Post on 23-Dec-2015
transcript
DementiaDementia
Sanjay K Nigam, M.D.Sanjay K Nigam, M.D.
Psychiatry Director,Psychiatry Director,
Greenville Regional HospitalGreenville Regional Hospital
History History
Careful and accurate history Careful and accurate history Distinguishing exceptional symptoms from Distinguishing exceptional symptoms from
complaints due to age-related cognitive decline complaints due to age-related cognitive decline Assess the patient for depression, and inquire about Assess the patient for depression, and inquire about
behavioral and psychotic disturbances behavioral and psychotic disturbances Consider conditions whose symptoms and signs Consider conditions whose symptoms and signs
mimic those of neurodegenerative dementia mimic those of neurodegenerative dementia Obtain and review the patient's medication history for Obtain and review the patient's medication history for
drugs drugs
TestingTesting
Office and LaboratoryOffice and Laboratory Radiologic Radiologic Invasive Invasive Differential DiagnosisDifferential Diagnosis
Rule out conditions or disorders that may mimic a Rule out conditions or disorders that may mimic a neurodegenerative dementia neurodegenerative dementia
History History careful and accurate history careful and accurate history
onset and course of memory and thinking problems onset and course of memory and thinking problems informed collateral source (generally a spouse or adult child) informed collateral source (generally a spouse or adult child) patient's cognitive performance or behavior that negatively affect patient's cognitive performance or behavior that negatively affect
his/her daily life his/her daily life temporal course of symptoms temporal course of symptoms
chronic, stepwise, or progressivechronic, stepwise, or progressive patient's recent and long-term memory patient's recent and long-term memory
everyday activities everyday activities driving, functioning at work, and/or interactions with family and peersdriving, functioning at work, and/or interactions with family and peers
functional loss is not due to physical decline (vision or hearing functional loss is not due to physical decline (vision or hearing loss) loss)
History (cont…)History (cont…) Distinguish exceptional symptoms Distinguish exceptional symptoms
from complaints due to age-related cognitive decline from complaints due to age-related cognitive decline Cognitive changes due to usual aging Cognitive changes due to usual aging
limited attentional resources ("I forgot what I came in here to get") limited attentional resources ("I forgot what I came in here to get") or to diminished speed of information processing ("I couldn't remember his name until later"). or to diminished speed of information processing ("I couldn't remember his name until later"). Such changes usually do not progress nor do they seriously interfere with everyday activities. Such changes usually do not progress nor do they seriously interfere with everyday activities.
Assess the patient for depression, and inquire about behavioral and psychotic disturbances Assess the patient for depression, and inquire about behavioral and psychotic disturbances patients with depressive "pseudodementia“patients with depressive "pseudodementia“
acute onsetacute onset past episodes of depression, anhedoniapast episodes of depression, anhedonia memory deficits that are equal for recent and remote events (vs. greater for recent events in AD),memory deficits that are equal for recent and remote events (vs. greater for recent events in AD), circumscribed (vs. global) cognitive defectscircumscribed (vs. global) cognitive defects
Patients with mild to moderate AD have memory and other cognitive disturbances, but do not Patients with mild to moderate AD have memory and other cognitive disturbances, but do not have the prominent delusions and gross perceptual distortions that are characteristic of have the prominent delusions and gross perceptual distortions that are characteristic of psychotic disorders psychotic disorders
conditions whose symptoms and signs mimic those of neurodegenerative dementia conditions whose symptoms and signs mimic those of neurodegenerative dementia Ask about other medical problems that might complicate the patient's evaluation or management Ask about other medical problems that might complicate the patient's evaluation or management
patient's medication history for drugs patient's medication history for drugs drugs that may cause or exacerbate loss of mental capacity, especiallydrugs that may cause or exacerbate loss of mental capacity, especially
opiates, opiates, sedative-hypnotics, sedative-hypnotics, analgesics, analgesics, anticholinergics, anticholinergics, anticonvulsants, anticonvulsants, corticosteroids, corticosteroids, centrally acting hypertensives,centrally acting hypertensives, psychotropics, psychotropics, alcohol.alcohol.
