This is a preview of how it works. The idea is to allow clinicians to work out the correct cluster from the problem list inputs. The calculator is in MS excel and follows the suggested algorithms precisely
Weight diabetes and metabolic problems in patients taking atypical antipsycho...Alex J Mitchell
Free slide show on weight gain, diabetes and metabolic problems in those taking atypical antipsychotic medication in schizophrenia, bipolar disorder and related conditions. Image credits retained by original authors. Please give correct acknolwedgements if you present any material from here.
Photos from Tour of Britain London Stage (Sept11) taken by me (alex mitchell). Photos mostly used a sports panning technique to capture movement with some fill-in flash. Available to download.
POCOG - The Future of Psycho-Oncology (Aug 2011)Alex J Mitchell
This is an invited talk on the "The Future of Psycho-Oncology" given to the POCOG group of the University of Sydney (lead Phyllis Butow) in August 2011.
This is a combined one page one side screener consisting of the PHQ9 and GAD7. Both are in the public domain seperately, but here I have simply combined the two. The PHQ9 includes the standard question on function.
patient health questionnaire, generalized anxiety disorder
[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)Alex J Mitchell
This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.
Rcpsych Workshop - Depression in medical settings (Mar11)Alex J Mitchell
Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.
COH Online- The future of screening for distress in cancer settings (February11)Alex J Mitchell
This is a presentation I did at the us city of hope comprehensive cancer center in february 2011. The topic was future of screening for distress (and depression) in cancer; including an overview of recent screening findings.
Top 100 Most Cited People in Psychiatry (Mental Health) (Jan 2011) [aka Top 1...Alex J Mitchell
This is an uptodate list of the top 100 most highly cited people in psychiatry (mental health). List includes neuroscientists and psychologists publishing in this field. Note that to qualify an author must be listed on a peer reviewed paper on web of science; not necessarily the lead author. Current as of 31-Jan-2011. Presentation also known as list of Top 100 Psychiatrists
Top 100 Papers & People in Psychiatry (Jan2011)Alex J Mitchell
Short slideshow of the top100 people and papers in psychiatry as of january 2011 based on Web of science. British emphasis, worlwide list in preparation.
Organizational chart of NHS staffing ratios 1999-2009Alex J Mitchell
This is an illustrative chart of NHS staffing, normalized per hospital consultant. In other words...for every 1 hospital consultant in the NHS there are X nurses; X managers X ambulance drivers etc.
Prepared by Alex J Mitchell (ajm80@le.ac.uk) from public data.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
MCRPsych09 - Evidence Based Diagnosis of Dementias (Nov09)
1. Evidence Based Diagnosis of the Dementias
Evidence Based Diagnosis of the Dementias
Validity of criteria for diagnosing subtypes of dementia
Validity of criteria for diagnosing subtypes of dementia
Alex Mitchell www.psycho-oncology.info
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary
Department of Liaison Psychiatry, Leicester General Hospital
MRCPsych Leicester Nov 2009
2. Pragmatic definition of dementia
• Dementia is an acquired global impairment of intellectual functioning
• Involving memory, language, thinking, and perception
• Associated with disability
• Usually is progressive and irreversible
• Current Treatments make a modest difference to the disease course
• Dementia is a syndrome with many underlying diseases
• Some diseases may yet not be adequately described
• Dementia is preceded by mild cognitive impairment (which may not come to
medical attention)
2
3. Concepts of Screening
• Screening (possible case) High convenience
» Eg MMSE
• Case-Finding (probable case)
» Eg NINCDS-ADRDA criteria,
• Severity Rating
» Eg ADAS-Cog
• Gold Standard (definite case)
» Pathology => disease High accuracy
4. Concepts of Dementia
High convenience
• Symptoms and signs
• Detailed symptoms (neuropsychology)
• Gross pathology
• In vivo pathology (neuroimaging)
• Microscopic pathology
• Immunochemistry
• Genetics High accuracy
10. Higher Cortical Functions and Association Cortices
Attending
Selecting
Recognizing
Association cortices = cognition
Imitating
Remembering
11. The “Association Cortices” have a distinctive neocortex
Cortical Maps: Brodmann
Lateral
Neocortex
~50 regions
Medial
Cytoarchitecture = Cell packing density and type
13. Distribution of AD in Different Settings
AD in the Community AD within Institutions
Moderate Moderate
44% 34%
Mild Severe
46% Mild
55%
11%
Severe
10%
CSHA Working Group, CMAJ, 1994.
