HOW TO EXAMINE PATIENTS WITH DEMENTIA

Serge Gauthier, MD, FRCPC

McGill Centre for Studies in Aging

Douglas Mental Health Research Institute

OUTLINE

• Usual clinical presentation of dementia

• Diagnostic criteria for the common degenerative dementias

• Natural history of AD

• Cases

CLINICAL PRESENTATION OF DEMENTIA

• Decline in intellectual abilities (memory plus one other domain)

• Interfering with social or occupational life

CLINICAL PRESENTATION OF DEMENTIA

• Decline in intellectual abilities (memory plus one other domain)

• Interfering with social or occupational life

CLINICAL PRESENTATION OF DEMENTIA - MEMORY

• Do you need reminders for appointments?

• Do you forget birthdays? (Women only!)

• Do you look for things at home?

• Do you remember recent conversations?

• Do you need to read back a page in your book to get back into the story?

CLINICAL PRESENTATION OF DEMENTIA - LANGUAGE

• Do you look for words? – do you say “give me the thing there…what do you call it?”

• Do you have trouble finishing your cross-word puzzles?

• Do you still do ‘Mystery words’?

CLINICAL PRESENTATION OF DEMENTIA - PRAXIS

• Do you still fix things in the house?

• Do you have trouble using your computer, using the phone?

• Do you have difficulties using kitchen appliances?

• Do you need help to get the shower running?

CLINICAL PRESENTATION OF DEMENTIA - GNOSIS

• Do you have difficulties recognizing people?

• Do you have trouble with directions when driving?

CLINICAL PRESENTATION OF DEMENTIA – EXECUTIVE ABILITIES

• Do you need help playing a card game?

• Do you find it difficult to plan a meal for the family?

• Do you need help to pay your bills on time?

• Do you need help to take your pills?

CLINICAL PRESENTATION OF DEMENTIA

• Decline in intellectual abilities (memory plus one other domain)

• Interfering with social or occupational life

CLINICAL PRESENTATION OF DEMENTIA – MOST SENSITIVE ADLs

• Using phone and other means of communication

• Planning an outing and completing it efficiently

• Using medication safely

• Using money appropriately

CLINICAL PRESENTATION OF DEMENTIA – MOOD AND BEHAVIOR

• Apathy (more quiet, socially withdrawn)

• Anxiety & depression (worries about the future, about money)

• False beliefs (blames spouse when looking for things)

• Irritability (when spouse takes over finances, when making mistakes)

CLINICAL PRESENTATION OF DEMENTIA

• There may be little insight and reporting is done by family

• Patients are nearly always brought in by someone

• There is often need for additional information (other family member, SW or OT going to the house)

ASSESSMENT OF DEMENTIA IN CLINICAL PRACTICE

• History with reliable informant is key to diagnosis

• Physical & neurological examination

• MMSE & MoCA

• Recommended blood work: CBC, TSH, lytes, Ca, glycemia. Brain CT or MRI without enhancement optional but done in most cases.

MoCA

►One-page► 30-point scale► 10 minutes to administerwww.mocatest.org

OUTLINE

• Usual clinical presentation of dementia

• Diagnostic criteria for the common degenerative dementias

• Natural history of AD

• Cases

DIAGNOSTIC CRITERIA FOR PROBABLE AD (90% accuracy)

Dementia established clinically, eg deficit in two or more areas or cognition, interfering with daily life, progressing gradually

No disturbance of consciousness Onset between 40 and 90 (below 65: early

onset)Absence of other brain or systemic disease

that could account for the dementia

PROPOSAL FOR MODIFIED NINCDS-AA DIAGNOSTIC CRITERIA – AD DEMENTIA

(McKhann et al, A&D 7, 263-9, 2011)

• No age specification• Memory decline not mandatory for the two

cognitive domains affected• Changes in personality, impaired motivation or

initiative as a possible domain• Probable AD: documented cognitive decline or

positive biomarker

BIOMARQUERS FOR AD

* Amyloid build up

- CSF Aß42 (low)

