EVALUATION OF THE PATIENT WITH DEMENTIA

Jonathan T. Stewart, MD
Professor 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 its 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

FRONTAL/SUBCORTICAL

Memory deficits Aphasia Apraxia Agnosia Personality more or less preserved MMSE valid

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 conditions Family Hx EtOH Medications (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 Alzheimers disease Does not detect executive deficits at all

BEYOND THE MMSE

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
ATTENTION:

LURIAS RECURSIVE FIGURES

LURIAS RECURSIVE FIGURES

LURIAS 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 12
Use

DMAS or Cornell scale for severely demented patients

THE REST OF THE WORKUP

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
Alzheimers

disease Diffuse Lewy body disease

ALZHEIMERS DISEASE
Slowly,

insidiously progressive postrolandic dementia; executive sxs much later Neurologic exam, labs, neuroimaging studies unremarkable Often familial, especially in younger patients

ANTI-DEMENTIA DRUGS

May improve cognitive function, ADLs 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 sxs common

Prominent psychotic sxs, esp visual hallucinations SEVERE NEUROLEPTIC INTOLERANCE

FRONTAL/SUBCORTICAL DEMENTIAS

Vascular dementia Frontotemporal dementia and Picks disease Alcoholic dementia Huntingtons disease, Wilsons disease, progressive supranuclear palsy, late Parkinsons 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) Binswangers 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, Klver-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

MEDS

OTHER

WOOF.

THREE BASIC PRINCIPLES

Simplicity Limited

goals The no-fail environment

THE CUSTOMER IS ALWAYS RIGHT!

DEPRESSION
20-30%

incidence in Alzheimers 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!

DONT FORGET SAFETY ISSUES!

DRIVING FIREARMS

POWER

TOOLS SMOKING IN BED POISONS, MEDICATIONS FALL RISK

GOOD LUCK!
MEDS OTHER

WOOF!