Physical Examination Physical Examination
for possible coexisting abnormalities for possible coexisting abnormalities Focus on focal deficits, extrapyramidal signs, and gait disturbances Focus on focal deficits, extrapyramidal signs, and gait disturbances dry skin, periorbital edema, thin hair, and depressed reflexes may dry skin, periorbital edema, thin hair, and depressed reflexes may
indicate hypothyroidism;indicate hypothyroidism; extrapyramidal signs may indicate Parkinson's disease or dementia extrapyramidal signs may indicate Parkinson's disease or dementia
with Lewy bodieswith Lewy bodies focal motor or sensory deficits may indicate vascular dementiafocal motor or sensory deficits may indicate vascular dementia gait disturbances may indicate communicating hydrocephalusgait disturbances may indicate communicating hydrocephalus Coexisting conditions that may exacerbate dementia include profound Coexisting conditions that may exacerbate dementia include profound
hearing or visual loss that isolates the patienthearing or visual loss that isolates the patient In more advanced stages of AD, neurologic examination often reveals In more advanced stages of AD, neurologic examination often reveals
motor dysfunction and reflex abnormalitiesmotor dysfunction and reflex abnormalities
Testing Testing standardized mental status tests standardized mental status tests urinalysis,urinalysis, neuroimaging, neuroimaging, complete blood count, complete blood count, blood chemistry battery blood chemistry battery
electrolytes, glucose, calcium, creatinine, and urea nitrogen, liver and electrolytes, glucose, calcium, creatinine, and urea nitrogen, liver and thyroid function, and serum vitamin B12 level thyroid function, and serum vitamin B12 level
Optional tests not routinely recommended Optional tests not routinely recommended human immunodeficiency virus serology, human immunodeficiency virus serology, syphilis serology, syphilis serology, lumbar puncture, and lumbar puncture, and electroencephalography. electroencephalography.
Selected Clinical Measures in Evaluating Patients Suspected Selected Clinical Measures in Evaluating Patients Suspected of Dementia of Dementia
Mini-Mental State Mini-Mental State Nineteen items measuring orientation, memory, Nineteen items measuring orientation, memory, concentration, language, and praxis; requires some test concentration, language, and praxis; requires some test materials; most widely used screening test materials; most widely used screening test
7 Minute Screen 7 Minute Screen Four tests (orientation, memory, clock drawing, and verbal Four tests (orientation, memory, clock drawing, and verbal fluency); usually completed in 7 to 8 minutes fluency); usually completed in 7 to 8 minutes
Global Deterioration Global Deterioration Scale (GDS) Scale (GDS)
Seven-point ordinal scale; has global descriptors for each Seven-point ordinal scale; has global descriptors for each severity level severity level
Geriatric depression Geriatric depression Scale Scale
Assesses 30 items (either self- or observer-rated) of Assesses 30 items (either self- or observer-rated) of depressive symptomatology in older adults depressive symptomatology in older adults
TestingTesting
RadiologicRadiologic identify CNS tumors, strokes, and hydrocephalus.identify CNS tumors, strokes, and hydrocephalus.
