Dementia (Hon)

Question 1

Definition of dementia

Answer 1

Decline in memory and at last one other cognitive function (aphasia, apraxia, agnosia, or a decline in executive function, such as planning, organizing, sequencing, or abstracting).

This decline impairs social or occupational functioning in comparison with previous functioning. The deficits should not occur exclusively during the course of delirium and should not be accounted for by another psychiatric condition, such as depression or schizophrenia.

Question 2

What is the incidence and prevalence of dementia:

Answer 2

More than 10% of persons over the age of 65 have dementia.

More than 30% of persons over the age of 85 have dementia.

Question 3

What are the degenerative causes of dementia?

Answer 3

Alzheimer's disease (80% of all cases)
(Diffuse) Lewy body disease
Parkinson's disease
Frontotemporal lobar degeneration
- frontotemporal dementia (Pick's Disease)
- Progressive nonfluent aphasia
- Semantic dementia
Progressive supranuclear palsy
Corticobasal degeneration
Multiple systems atrophy
Huntington's disease
Olivopontocerebellar degeneration

Question 4

What are the vascular causes of dementia?

Answer 4

Multiple infarction
Single stroke
Binswanger's disease
Vasculitis
Subarachnoid hemorrhage

Question 5

What are the infectious causes of dementia?

Answer 5

Fungal meningitis
Syphilis
AIDS dementia
Creutzfeldt-Jakob disease
Post-herpes simplex encephalitis

Question 6

What are the psychiatric causes of dementia?

Answer 6

Depression
Alcohol abuse
Drug-related disorder
Personality disorder
Anxiety disorder

Question 7

What are the toxic or metabolic causes of dementia?

Answer 7

Vitamin B12 deficiency
Thyroid deficiency
System failure: liver, renal, cardiac, respiratory
Heavy metals
Toxins (e.g. Glue sniffing)

Question 8

The traumatic causes of dementia:

Answer 8

Subdural hematoma
Closed head injury
Open head injury
Chronic traumatic encephalopathy (Pugilistic brain injury)
Anoxic brain injury

Question 9

What tumors could cause dementia?

Answer 9

Glioblastoma
Lymphoma
Metastatic tumor

Question 10

What other causes could there be for dementia?

Answer 10

Symptomatic hydrocephalus

Question 11

Describe getting the history of dementia from the patient:

Answer 11

It is essential that history be obtained not only from the patient, but from spouse or other family members, caregivers, etc. The patient will often deny that they have any problem. Sometimes the family member may not want to speak freely in front of the patient. Consider a separate interview.

What difficulties does the patient have?:

• short-term memory problems
• time course (rapid or slow progression)
• functioning of patient - work, finances, reading the newspaper, watching T.V., shopping, hobbies
• safety concerns: driving, cooking, weapons in home
• H/O head injury, toxin exposure, infection, psychiatric problems
• Family history of dementia?

Question 12

Describe how to examine patient for dementia:

Answer 12

Standardized short mental state test (e.g. Folstein Mini-Mental State Examination or Montreal Cognitive Assessment - MOCA).
Ask about news events.
Look for cardiovascular risk factors (HTN, arterial bruits, arrhythmia, heart murmurs)
Full neurologic examination

Question 13

Describe laboratory studies recommended for dementia:

Answer 13

All cases:

• CBC
• Chemistry panel
• Sed rate
• Thyroid function studies
• B12 level
• RPR
• CT or MRI of the head

Selective recommendation:

• EEG (Creutzfeldt-Jakob, encephalitis, Sz.)
• Lumbar puncture (CA, infection, vasculitis, NPH)
• CXR
• HIV testing
• Drug screen
• SPECT or PET scan
• Heavy metal screen

Question 14

What are the criteria for clinical diagnosis of Alzheimer’s Disease?

Answer 14

Dementia established by means of clinical examination and documented with the Mini-Mental State Examination or similar examination and confirmed with neuropsychological tests.
Deficits in 2 or more areas of cognition.
Progressive worsening of memory and other cognitive function.
No disturbance of consciousness.
Onset between the ages of 40 & 90 year, most often after 65.
Absence of systemic disorders or other brain diseases that in and of themselves could account for the progressive deficits in memory and cognition.

Question 15

What are supporting findings in the diagnosis of probable Alzheimer’s Disease?

Answer 15

Progressive deterioration of specific cognitive functions such as aphasia, apraxia, or agnosia.
Impaired activities of daily living and altered patterns of behavior.
Family history of similar disorders, particularly if confirmed neuropathologically.
Normal L.P.
EEG: normal or mild generalized slowing.
Progressive atrophy documented by MRI or CT brain.