CSHA Working Group, Can J Aging, 1994.
14. Probability of Institutionalization by Severity
1.0
0.867
0.8
Institutionalization
Probability of
0.6
0.4 0.345
0.2
0.017
0.0
Mild Moderate Severe
(MMSE: 21–30) (MMSE: 11–20) (MMSE: 0–10)
Severity of AD
Hauber AB, Gnanasakthy, Snyder EH, et al. Pharmacoeconomics. 2000(April);17(4):35
15. Outcome measures used in Alzheimer’s Disease
ADAS-Cog
Cognition Function Alzheimer’s Disease
(ADAS-Cog) (DAD/ADCS- Assessment Scale, Cognitive
ADL) subscale
Global CIBIC-plus
(CIBIC-plus) Clinician Interview-Based
Impression of Change with
Caregiver Input
DAD
Disability Assessment in
Dementia
Behaviour
ADCS-ADL
(NPI) Alzheimer's Disease Co-
Operative Study – Activities of
Daily Living
NPI *
Caregiver burden Neuropsychiatric Inventory
*Contains subscale NPI-D, which measures caregiver distress SCGB
Screen for Caregiver Burden
19. Primer on Neuropsychology of Memory
Registration
Memory
Retrieval
Retention
Implicit Declarative
Learning of
Learning of Skills & Automatic Behaviours
Information
Working Memory Short-term Memory Long-term Memory
Retention over Seconds Retention over Minutes Retention over days
Motor Conditioning Priming
Visuospatial Verbal Semantic Memory Episodic Memory
Database of information Narrative Account
22. Alzheimer’s disease
Auguste D, November 3, 1906
37th Assembly of Southwest German Psychiatrists in Tübingen, Germany
“atrophied brain; numerous ganglia cells have disappeared”
“remarkable changes in neurofibrils”
“millet-seed lesions, characterized by the deposits of a peculiar substance spread over entire cerebral cortex”
“we clearly have a distinct disease process”
23. History of AD
• 1906 Alzheimer presented Auguste D
• 1910 Kraepelin Coined “Alzheimer’s disease” (Psychiatrie: Ein Lehrbuch fur Studierende und
Ärzte, Leipzig)
• 1960 Electron microscopic studies in the 1960s by M Kidd and R Terry (with H Wisniewski, M
Shelanski, B Ghetti, K Iqbal, D Dickson, etc.) revealed the ultrastructural features of AD
• 1968 Tomlinson, Blessed and Roth (1968, 1970) showed that the brains of healthy and
demented older adults differ and that most demented persons have AD
• 1976 Cholinergic deficit (ChAT) in AD brains (Davies and Maloney, 1976; Bowen et al.,
1976
• 1991 APP mutation causing dominantly inherited AD (Goate et al., 1991)
• 1991 Concept of mild cognitive impairment, or MCI (Flicker et al)
• 1992 Presenilin 1 (St George-Hyslop et al., 1992)
• 1993 ApoE identified as the major susceptibility gene for AD (Strittmatter et al., 1993)
• 1993 Tacrine approved
• 1995 Presenilin 2 (Rogaev et al., 1995) mutations identified
• 1996 Donepezil approved
• 2001 Galantamine approved
• 2003 memantine approved
29. Neurofibrillary
Tangles
Neurons have an internal support structure partly
made up of microtubules. A protein called tau
helps stabilize microtubules. In AD, tau changes,
causing microtubules to collapse, and tau
proteins clump together to form neurofibrillary
tangles.
41. Simple Measures of Accuracy
Dementia Dementia
PRESENT ABSENT
Test +ve True +ve False +ve PPV
Test -ve False -Ve True -Ve NPV
Sensitivity Specificity Prevalence
42. Theory of Diagnostic Tests
Point of Partial Rarity?
Number
of Cognitive Impairment
Individuals
Dementia
True ‐ve
True ‐ve
True +ve
True +ve
False ‐ve
False ‐ve False +ve
False +ve
Score on Hypothetical Diagnostic Test Optimum Cut‐off value
43. Ganguli M et al. Detection and Management of Cognitive Impairment in Primary Care: The Steel Valley Seniors Survey. JAGS 52:1668–1675, 2004.
GP Testing by Actual MMSE Score (n=162)
44. MMSE modest sensitivity and
specificity in dementia vs no
dementia.
