evaluation of the patient with dementia

EVALUATION OF THE PATIENT WITH DEMENTIA

Jonathan T. Stewart, MDProfessor in Psychiatry

University of South Florida College of Medicine

Chief, Geropsychiatry Section

Bay Pines VA Medical Center

DEMENTIA

A syndrome characterized by acquired, progressive cognitive impairment

Affects 10% of individuals over 65 Caused by at least 80 different diseases, many

reversible Unfortunately, the most common diseases (85 – 90%)

are irreversible Diagnosis will have prognostic and treatment

implications All demented patients need a work-up

…and it’s mostly a good history

PRIMARY SYMPTOMS

ATTENTION MEMORY POSTROLANDIC (“COGNITION”) EXECUTIVE (FRONTAL/SUBCORTICAL) INSIGHT

PRIMARY SYMPTOMS

ATTENTION: clouded sensorium, delirium MEMORY: forgetfulness POSTROLANDIC: aphasia, apraxia, getting

lost EXECUTIVE: poor judgment, disinhibition,

abulia, urge incontinence INSIGHT: anosognosia, catastrophic

reactions

TWO TYPES OF DEMENTIA

Postrolandic Frontal/subcortical

POSTROLANDIC

Memory deficits Aphasia Apraxia Agnosia Personality more or

less preserved MMSE valid

FRONTAL/SUBCORTICAL

Memory deficits Loss of behavioral plasticity

and adaptability, judgment Personality changes

Disinhibition Abulia

Urge incontinence MMSE useless

THE REST OF THE HISTORY

Time course Depressive symptoms Past medical history

Medical and psychiatric conditionsFamily HxEtOHMedications (including OTC, OPM)

THE REST OF THE EXAM

Physical exam Neurologic exam Mental status exam

THE FOLSTEIN MMSE

Most studied and used of the standardized exams

Quick and easy to administer Excellent inter-rater reliability Accurately measures the severity and

progression of Alzheimer’s disease Does not detect executive deficits at all

BEYOND THE MMSE

ATTENTION: digit span or “DLROW” MEMORY: 3 word recall, orientation POSTROLANDIC: naming, praxis,

calculations, intersecting pentagons EXECUTIVE: contrasting programs,

Luria figures, go-no go, controlled word fluency, frontal release signs

LURIA’S RECURSIVE FIGURES

LURIA’S RECURSIVE FIGURES

LURIA’S RECURSIVE FIGURES

THE GERIATRIC DEPRESSION SCALE (GDS)

Good screen for most patients Easy to administer and score Face-valid, so patients can “fake good”

or “fake bad” Valid for demented patients with an

MMSE above about 12Use DMAS or Cornell scale for severely

demented patients

THE REST OF THE WORK-UP

Basic labs Thyroid function tests B12 (methylmalonic acid and homocysteine

if borderline) Serology HIV, drug screen, others, as indicated Neuroimaging study, usually LP or EEG, rarely

PLEASANT SURPRISES

Depression Iatrogenic (anticholinergics, sedatives, narcotics, H2

blockers, multiple meds) Hypothyroidism B12 deficiency Neurosyphilis Alcoholic dementia Normal pressure hydrocephalus Subdural hematoma Others

POSTROLANDIC DEMENTIAS

Alzheimer’s disease Diffuse Lewy body disease

ALZHEIMER’S DISEASE

Slowly, insidiously progressive postrolandic dementia; executive sx’s much later

Neurologic exam, labs, neuroimaging studies unremarkable

Often familial, especially in younger patients

ANTI-DEMENTIA DRUGS

May improve cognitive function, ADL’s to a modest extent; often ineffective Dechallenge if no meaningful benefit

Possibly delay nursing home placement Cholinesterase inhibitors may cause nausea,

diarrhea, weight loss Memantine occasionally causes agitation THESE AGENTS DO NOT SLOW THE

RATE OF DECLINE

A TYPICAL STUDY

BEWARE!

DIFFUSE LEWY BODY DISEASE

Second most common dementia in autopsy studies

Characterized by Lewy bodies throughout the cortex

Non-familial 2:1 male:female ratio

CLINICAL FEATURES

Postrolandic dementia More rapidly progressive than AD Fluctuation, episodes of “pseudodelirium” common

Mild parkinsonism Tremor often absent Poor response to antiparkinsonian meds Shy-Drager sx’s common

Prominent psychotic sx’s, esp visual hallucinations SEVERE NEUROLEPTIC INTOLERANCE

FRONTAL/SUBCORTICAL DEMENTIAS

Vascular dementia Frontotemporal dementia and Pick’s disease Alcoholic dementia Huntington’s disease, Wilson’s disease, progressive

supranuclear palsy, late Parkinson’s disease AIDS dementia complex, neurosyphilis, Lyme disease Normal pressure hydrocephalus Most head injuries Anoxia, carbon monoxide Multiple sclerosis Tumors ANY ADVANCED DEMENTIA

TYPES OF VASCULAR DEMENTIA

Multi-infarct dementia Small vessel disease

Lacunar state (gray > white)

Binswanger’s disease (white)

Hemorrhagic vascular dementia Strategic infarct dementia Dementia due to hypoperfusion

SMALL VESSEL DISEASE

At least 50% of all vascular dementia Often coexists with MID Usual vascular risk factors, especially

HPT Steady, not step-wise deterioration Relatively more abulia than disinhibition

FRONTOTEMPORAL DEMENTIA

Relatively uncommon, non-familial illness

Prominent (macroscopic) atrophy of frontal and anterior temporal cortex

Symptoms include executive deficits, Klüver-Bucy syndrome

About 25% of pts have Pick bodies

MANAGEMENT

BEHAVIORAL PROBLEMS IN DEMENTIA

Present in 80% of cases Major source of caregiver stress,

institutionalization Common at all stages of the disease Much more treatable than the

underlying dementia Poorly described in the literature

WOOF.

MEDS OTHER

THREE BASIC PRINCIPLES

Simplicity Limited goals The “no-fail” environment

“THE CUSTOMER IS ALWAYS

RIGHT!”

DEPRESSION

20-30% incidence in Alzheimer’s disease, often early in the course of the illness

Most important treatable cause of excess disability

Responds very well to treatment

ACUTE BEHAVIOR CHANGE

I atrogenic I nfection I llness I njury I mpaction I nconsistency I s the patient depressed?

AGITATION

Present in up to 80% of patients Up to 34% of patients are combative Few predictors Probably a very heterogeneous problem Cornerstone of treatment is

nonpharmacologic

EMPIRICALLY EFFECTIVE MEDS FOR AGITATION

Atypical neuroleptics (best when agitation is clearly related to delusions or hallucinations)

Anticonvulsants Trazodone Beta-blockers Buspirone Benzodiazepines Others

THE BEST NUMBER OF MEDICATIONS TO USE IS

ZERO (or sometimes one)

WHEN IN DOUBT, GET RID OF MEDICATIONS!

DON’T FORGET SAFETY ISSUES!

DRIVING FIREARMS POWER TOOLS SMOKING IN BED POISONS, MEDICATIONS FALL RISK

WOOF!

MEDS OTHER

GOOD LUCK!