Question 16

What are some treatments of Alzheimer’s Disease?

Answer 16

Main goal of treatment is to slow the progression of the disease.
Acetylcholinesterase inhibitors:
- donepizil (aricept)
- rivastigmine (exelon)
- galantamine (reminyl)
NMDA receptor antagonist
- memantine (namenda) - indicated for moderate to severe dementia of probable Alzheimer’s disease
Consider B complex, lipid-lowering agent, aspirin

Question 17

Describe mild cognitive impairment:

Answer 17

Memory complaint, often noted by the patient
Tested abnormal memory for age, and yet does not meet the criteria for dementia
- normal general cognitive function
- normal activities of daily living
Probably a precursor to Alzheimer’s disease
Patients with MCI are 5x more likely to develop clinically probable Alzheimer’s disease than age-matched controls.
Treatment with AchEl medications may slow progression to Alzheimer’s disease

Question 18

What are the criteria for probable vascular dementia?

Answer 18

Dementia defined similarly to DSM-V criteria.
Cerebrovascular disease defined by the presence of focal signs on neurologic examination, such as hemiparesis, lower facial weakness, Babinski sign, sensory deficit, hemianopia, consistent with stroke, and evidence of relevant cerebrovascular disease at brain imaging including multiple large-vessel infarcts or a single strategically situated infarct (angular gyrus thalamus, basal forebrain, or posterior or anterior cerebral artery territories), as well as multiple basal ganglia and white matter lesions and white matter lacunes or extensive periventricular white matter lesions, or combination thereof.

Question 19

What is the tetrad of symptoms for Lewy Body Disease?

Answer 19

Dementia
Parkinsonian symptoms (generally bradykinesia & rigidity w/o tremor)
Prominent psychotic symptoms (usually visual hallucination)
Extreme sensitivity to antipsychotic agents

Question 20

Describe Lewy Body Disease

Answer 20

Often progresses more rapidly than Alzheimer’s disease.
Symptoms generally vary a great deal more from one day to the next than do symptoms in Alzheimer’s disease.
Up to 81% of patients with diffuse Lewy Body Disease have unexplained periods of markedly increased confusion that lasts days to weeks and closely mimics delirium.

Question 21

Describe the symptoms of Lewy Body Disease:

Answer 21

Mild to moderate Parkinsonian features are often present early in the disease. Bradykinesia, rigidity and falls are often prominent. Tremor is often absent. Response to Levodopa is often poor.
Dysautonomia is common.
Psychotic symptoms are much more common and occur earlier in diffuse Lewy Body Disease than in Alzheimer’s disease.
- visual hallucinations is the most common psychotic symptom - generally animals or people, often children.
- these hallucinations are often not particularly bothersome.

Question 22

What should you beware of with patients who have Lewy Body Disease?

Answer 22

BEWARE!!!
Most patients with Body Diffuse Lewy Disease experience severe, potentially life-threatening adverse reactions if treated with antipsychotic agents. If an antipsychotic is truly needed, use one of the newer agents (e.g. Seroquel or Zyprexa)

Question 23

Compare Parkinson’s Disease vs. Diffuse Lewy Body Disease

Answer 23

Parkinson’s Disease

• midbrain Lewy bodies
• executive dementia sometimes occurs late in illness
• Resting tremor usually present
• Autonomic dysfunction sometimes seen
• hallucinations only in response to antiparkinsonian drugs

Diffuse Lewy Body Disease

• cortical Lewy bodies
• Cortical dementia always occurs early in illness
• resting tremor usually absent
• Autonomic dysfunction prominent
• Hallucinations common in absence of antiparkinsonian drugs

Question 24

Tell me about Frontotemporal Degeneration:

Answer 24

Includes several forms of dementia characterized by a slowly progressive deterioration of social skills and changes in personality, along with impairment of intellect, memory, and language.
The disease varies greatly in the way it affects individuals, but often see common core of symptoms:
- loss of memory
- lack of spontaneity
- difficulty in thinking or concentrating
- disturbances of speech
Other symptoms include: gradual emotional dullness, loss of moral judgement, and progressive dementia.
Usually affects individuals between ages of 40 & 60.
Patients typically have atrophy of the frontal and temporal lobes of the brain.
No cure. Length of progression 2-10 years.

Question 25

What is Normal Pressure Hydrocephalus?

Answer 25

Triad:
- dementia
- gait disturbance
- urinary incontinence
POTENTIALLY reversible with ventriculoperitoneal shunting (gait disturbance is the most likely to be reversed with shunting).