Data from Cambridge CFAS
45. Anim als nam ed in 1 m in (m m s>19) - CERAD data set
12
10
percent of total
8
6
4
2
0
0 10 20 30 40
num ber of anim als nam ed
Normal Controls, CS = 1, n = 386
Alzheimer patients, CS = 0, n = 380
47. Dementia in DSMIV
• Short-term memory impairment AND dementia
• At least one of the following:
» Aphasia - language impairments
» Apraxia - motor memory impairments
» Agnosia - sensory memory impairments
» Abstract thinking / Exec. fn impairments
• Impairment in social and/or occupational function
• Not explainable by another disorder (such as delirium)
48. Dementia in ICD10
• Dementia (memory and thinking)
• Incidious onset > 6months
• Poor function
• Normal consciousness
• Executive dysfunction
49.
50. Diagnostic criteria & dementia prevalence
Canadian Study of Health and Aging (CSHA)
Criteria (n=1879) % of CSHA population
ICD-10 3.1
CAMDEX 4.9
ICD-9 5.0
DSM-IV 13.7
DSM-IIIR 17.3
DSM-III 29.1
Erkinjuntti T, Ostbye T, Steenhuis R, Hachinski V. The effect of different
diagnostic criteria on the prevalence of dementia. NEJM 1997 337(23):1667-74.
50
53. Additional Behavioral Influences
Small and Large Vessel Vascular Supply
Blood vessels in human brain. A plastic emulsion was
injected into brain vessels and brain tissue was dissolved.
Zlokovic & Apuzzo: Neurosurgery 43(4):877-878, 1998.
55. Diagnosis - Hachinski Scale
Item Score
Sudden onset 2
Stepwise deterioration 1
Fluctuating course 2
Nocturnal confusion 1
Relative preservation of personality 1
Depression 1
Somatic complaints 1
Emotional incontinence 1
History of hypertension 1
History of stroke 2
Evidence of associated atherosclerosis 1
Maximum = 18 Focal neurological symptoms 2
7 : Vascular Focal neurological signs 2
5- 6 : Mixed
< 4 : Alzheimer’s
55
56. MRI Markers of SIVD
Lacunar
Infarction
White Matter
Hyperintensitie
s
57. Clinical criteria for VaD
1. National Institutes of Neurological Disorders and Stroke-
Association Internationale pour la Recherche et
l’Enseignement en Neurosciences (NINDS-AIREN)
2. State of California Alzheimer’s Disease Diagnostic and
Treatment Centers (ADDTC)
3. Diagnostic and Statistical Manual of Mental Disorders. 4th
edition (DSM-IV)
4. Hachinski Ischemic scale
5. International Classification of Disease-10 (ICD-10)
62. Subtype of VaD
Macrovasculare thromboembolic (multi-infarct dementia )
Single strategic strokes
Multiple subcortical lacunar strokes ( lacunar state )
Extensive WMLs or Binswanger’s disease
Mixture of type 1,2,3,and 4 esp. lacunar-Binswanger
Postischemic dementia
Hemorrhagic dementia
Genetic cerebrovascular disease
Vascular-Alzheimer dementia
Vasculitides and other miscellaneous causes
63. Multi-infarct dementia (MID)
• 21.6% of VaD
• Large and medium vessels
– Carotid artery atherosclerosis
– MCA infarction
– watershed infarction
– Cardiac emboli
64. Lacunar Stroke
• 33-70 % of VaD
• Lenticulostriate branches (MCA)
Thalamogeniculate, choroidal and
thalamoperforator branches (PCA, Pcom)
• Frontal white matter 34.8%
• Basal ganglia 34.2%
• Pons 8%
• > 10-15 infarctions of deep structures
• 10 cm3 or 0.5% of intracranial volume
• >1/4 white matter
65. Comparison of VaD AD
Features
History Abrupt, stepwise Insidous and progression
Risk factors Cerebrovascular risks Family hx, APOE4 allele
Mental status Psychomotor slowing Recent memory
Finding Frontal executive function Visuospatial decline
Memory Retrieval and procedural Worse memory, orientation
memory and recognition
Language Sentence complexity and Naming and comprehension
prosody
Behavioral Apathy, depression, Delusion, poor insight
emotional lability
Neuro exam Focal neuro deficit none
MRI WMLs and stroke Diffuse/ mesial temporal
atrophy
PET/SPECT Patchy, global or frontal Bilateral temporoparietal
(hypometabolism )
72. 2005 Consortium Criteria DLB – Important Criteria
• 1. Central feature (essential for a diagnosis of possible or probable DLB)
• Dementia (progressive cognitive decline of sufficient magnitude to interfere with normal social or
occupational function)
• Prominent or persistent memory impairment
• Deficits on tests of attention, executive function, and visuospatial ability may be
especially prominent.