Invasive Invasive Not applicable under normal circumstances Not applicable under normal circumstances Invasive diagnostic procedures (e.g., brain biopsy) in Invasive diagnostic procedures (e.g., brain biopsy) in
patients with suspected dementia offer little advantage over patients with suspected dementia offer little advantage over clinical diagnosis and are unlikely to significantly alter clinical diagnosis and are unlikely to significantly alter clinical management; thus, they should only be considered clinical management; thus, they should only be considered in patients with an unusual clinical course in patients with an unusual clinical course
Differential Diagnosis Differential Diagnosis
Rule out conditions or disorders that may mimic a Rule out conditions or disorders that may mimic a neurodegenerative dementia neurodegenerative dementia normal age-related behaviorsnormal age-related behaviors medication-induced confusion/dementiamedication-induced confusion/dementia focal deficits that point to specific conditions/diseasesfocal deficits that point to specific conditions/diseases basic laboratory studiesbasic laboratory studies
hypothyroidism, B12 or folate deficiency, syphilis, AIDShypothyroidism, B12 or folate deficiency, syphilis, AIDS
NeuroimagingNeuroimaging subdural hematoma, tumor, and infarctssubdural hematoma, tumor, and infarcts
Mental IllnessMental Illness DepressionDepression
Causes of Dementia in Adults by Etiologic CategoryCauses of Dementia in Adults by Etiologic Category Neurodegenerative DisordersNeurodegenerative Disorders
Alzheimer s diseaseAlzheimer s disease Down syndromeDown syndrome Parkinson's diseaseParkinson's disease Dementia with Lewy bodiesDementia with Lewy bodies Frontotemporal dementias:Frontotemporal dementias:
Pick s diseasePick s disease Frontotemporal lobar degeneration, including frontal-lobe dementia, frontal-lobe Frontotemporal lobar degeneration, including frontal-lobe dementia, frontal-lobe
dementia associated with motor-neuron disease, progressive nonfluent aphasia, dementia associated with motor-neuron disease, progressive nonfluent aphasia, semantic dementiasemantic dementia
TauopathiesTauopathies Frontotemporal dementia with parkinsonism linked to chromosomeFrontotemporal dementia with parkinsonism linked to chromosome Familial progressive subcortical gliosisFamilial progressive subcortical gliosis Familial multiple system tauopathyFamilial multiple system tauopathy Corticobasal degenerationCorticobasal degeneration Progressive supranuclear palsyProgressive supranuclear palsy
Multiple system atrophyMultiple system atrophy Huntington diseaseHuntington disease Mesolimbocortical dementiaMesolimbocortical dementia Amyotrophic lateral sclerosis (ALS)-parkinsonism-dementia complexAmyotrophic lateral sclerosis (ALS)-parkinsonism-dementia complex Argyrophilic brain diseaseArgyrophilic brain disease
Causes of Dementia in Adults by Etiologic CategoryCauses of Dementia in Adults by Etiologic Category Cerebrovascular DisordersCerebrovascular Disorders
Vascular dementias: Vascular dementias: Multi-infarct dementia Multi-infarct dementia Subacute arteriosclerotic encephalopathy (Binswanger s disease)Subacute arteriosclerotic encephalopathy (Binswanger s disease) Amyloid angiopathyAmyloid angiopathy Hereditary cerebral hemorrhage with amyloidosis-Dutch Type Hereditary cerebral hemorrhage with amyloidosis-Dutch Type
(HCWA-D)(HCWA-D) Cerebral autosomal-dominant arteriopathy with subcortical infarcts Cerebral autosomal-dominant arteriopathy with subcortical infarcts
and leukoencephalopathy (CADASIL) and leukoencephalopathy (CADASIL) Hippocampal sclerosisHippocampal sclerosis VasculitisVasculitis Subarachnoid hemorrhageSubarachnoid hemorrhage Neurocognitive disorders associated with cardiac bypass Neurocognitive disorders associated with cardiac bypass
