An overview of

dementiaDr. Cijo Alex MDSR in Psychiatry

SMVMCH

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September 21 – World Alzheimer’s day

September 21st was selected as world Alzheimer’sday as it marked the tenth anniversary ofAlzheimer's Disease International, back in 1994.

ADI is an international association based in London,UK which is active in the field of Alzheimer’sdementia.

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Contents

1. Introduction2. Epidemiology and global burden3. Causes4. Clinical features 5. Investigations6. Treatment7. Prognosis8. Others

a) Cortical and sub cortical dementiab) Dementia and deliriumc) Pseudo dementiad) Mild cognitive impairment

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Introduction

Dementia literally means ‘to depart from mind’ in Latin.

It was the German Psychiatrist Emil Kraepelin who firstused the term ‘dementia praecox’ to describe themodern day schizophrenia.

Later, it was from 1920’s that the term dementia wasstarted to be used in the modern day meaning.

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Introduction contd...

What is dementia ?

Dementia is syndrome due to disease of the brain,usually chronic and progressive, in which there isdisturbance in multiple higher cortical functions,including memory, thinking, orientation, comprehension,calculation, language, learning ability, and judgment.

– ICD 10 by WHO

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Introduction contd...

- Dementia is a syndrome

- Dementia is more than just amnesia

- Dementia is often chronic, progressive and irreversible

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Epidemiology and global burden

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Causes of dementia

Generally, Alzheimer’s disease is considered the mostcommon cause of dementia worldwide (60%) and vasculardementia as the second commonest (30%). Other lesscommon types constitute up to 10% of dementias.

However, there is marked regional variation in theprevalence. We have convincing evidence to state thatvascular dementia is more common in our part of theworld.

Study by Shaji et al from Trichur states AD:VD = 1.6:1.5

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Causes of dementiaParenchymatous

brain disease

Alzheimer’s disease, Picks disease, Huntington disease,

Parkinson’s disease, Progressive supranuclear palsy

Vascular Multi-infarct dementia, Single infarct dementia,

Binswagners disease, Specific vascular syndromes

Infections* Creutzfeldt Jacob disease, AIDS dementia, Neurosyphilis,

Chronic meningitis , Encephalitis, Whipples disease, Lyme

disease, Sarcoidosis

Metabolic* Wilsons Disease, Hepatic encephalopathy, Uremic

encephalopathy

Endocrine* Thyroid , Parathyroid , Pituitary or Adrenal dysfunction

Deficiencies* Vitamin B1, B3, B6 or B12 deficiency

Toxic causes*

Heavy metals, CO, Alcohol, Drugs like antiepileptics,

benzodiazepines and analgesics , Dialysis dementia

(Aluminium toxicity)

Other Causes*

Chronic subdural haematoma, Normal pressure

hydrocephalus, Dementia Pugilistica aka punch drunk

syndrome, neoplasm’s and other SOL.

* Generally considered reversible causes of dementia

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Clinical features

Disturbances are seen in multiple higher cortical functionslike memory, thinking, orientation, comprehension,calculations, learning, language and judgment.

Recent memory is first impaired followed by impairmentof remote memory. Immediate memory, ie attention andconcentration is usually intact and consciousness is clear.

Symptoms specific to the cause of dementia are alsonoted.

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Investigations in dementia

Investigations in dementia are of two broad categories,

1. To confirm / diagnose dementia

and

2. To diagnose the cause of dementia

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Investigations contd..

1.Investigations to diagnose dementia.

After we clinically suspect dementia in a patient,scales are often used to assess memory and othercognitive functions.

2.Investigations to diagnose the cause of dementia

Once dementia is diagnosed, we need to do a batteryof tests to identify the cause of dementia.

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Investigations contd…

SCALES USED IN DEMENTIA

Cognition

Mini Mental Status Examination (MMSE),

Modified MMSE (3MMSE),

Hindi MMSE - Indian version of MMSE (English and Hindi)

Clock drawing test , Trail marking Test,

Addembrook’s cognitive examination,

Alzheimer’s disease assessment scale for cognition (ADAS Cog),

Montreal Cognitive Assessment

Global function

Barthel index, Bristol ADL scale

General

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Investigations contd…INVESTIGATIONS IN DEMENTIA

Blood CBCLFT – Hepatic Encephalopathy, RFT – Uremic Encephalopathy, TFT – Hypothyroidism VDRL – Neurosyphilis or GPI, ELISA for HIV – AIDS Dementia Complex

Urine Wilsons disease

Structural imaging Diffuse Cortical Atrophy with flattened sulci and ventricular enlargement in AD.In research, Hippocampal atrophy is considered a biomarker of AD.Infarct, Chronic SDH and Other SOL may be visible.