• 2. Core features (two core features are sufficient for a diagnosis of probable
DLB, one for possible DLB)
• Fluctuating cognition with pronounced variations in attention and alertness
• Recurrent visual hallucinations
• Spontaneous features of parkinsonism
• 3. Suggestive features (If one or more of these is present in the presence of one or
more core features, a diagnosis of probable DLB can be made. In the absence of any
core features, one or more suggestive features is sufficient for possible DLB.
Probable DLB should not be diagnosed on the basis of suggestive features alone.)
• REM sleep behavior disorder
• Severe neuroleptic sensitivity
• Low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET
imaging
73. 2005 Consortium Criteria DLB – Less Important Criteria
• 4. Supportive features (commonly present but not proven to have diagnostic
specificity)
• Repeated falls and syncope
• Transient, unexplained loss of consciousness
• Severe autonomic dysfunction, e.g., orthostatic hypotension, urinary incontinence
• Hallucinations in other modalities
• Systematized delusions
• Depression
• Relative preservation of medial temporal lobe structures on CT/MRI scan
• Generalized low uptake on SPECT/PET perfusion scan with reduced occipital activity
• Abnormal (low uptake) MIBG myocardial scintigraphy
• Prominent slow wave activity on EEG with temporal lobe transient sharp waves
• 5. A diagnosis of DLB is less likely
• In the presence of cerebrovascular disease evident as focal neurologic signs or on
brain imaging
• In the presence of any other physical illness or brain disorder sufficient to account in
part or in total for the clinical picture
74. Special Notes on PDD vs LBD
• DLB should be diagnosed when dementia occurs before or concurrently with
parkinsonism (if it is present). The term Parkinson
• disease dementia (PDD) should be used to describe dementia that occurs in
the context of well-established Parkinson disease. In a practice setting the
term that is most appropriate to the clinical situation should be used and
generic terms such as LB disease are often helpful. In research studies in
which distinction needs to be made between DLB and PDD, the existing 1-
year rule between the
• onset of dementia and parkinsonism DLB continues to be recommended.
Adoption of other time periods will simply confound data
• pooling or comparison between studies. In other research settings that may
include clinicopathologic studies and clinical
77. Lewy Body Inclusions
• Characteristic inclusions in substantia nigra neurons of
patients with Parkinson’s disease
• Immunoreactive for neurofilaments, ubiquitin and alpha-
synuclein, but not tau (NFT are tau and ubiquitin
positive)
• In substantia nigra it is cytoplasmic, round, eosinophilic
with clear halo
• In cortex less distinct appearance, best visualized with
alpha-synuclein immunohistochemistry
84. Types of Recognition
• Unassisted Clinical Ability
• Clinician Prompts
» GDS, CDR
• Patient Complaints / Relatives QQ
» Subjective Memory Complaints (SMC)
• Simple (Bedside) Single Item Cognitive Tests
» Verbal fluency, Name & Address, Orientation
• Short Batteries
» MMSE
• Long Batteries
» CAMCOG
• Criterion Standard
85. What Makes for a Good Screening Test?
• Often Examined
» Rapid training & administration
» Simple scoring & interpretation
» Good rule-out accuracy, ideally good rule-in accuracy also
• Rarely Examined
» High patient acceptance
» Multiple validation samples & settings
» Superiority to unassisted recognition
» Minimal bias => education, language
UK National Screening Committee (UK-NSC) www.nsc.nhs.uk/whatscreening/whatscreen_ind.htm
86. GP Screening Preferences
• 74% of people consult a GP first after noticing
symptoms of cognitive decline 3
• 82% of GPs say screening for dementia is worthwhile
» but 24% routinely screen (GPs)