Causes of Dementia in Adults by Etiologic Category Causes of Dementia in Adults by Etiologic Category
Prion-Associated DisordersPrion-Associated Disorders Creutzfeldt-Jakob diseaseCreutzfeldt-Jakob disease Variant Creutzfeldt-Jakob disease (linked to bovine spongiform Variant Creutzfeldt-Jakob disease (linked to bovine spongiform
encephalopathy)encephalopathy) Gerstmann-Sträussler-Scheinker diseaseGerstmann-Sträussler-Scheinker disease Fatal familial insomnia Fatal familial insomnia
Neurogenetic DisordersNeurogenetic Disorders Spinocerebellar ataxiasSpinocerebellar ataxias Dentatorubral-pallidoluysian atrophyDentatorubral-pallidoluysian atrophy Hallervorden-Spatz diseaseHallervorden-Spatz disease GangliosidosesGangliosidoses Kufs disease (adult neuronal ceroid lipofuscinosis)Kufs disease (adult neuronal ceroid lipofuscinosis) Machado-Joseph disease (Azorean disease)Machado-Joseph disease (Azorean disease) Lafora's diseaseLafora's disease Mitochondrial encephalopathiesMitochondrial encephalopathies Myotonic dystrophyMyotonic dystrophy PorphyriasPorphyrias Hepatolenticular degeneration (Wilson s disease) Hepatolenticular degeneration (Wilson s disease)
Causes of Dementia in Adults by Etiologic Category Causes of Dementia in Adults by Etiologic Category Infectious DisordersInfectious Disorders
Meningitis (e.g., tuberculosis)Meningitis (e.g., tuberculosis) Encephalitis:Encephalitis:
Herpes simplexHerpes simplex Human immunodeficiency virusHuman immunodeficiency virus Lye diseaseLye disease Progressive multifocal leukoencephalopathyProgressive multifocal leukoencephalopathy NeurosyphilisNeurosyphilis Whipple s diseaseWhipple s disease
Toxic/Metabolic EncephalopathiesToxic/Metabolic Encephalopathies Systemic Systemic
Thyroid, parathyroid, pituitary, adrenal, liver, pulmonary, pancreas, kidney, or blood disorders Thyroid, parathyroid, pituitary, adrenal, liver, pulmonary, pancreas, kidney, or blood disorders Sarcoidosis Sarcoidosis Sjögren s syndromeSjögren s syndrome Systemic lupus erythematosusSystemic lupus erythematosus HyperlipidemiaHyperlipidemia Nutritional deficiencies (vitamins B1, B12)Nutritional deficiencies (vitamins B1, B12) Fluid and electrolyte abnormalitiesFluid and electrolyte abnormalities HypoglycemiaHypoglycemia Hypoxic/ischemic disordersHypoxic/ischemic disorders
Toxic:Toxic: DrugsDrugs AlcoholAlcohol Industrial agentsIndustrial agents Heavy metals (Pb, Hg, Mn, Ar, Th, Al, Sn, Bi)Heavy metals (Pb, Hg, Mn, Ar, Th, Al, Sn, Bi) Carbon monoxideCarbon monoxide
Diagnostic Criteria Diagnostic Criteria DSM-IV criteria DSM-IV criteria
Development of multiple cognitive deficitsDevelopment of multiple cognitive deficits::1. Memory impairment, and1. Memory impairment, and2. At least one of the following: 2. At least one of the following: Aphasia Aphasia Apraxia Apraxia Agnosia Agnosia
Disturbed executive functioning (planning, organizing, sequencing, Disturbed executive functioning (planning, organizing, sequencing, abstracting). abstracting).
Course is characterized by continued gradual cognitive and functional Course is characterized by continued gradual cognitive and functional decline.decline.
Deficits are sufficient to interfere significantly with social and Deficits are sufficient to interfere significantly with social and occupational functioning and represent a decline from past functioning.occupational functioning and represent a decline from past functioning.
Other causes (medical, neurologic, psychiatric) of dementia are Other causes (medical, neurologic, psychiatric) of dementia are excluded. excluded.
