DementiaDementia

Dr Chandra Prajapati Dr Chandra Prajapati FRCP, FRCPIFRCP, FRCPI

Consultant PhysicianConsultant Physician

DementiaDementia

a serious loss of global cognitive function in a previously unimpaired

person, beyond what might be expected from normal ageing

DeliriumDelirium

1. Acute onset and fluctuating course

2. Inattention– Difficulty focussing attention– Easily distractible

3. Disorganised thinking– Disorganised / incoherent / unclear / unpredictable

switching

4. Altered level of consciousness – Vigilant /hyperactive– Drowsy→ comatose /hypoactive

Delirium Delirium vsvs. Dementia . Dementia • Delirium or acute confusional state, is a syndrome

presenting as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. – Reversible– May last up to six months

• Dementia is a non-specific syndrome affecting memory, attention, language and problem solving lasting more than six months – Later complicated by orientation and behaviour

problems– 10% may have reversible cause

Dementia Dementia

• Currently 35.6 million sufferer worldwide• Number likely to increase > 60 million by 2030• In UK

– Currently 800,000– By 2021 10,00,000– By 2051 17,00,000

• SASH area– Current number is as high as would be expected by

2051 in other areas

DementiaDementia

• Dementia care cost worldwide = IHD+DM+cancer care

• Dementia care in 2010 @ 604 Billion USD

• 1% of world GDP

• If dementia care were a country, it would be 18th largest economy in the world

CAIDE dementia risk scoreCAIDE dementia risk score

CAIDE Dementia scoreCAIDE Dementia score

Likelihoods of Dementia risk in 20 years

Score Risk 0-5 1%6-7 1.9%

8-9 4.2% 10-11 7.4%

12-15 16.4%

When the cut-off was set at 9 points or more, the sensitivitywas 0.77, the specificity was 0.63, and the negativepredictive value was 0.98

Dementia typesDementia types

• Alzheimer

• Vascular

• Lewy Body dementia

• Fronto-temporal dementia

• Cortico-basal degeneration – PD– Alien Hand syndrome– Apraxia– Aphasia

Type of dementiaType of dementia

• Fixed memory loss– Traumatic brain injury– Hypoxic-ischaemic brain injury– Alcohol– Infections i.e encephalitis

• Slowly progressive– Alzheimer– Vascular dementia– Post infections

• Rapidly Progressive– CJD– Others: Alzheimer, LBD, FTD, CBD, PSP

Dementia in younger age groupDementia in younger age group

• Uncommon under 65– Consider Alzheimer– Familial causes i.e. FTD, Huntington’s disease– Frequent head trauma i.e. boxers ( dementia

pugilistica) and footballers– Vascular

• antiphospholipid syndrome• CADASIL(cerebral autosomal dominant arteriopathy with

subcortical infarcts and leukoencephalopathy) • MELAS (mitochondrial encephalopathy, lactic acidosis and

stroke like symptoms)• Homocysinuria• Binswanger disease ( sub cortical white matter atrophy due

to small vessel disease)

Dementia in younger age groupDementia in younger age group

Rare under 40– Consider familial Alzheimer– Drugs– Alcohol– Metabolic disorders– Infections i.e HIV, Cryptococcal infection,

syphilis, Lymes diasease etc

AssessmentAssessment

• Specialist assessment– AMTS– MMSE– Clock draw test– Trail making test

• Exclude other causes i.e. depression, anxiety

• Consider carer views; DO NOT SOLELY RELY ON ASSESSMENT

Diagnostic testsDiagnostic tests

• Bloods– FBC, Electrolytes and calcium, Glucose,

B12,Folate, TFTs, TPHA

• Radiology– CT/MRI– Functional Neuroimaging i.e. SPECT or PET

• Brain Biopsy!

MRI Alzheimer vs ControlMRI Alzheimer vs Control

MRI in AlzheimerMRI in Alzheimer

SPECTSPECT

Perfusion SPECT scan showing

evidence of biparietal and bitemporal hyperperfusion in a) an Alzheimer's disease case compared to b) a control subject.

MRI in DementiaMRI in Dementia

Progression of MTA in AlzheimerProgression of MTA in Alzheimer

MRI – Vascular DementiaMRI – Vascular Dementia

MRI Vascular dementiaMRI Vascular dementia

DaT in LBDDaT in LBD

ManagementManagement

• 10% may have reversible cause – Treat the cause i.e. B12, Folate, Levothyroxine

• Remaining – NO CURE• Pharmacological

– Acetylcholine esterase inhibitor• Donepezil (Aricept)• Galantamine (Reminyl)• Rivastigmine (Exelon)

– NMDA (N-Methyl-D-Aspartate) receptor blocker• Memantine (Ebixa)

ManagementManagement

• Symptom management• AVOID ANTIPSYCHOTICS• Carer Support

– Consider carer’s views

• Dementia support/crisis team• Specialist care at home or in care homes• Severe dementia – Holistic care, advance

care planning, Palliative care

Barrier to dementia care Barrier to dementia care

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Inactivity in seeking +

Offering help

Stigmata of Dementia

False beliefNothing Available

False beliefNothing can be done

Thank youThank you