» 39% psychiatrists use the MMSE1
• 93% would use a brief effective tool2
1 Gilbody, House Sheldon (2002) Br J Psychiatry
2 Bush et al Can Fam Physician. 1997
3 Wilkinson et al (2004);
88. Simple Memory Complaints Accuracy?
Lam et al. Int J Geriatr Psychiatry 2005; 20: 876–882. (n=306)
100
90 88 87.3
Controls 80.3
80
MCI
73.3 73.2
MCI=>Dementia 70.2
70 68.2 67.6
AD (CDR1)
63.8
60 58
48.5
50
45.1
43.7
41.3
39.4
40
35.1
30.3
30 28
25.5
20
16
10
0
Forgetting w here things are Unable to recall the nam es of Unable to follow and recall Subjective m em ory problem s* Consider ow n m em ory to be
placed good friends* conversation** w orse than others of a sim ilar
age**
90. Recognition of “Dementia” by GPs
Using documentation of dementia in the medical notes
Dementia Dementia
(DSMIV)
ABSENT
Dementia in 54 4 58
notes
PPV 93%
No dementia in 58 1144 1202
notes
NPV 95%
112 1148 1260
Sensitivity Specificity
Prevalence 8%
48% 99.6%
92. Predictors of Non-Recognition
• Good Activities of daily living
• Low years since symptoms first started
• Low presence of somatic comorbidity [Van Hout, 2002]
• male lived at home
• Coped better
• more depression Dementia: Predictors of diagnostic accuracy and the
contribution of diagnostic recommendations
Author(s): van Hout HPJ, Vernooij-Dassen MJFJ,
• milder dementia Hoefnagels WHL, Kuin Y, Stalman WAB, Moons
KGM, Grol RPTM
Source: JOURNAL OF FAMILY PRACTICE 51 (8):
693-699 AUG 2002
94. MMSE Limitations
• Takes 8-13 minutes. Too long
• Scores are affected by age, ethnicity, language and education
• Little executive or memory
• Some GPs find it difficult to interpret
• Patients acceptability not the best
95. Short Instruments
• 7 minute screen • Mini-Mental State Examination
(MMSE)
• Short Form, Informant QQ on
Cognitive Decline in the Elderly • Short and Sweet Screening
(short IQCODE) Instrument (SASSI)
• Abbreviated Mental Test (AMT) • Short Test of Mental Status
(STMS)
• Cambridge Cognitive
Examination (CAMCOG) • The 6 Item Cognitive Impairment
Test (6CIT)
• Clock Drawing Test (CDT)
• The General Practitioner
• Memory Impairment Screen
Assessment of Cognition
(MIS)
(GPCOG)
• Mental Alternation Test (MAT)
• The Rowland Universal
• Mini-Cog Dementia Assessment Scale
(RUDAS)
• Time and change Test (T&C)
98. Dementia Prognosis
Early Symptoms
90%
(Mini-Mental State Examination Score)
(Brain Volume / Intracranial Volume)
Pathological Burden
30
PRE-SYMPTOMATIC
Diagnosis
Diagnosis
85% PRE-CLINICAL
Mild Cognitive Impairment
Death
Death
80% 23
CLINICAL
Mild Dementia
75%
Disease Severity
20
Moderate Dementia
Unmodified Dementia
70%
12
Dementia with Risk Factors
Severe Dementia
T-10 T-5 T0 T+5 T+10
Time in Years Explanation
See text for details
Further Reading: Fox NC, Crum WR, Scahill RI et al. (2001) Lancet 358, 201-205
Imaging of onset and progression of Alzheimer’s disease with voxel compression of serial magnetic resonance images
99. Dementia Treatment
Early Symptoms
90% Pathological Burden
30
((Mini-Mental State Examination Score)
(Brain Volume / Intracranial Volume)
PRE-SYMPTOMATIC
Diagnosis
PRE-CLINICAL
85%
Institutional Care
CLINICAL
Mild Cognitive Impairment
Unmodified 23
80%
Treatment A
Treatment B
Mild Dementia
75%
Care
Treatment C 20
Disease Severity
Care
Moderate Dementia
Care
70%
12
Severe Dementia
T-10 T-5 T T+5 T+10 T+15
0
Time in Years Explanation
See text for details
100. Biochemical Progression of AD-Tau
Delacourte, Andre. The natural and molecular history of Alzheimer’s disease. J Alzheimer’s Disease 2006;9:1
101. tive
tic
olic
r
ra
cula
Etiology
uma
ene
tab
Vas
Deg
Me
Tra
MCI
Clinical classifi cation
Amnestic
MCI
Multiple
Domain
MCI Single
Non-memory
Domain
Heterogeneity of MCI from clinical and etiological perspectives.
Open cells are most common.