Diagnostic CriteriaDiagnostic Criteria NINCDS-ADRDA Probable Alzheimer's Disease NINCDS-ADRDA Probable Alzheimer's Disease
Dementia established by examination and documented by objective Dementia established by examination and documented by objective testing for:testing for:
Deficits in two or more cognitive areasDeficits in two or more cognitive areas Progressive worsening of memory and other cognitive functionsProgressive worsening of memory and other cognitive functions No disturbance in consciousnessNo disturbance in consciousness Onset between 40 and 90 years of ageOnset between 40 and 90 years of age Absence of systemic disorders or other brain diseases that could account for Absence of systemic disorders or other brain diseases that could account for
the progressive deficits in memory and cognition the progressive deficits in memory and cognition Diagnosis supported by:Diagnosis supported by:
Progressive deficits in language (aphasia), motor skills (apraxia), and Progressive deficits in language (aphasia), motor skills (apraxia), and perception (agnosia)perception (agnosia)
Impaired activities of daily living and altered patterns of behaviorImpaired activities of daily living and altered patterns of behavior Family history of similar disordersFamily history of similar disorders Consistent laboratory or radiologic results (e.g., cerebral atrophy on computed Consistent laboratory or radiologic results (e.g., cerebral atrophy on computed
tomography tomography
NINCDS-ADRDA, National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association
Diagnostic Indicators for the More Common Non-Alzheimer DementiasDiagnostic Indicators for the More Common Non-Alzheimer Dementias
Dementia with Lewy bodies Dementia with Lewy bodies Presence of dementia and at least one of the following three features early in Presence of dementia and at least one of the following three features early in
the disease course: the disease course: visual hallucinations, visual hallucinations, parkinsonism, and parkinsonism, and fluctuating cognitive statusfluctuating cognitive status
Vascular dementia (VaD) Vascular dementia (VaD) Presence of dementia with abrupt onset Presence of dementia with abrupt onset
within 3 months of stroke within 3 months of stroke oror abrupt deterioration or abrupt deterioration or stepwise progression of dementia, and fluctuating course stepwise progression of dementia, and fluctuating course
Frontotemporal dementias Frontotemporal dementias Presence of dementia withPresence of dementia with disinhibition, impulsivity, impaired judgment, and/or disinhibition, impulsivity, impaired judgment, and/or amotivational states resulting in disturbed personality, behavior, and language amotivational states resulting in disturbed personality, behavior, and language
Depression Depression Presence of dementia with noncognitive changes (lack of interest, loss of Presence of dementia with noncognitive changes (lack of interest, loss of
energy, and difficulty in concentrating)energy, and difficulty in concentrating)
TreatmentTreatment Medical Therapy Medical Therapy
focus pharmacotherapy focus pharmacotherapy palliation of cognitive symptoms and palliation of cognitive symptoms and slowing of disease progressionslowing of disease progression
cholinesterase inhibitors donepezil or rivastigmine cholinesterase inhibitors donepezil or rivastigmine Contraindications for this therapy Contraindications for this therapy
cardiac and gastroenteric complications cardiac and gastroenteric complications antioxidant therapy as a treatment strategy for ADantioxidant therapy as a treatment strategy for AD
Evidence for increased oxidative stress and free radical injury in AD motivated a large-scale trial of selegiline (a Evidence for increased oxidative stress and free radical injury in AD motivated a large-scale trial of selegiline (a monamine oxidase inhibitor) and alpha-tocopherol (vitamin E at 1000 IU b.i.d.) for moderately demented AD monamine oxidase inhibitor) and alpha-tocopherol (vitamin E at 1000 IU b.i.d.) for moderately demented AD patients patients
Both compounds used independently (not in combination) delayed progression to clinical milestones (e.g. Both compounds used independently (not in combination) delayed progression to clinical milestones (e.g. institutionalization) by approximately 8 months. institutionalization) by approximately 8 months.
Favorable safety and cost profiles of vitamin E make it acceptable to many patients in the absence of additional Favorable safety and cost profiles of vitamin E make it acceptable to many patients in the absence of additional studies confirming efficacy.studies confirming efficacy.
Neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available Neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available evidence evidence
Prevent new insult Prevent new insult Treat the underlying causes of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, or diabetes) Treat the underlying causes of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, or diabetes)
Treat reversible dementias Treat reversible dementias hypothyroidism, vitamin B12 deficiency, overmedication, depression, and opportunistic infections hypothyroidism, vitamin B12 deficiency, overmedication, depression, and opportunistic infections
accompanying HIV infection accompanying HIV infection no approved therapies for dementia with Lewy bodies or frontotemporal dementias.no approved therapies for dementia with Lewy bodies or frontotemporal dementias. Treat behavioral symptoms Treat behavioral symptoms
If moderate to severe mood, behavioral, or other neurologic disturbances are present, use psychotropic (e.g., If moderate to severe mood, behavioral, or other neurologic disturbances are present, use psychotropic (e.g., antipsychotics and antidepressants) and antiepileptic agents for short periods of time, as appropriate antipsychotics and antidepressants) and antiepileptic agents for short periods of time, as appropriate
Lifestyle MeasuresLifestyle Measures safe, supportive, and orderly environmentsafe, supportive, and orderly environment
most contentious issues for families to deal with most contentious issues for families to deal with driving, cooking, independent living, control of financial affairs, self-medication, and participation in driving, cooking, independent living, control of financial affairs, self-medication, and participation in
community affairscommunity affairs Physician and caregiver working togetherPhysician and caregiver working together
Recommend establishment of durable power of attorney Recommend establishment of durable power of attorney for financial and health care decision-makingfor financial and health care decision-making
RecommendRecommend establishment of daily routines establishment of daily routines Constant supervision to monitor the safety of the residential settingConstant supervision to monitor the safety of the residential setting Recommend driving evaluation when necessaryRecommend driving evaluation when necessary
Driving evaluations may be obtained from independent driving evaluation centers, some Driving evaluations may be obtained from independent driving evaluation centers, some occupational therapists, or from the state agency regulating driving privileges.occupational therapists, or from the state agency regulating driving privileges.
Nutrition and hydrationNutrition and hydration increased risk for nutritional imbalance, dehydration, and weight lossincreased risk for nutritional imbalance, dehydration, and weight loss
Encourage maintenance of an active and healthy lifestyle.Encourage maintenance of an active and healthy lifestyle. ExerciseExercise Sleep-restSleep-rest..
consistent daily routine consistent daily routine reducing environmental stimuli in the evening, reducing environmental stimuli in the evening, avoiding caffeine and other stimulants,avoiding caffeine and other stimulants, establishing toileting routines, and establishing toileting routines, and possibly the short-term use of a mild hypnotic to establish a normal sleep-cycle.possibly the short-term use of a mild hypnotic to establish a normal sleep-cycle.
Oral hygieneOral hygiene
Invasive Procedures Invasive Procedures Invasive approaches are not appropriate for most common dementias.Invasive approaches are not appropriate for most common dementias.
Ventricular shunting may be needed to ameliorate normal-pressure hydrocephalus, Ventricular shunting may be needed to ameliorate normal-pressure hydrocephalus, or surgical excision may be indicated for CNS neoplasms.or surgical excision may be indicated for CNS neoplasms.
Complementary Medicine Complementary Medicine Ginkgo biloba.Ginkgo biloba.
Ginkgo biloba is an herb with putative antioxidant and anti-inflammatory properties. Ginkgo biloba is an herb with putative antioxidant and anti-inflammatory properties. Gingko may benefit persons with Alzheimer's disease or mixed dementia including Gingko may benefit persons with Alzheimer's disease or mixed dementia including Alzheimer's disease and vascular dementia Alzheimer's disease and vascular dementia
Many studies of gingko have been inconclusive:Many studies of gingko have been inconclusive: treatment effects are weak and dropout rates have led to selection bias. More treatment effects are weak and dropout rates have led to selection bias. More
rigorous studies are in progress.rigorous studies are in progress. A Dutch study (the Maastrict Ginkgo Trial) employing standard designs and A Dutch study (the Maastrict Ginkgo Trial) employing standard designs and
stringent controls found no cognitive benefit for treatment groups over placebo stringent controls found no cognitive benefit for treatment groups over placebo groupsgroups
Gingko biloba has been reported to have antiplatelet effects, requiring caution for Gingko biloba has been reported to have antiplatelet effects, requiring caution for patients on anticoagulant and aspirin therapies.patients on anticoagulant and aspirin therapies.