Functional imaging SPECT or PET in atypical cases – FTD

EEG CJD shows triphasic waves

Lumbar Puncture NPH, Chronic meningitis

Genetic mapping Huntingtons chorea

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Treatment

Treatment of dementia will largely depend on theetiology.

AD is often treated with cholinesterase inhibitors likeDonapezil and NMDA antagonists like Memantine.

Ginkobilobo and NSAIDS may have a role. Insomniaand psychotic or mood symptoms need appropriatecare.

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Treatment contd...

Dementia is a chronic and devastating illness which takes

away the identity of the person. By the terminal stages,patients often become empty shells of their former selves.Realizing this can be fatal to them.

Following non pharmacological approaches are of greathelp – Insight oriented psychotherapy, Assistance ingrieving, Maximizing any areas of intact functioning,Activity scheduling and day structuring, Cognitive skillstraining, Family psycho education, Care giver stress andburn out management.

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Prognosis

Prognosis of dementia will largely depend on theetiology.

AD often has an insidious onset with chronic andprogressive course.

VD typically has an acute onset and step ladder patternof progression.

Reversible causes of dementia show a good prognosis.

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Other topics related to dementia

a) Cortical and sub cortical dementia

b) Dementia and delirium

c) Pseudo dementia

d) Mild cognitive impairment

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Cortical and sub cortical dementia

Dementias are often classified into two broadcategories of cortical and sub cortical based on the areaof brain affected and the resulting clinical features.

This division is not very sharp as clinical features oftenoverlap. As a general rule, cortical dementia exhibitsmore cognitive dysfunction while sub cortical dementiahas more motor symptoms.

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Cortical and sub cortical dementia contd…

CORTICAL AND SUBCORTICAL DEMENTIA

Feature Cortical dementia Sub cortical dementia

Site of brain Outer cortex Sub cortical grey matter

Examples AD, Picks HD , PD , WD , PSP , HIV D

Motor symptoms Rare Usual

Memory symptoms Common Less marked

Language Aphasia +, Dysarthria - Aphasia - , Dysarthria +

Calculation Acalculia + Acalculia -

Co ordination Preserved Impaired

Posture Upright Bowed or extended

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Dementia and delirium

Delirium is an etiologically nonspecific syndromecharacterized by disturbances in consciousness,cognition, psychomotor activity, sleep wake cycle andemotions. It is aka acute confusional state, acute brainsyndrome, ICU psychosis etc.

Delirium has a potential to get confused with dementia,especially if no history is available regarding the onset.Further, they both can exist together complicating the

clinical picture.

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DEMENTIA VS DELIRIUM

Feature Delirium Dementia

Onset Acute Insidious

Course Fluctuating Progressive

Duration Weeks Chronic, often life long

Attention and concentration

Impaired Intact

Orientation Impaired Intact, Impaired in later stages

Memory Impaired immediate and recent

Impaired recent. Remote memory imaired in late stages

Perception Hallucinations and illusions common

Variable

Thought Delusions common Variable

Diurnal variation (+) Sun downing (-)

Floccilation (+) (-)

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Psuedo dementia

Psuedo dementia (PDEM) is a word coined by Kiloh.PDEM often occurs in depression where patients showsome cognitive dysfunction and has the potential to bemistaken for dementia. Differentiating dementia andpsuedo dementia is important in clinical practice.

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DEMENTIA VS PSUEDODEMENTIA

Dementia Psuedo dementia

History

Onset not clear Onset is somewhat clear

Slower progression Rapid progression of symptoms

Pt may even refuse medical help

Pt wanting medical help

Past psychiatric dysfunction rare

Past h/o depression common

Clinical features

Pt highlights achievements

Pt highlights failures

Pt struggle to perform Little effort to perform

Pt may appear unconcerned

Pt appears deeply concerned

Confabulation present Absent

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MCI

Mild cognitive impairment (MCI) MCI primarily identifiesa person with deteriorating cognitive impairment, butnot severe enough to be diagnosed as dementia.European Consortium Task Force guidelines for MCIincludes,

1) Complaints about cognitive impairment,

2) Cognitive impairment on clinical examination,

3) Cognitive impairment not severe to interfere with ADL,

4) No dementia.

Management of MCI may include COX II inhibitors,Tocopherol and antioxidants. MCI conversion toDementia of 2 – 30% per year is reported by Lishman.

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Thank you

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