- PET amyloid (high)

* Evidence of neuronal injury

- CSF tau (high)

- MRI (atrophy)

- PET-FDG (hypometabolism)

DIAGNOSTIC CRITERIA FOR DEMENTIA PROBABLY DUE TO AD USING BIOMARKERS

(Modified from McKhann et al, 2011)

Aß Neuronal injury

• Probable AD with + + high likelihood• Probable AD with + or untested untested or +

intermediate likelihood• Probable AD dementia untested or conflicting results• Possible AD dementia + +

(atypical clinical presentation)

* Unlikely AD dementia - -

CRITERIAS FOR VASCULAR DEMENTIA (VaD)

• Decline in two or more cognitive abilities interfering with daily life but not caused by the physical effects of stroke

• Evidence of stroke by history, physical exam or brain imaging

• Temporal relationship between dementia and stroke (within 3 months of a stroke)

CRITERIAS FOR DEMENTIA WITH LEWY BODIES (DLB)

• Progressive intellectual decline interfering with daily life

• One or two of

* fluctuations of cognition

* visual hallucinations

* spontaneous parkinsonism

* Supportive features: REM Behavior Disorder, neuroleptic hypersensitivity

CRITERIAS FOR PARKINSON DISEASE DEMENTIA (PDD)

• Idiopathic PD (2 of rigidity, bradykinesia, resting tremor)

• Impairment of attention, executive and visuo-spatial abilities

• Often with visual hallucinations

OUTLINE

• Usual clinical presentation of dementia

• Diagnostic criteria for the common degenerative dementias

• Natural history of AD

• Cases

PROGRESSION OF SYMPTOMS IN ALZHEIMER’S DISEASE

Lovestone & Gauthier 2000

STAGING OF AD: THE GLOBAL DETERIORATION SCALE (Reisberg)

• 1, 2: normal or minimal cognitive complaints

• 3: early cognitive impairment (MCI)

• 4, 5: mild to moderate dementia

• 6, 7: severe dementia

OUTLINE

• Usual clinical presentation of dementia

• Diagnostic criteria for the common degenerative dementias

• Natural history of AD

• Cases

CASE 1

• Woman age 82 with progressive memory decline over 2 years

• False beliefs of “people stealing things from her”

• MMSE 23/30

• Good general health

• “Normal for age” head CT scan

CASE 1

• Likely diagnosis?

• Any extra tests?

CASE 2

• Man age 82 needing reminders for appointments, forgetting conversations, once could not find his car on the street, over 2 years

• MMSE 22/30

• Diabetes type 2; labile HBP

• CT with mild WMC (capping) and one lacunar infarct in right external capsule

CASE 2

• Likely diagnosis?

• Any extra tests?

CASE 3

• Woman age 72 needing reminders for appointments, forgetting conversations for 1 year

• Thinks that there are other persons in her house. Sets table for extra people.

• MMSE 24/30

• CT mild cortical atrophy

CASE 3

• Likely diagnosis?

• Any extra tests?

CASE 3

• PET-FDG with occipital hypometabolism

• If available: DAT scan

CASE 4

• Man age 40 making mistakes at work (forgets orders from customers) for 1 year

• Irritable at home since wife has to supervise finances.

• Mother had AD died at age 45.

• MMSE 21/30

• CT mild cortical atrophy

CASE 4

• Likely diagnosis?

• Any extra tests?

CASE 4

• PS1 mutation confirms EOFAD.

CASE 5

• Man age 52 making mistakes at work (pharmacist) for 1 year

• Irritable since partner at work has to supervise him. Makes inapropriate jokes in restaurants.

• Mother had a dementia, died at age 60.• MMSE 26/30• CT mild cortical atrophy especially right

anterior temporal

CASE 5

• Likely diagnosis?

• Any extra tests?

CASE 5

• PET-FDG right fronto-temporal hypometabolism

• SPECT right fronto-temporal hypometabolism

• Genetic testing confirms a progranulin mutation