ComplicationsComplications
Monitor patients for side effects of drug regimens and Monitor patients for side effects of drug regimens and for interactions with other medications for interactions with other medications Because neuroactive compounds commonly used by the Because neuroactive compounds commonly used by the
elderly can exacerbate dementia symptomselderly can exacerbate dementia symptoms dose reduction or discontinuation of benzodiazepines, dose reduction or discontinuation of benzodiazepines,
antidepressants, and minor and major tranquilizersantidepressants, and minor and major tranquilizers Neuroleptics can induce orthostatic hypotension, which can lead to Neuroleptics can induce orthostatic hypotension, which can lead to
falls, fractures, stroke, or even heart attack in the elderlyfalls, fractures, stroke, or even heart attack in the elderly If such adverse effects are suspected, discontinue or reduce the If such adverse effects are suspected, discontinue or reduce the
medication and routinely monitor the patient throughout treatment.medication and routinely monitor the patient throughout treatment.
Special Circumstances Special Circumstances
If dementia appears to be rapidly progressing (onset If dementia appears to be rapidly progressing (onset and progression measured in weeks and months as and progression measured in weeks and months as opposed to years), opposed to years), consider the possibility of Creutzfeldt-Jakob disease (CJD), consider the possibility of Creutzfeldt-Jakob disease (CJD),
a potentially transmissible dementia.CJD is a prion disease,a potentially transmissible dementia.CJD is a prion disease, a member of a rare family of diseases that includes scrapie in sheep a member of a rare family of diseases that includes scrapie in sheep
and bovine spongiform encephalopathy (BSE) in cows (popularly and bovine spongiform encephalopathy (BSE) in cows (popularly known as "mad cow disease").known as "mad cow disease").
When to Consult or ReferWhen to Consult or Refer Refer patients suspected of having a potentially treatable Refer patients suspected of having a potentially treatable
neurologic conditionneurologic condition e.g., normal-pressure hydrocephalus, mass lesion) to a neurologist or e.g., normal-pressure hydrocephalus, mass lesion) to a neurologist or
neurosurgeon for evaluation.neurosurgeon for evaluation.
Consider referring patients with dementia to a dementia Consider referring patients with dementia to a dementia specialist if theyspecialist if they Are <55 years of age; Are <55 years of age; Have rapidly progressing dementia (e.g., possible Creutzfeldt-Jakob Have rapidly progressing dementia (e.g., possible Creutzfeldt-Jakob
disease); disease); Have psychosis early in the course of dementia; Have psychosis early in the course of dementia; Have prominent focal deficits (e.g., progressive aphasia); or Have prominent focal deficits (e.g., progressive aphasia); or Reveal neurologic abnormalities (e.g., extrapyramidal dysfunction).Reveal neurologic abnormalities (e.g., extrapyramidal dysfunction). Refer patients who have refractory psychological symptoms (e.g., Refer patients who have refractory psychological symptoms (e.g.,
depression) to a psychiatrist. depression) to a psychiatrist. Refer patients and their family/caregivers who need additional Refer patients and their family/caregivers who need additional
reassurance or assistance to community resources and/or geriatric case reassurance or assistance to community resources and/or geriatric case managers if appropriate. managers if appropriate.
Prognosis Prognosis Recall that Alzheimer's disease is a treatable disorder.Recall that Alzheimer's disease is a treatable disorder.
Drugs can ameliorateDrugs can ameliorate the cognitive and behavioral symptoms of Alzheimer's disease (AD) and the cognitive and behavioral symptoms of Alzheimer's disease (AD) and aid in maintaining activities of daily living, but progression is inevitable (as in the aid in maintaining activities of daily living, but progression is inevitable (as in the
other most common neurodegenerative dementias).other most common neurodegenerative dementias). cholinesterase inhibitors cholinesterase inhibitors
Symptomatic progression of the disease may be delayed up to 12 months in Symptomatic progression of the disease may be delayed up to 12 months in patients with AD patients with AD
The total duration of the illness averages between 7 and 10 years. The total duration of the illness averages between 7 and 10 years. For those patients who have endstage disease, For those patients who have endstage disease,
death results from aspiration, pneumonia, pulmonary embolus, sepsis, or death results from aspiration, pneumonia, pulmonary embolus, sepsis, or exhaustion resulting from lack of food and waterexhaustion resulting from lack of food and water
.Although not well studied, it is widely accepted that strokes affecting .Although not well studied, it is widely accepted that strokes affecting critical volumes and locations can cause irreversible dementia.critical volumes and locations can cause irreversible dementia.
Pure vascular dementia has been over-reported in clinical studies.Pure vascular dementia has been over-reported in clinical studies. Patients with presumptive vascular dementia are frequently found to have Patients with presumptive vascular dementia are frequently found to have
Alzheimer's disease on histological examination Alzheimer's disease on histological examination Vascular dementia and mixed dementia (vascular and AD) have the same Vascular dementia and mixed dementia (vascular and AD) have the same
prognosis as AD aloneprognosis as AD alone
Patient EducationPatient Education Disclose diagnosis of dementia to the patient and familyDisclose diagnosis of dementia to the patient and family
to allow for discussion of advance planning, treatment options, prognosis, and support to allow for discussion of advance planning, treatment options, prognosis, and support groups.groups.
Advise patients and caregivers that dementia may be less disablingAdvise patients and caregivers that dementia may be less disabling if the patient's activities are structured and surroundings are safe and familiar.if the patient's activities are structured and surroundings are safe and familiar.
Educate caregivers regarding the signs and symptoms associated with dementia.Educate caregivers regarding the signs and symptoms associated with dementia. Advise patient, family, and caregivers that treatment of the most common Advise patient, family, and caregivers that treatment of the most common
dementias (AD, DLB, VaD) is symptomaticdementias (AD, DLB, VaD) is symptomatic e.g. memory and thinking may improve a littlee.g. memory and thinking may improve a little they should not expect reversal of the symptoms of dementia from therapies available they should not expect reversal of the symptoms of dementia from therapies available
today.today. Self-care InstructionsSelf-care Instructions
Advise patient and caregivers to learn the signs and symptoms of adverse drug reactions Advise patient and caregivers to learn the signs and symptoms of adverse drug reactions [and [and
to contact a physician promptly if an adverse reaction is suspectedto contact a physician promptly if an adverse reaction is suspected
Follow-upFollow-up
Re-evaluate a patient suspected of dementia at Re-evaluate a patient suspected of dementia at 6- to 12-month intervals6- to 12-month intervals
Assess disease progression, Assess disease progression, Confirm the diagnosis, and Confirm the diagnosis, and Establish a prognosis Establish a prognosis
Prevention and ScreeningPrevention and Screening Recall that insufficient evidence exists regarding the recommendation for Recall that insufficient evidence exists regarding the recommendation for
or against routine screening for dementia with standardized tests in or against routine screening for dementia with standardized tests in asymptomatic individuals.asymptomatic individuals.
Treat the underlying causes/risk factors of vascular dementia (VaD) (e.g., Treat the underlying causes/risk factors of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, and diabetes) to prevent stroke or additional hypertension, atherosclerosis, and diabetes) to prevent stroke or additional insult following stroke.insult following stroke.
Consider timely correction of metabolic disturbances (e.g., vitamin B12 Consider timely correction of metabolic disturbances (e.g., vitamin B12 deficiency, hypothyroidism, alcoholism) associated with dementia to deficiency, hypothyroidism, alcoholism) associated with dementia to reduce the incidence of subsequent dementia.reduce the incidence of subsequent dementia.
Be aware that neither estrogen therapy nor prednisone is recommended for Be aware that neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available evidencethe treatment of AD, based on available evidence
Be aware that nonsteroidal anti-inflammatory drugs (NSAIDS) are not Be aware that nonsteroidal anti-inflammatory drugs (NSAIDS) are not recommended for the prevention of AD, based on available evidencerecommended for the prevention of AD, based on available evidence
Be aware that genetic screening in patients suspected of having AD is of Be aware that genetic screening in patients suspected of having AD is of no diagnostic value at this time. no diagnostic value at this time.