1. DementiaNyreese N. Castro MPH, CPH, BS.

2. Dementia is a clinical syndrome involving asustained loss of intellectual functions andmemory of sufficient severity to cause dysfunctionin daily living. Its key features include: Progressive decline of intellectual (usually overmonths to years) Loss of short-term memory and at least one othercognitive deficit No disturbance of consciousness Deficit severe enough to cause impairment offunction Not delirious 3. Dementia in the geriatric population can begrouped into two broad categories: Reversible or partially reversible dementias Nonreversible dementias 4. Causes of Nonreversible Dementias 5. Dementia is an acquired persistent and progressiveimpairment in intellectual function, with compromise ofmemory and at least one other cognitive domain,most commonly: language impairment apraxia (inability to perform motor tasks, such ascutting a loaf of bread, despite intact motor function) agnosia (inability to recognize objects) impaired executive function (poor abstraction, mentalflexibility, planning, and judgment). The diagnosis of dementia requires a significantdecline in function that is severe enough to interferewith work or social life. 6. Depression and delirium are also common inelders, may coexist with dementia, and may alsopresent with cognitive impairment. Depression is a common concomitant of earlydementia. A patient with depression and cognitiveimpairment whose intellectual function improveswith treatment of the mood disorder has analmost fivefold greater risk of suffering irreversibledementia later in life. Delirium, characterized by acute confusion,occurs much more commonly in patients withunderlying dementia. 7. Clinical Findings Screening: 1. Cognitive Impairment 2. Decision Making Capacity 8. Cognitive Impairment Although there is no consensus at present on whether older patients should be screened for dementia, the benefits of early detection include identification of potentially reversible causes, planning for the future (including discussing values and completing advance care directives), and providing support and counseling for the caregiver. 9. The combination of a clock drawing task with a three-item word recall (also known as the "mini-cog") is asimple screening test that is fairly quick to administer.Although a number of different methods foradministering and scoring the clock draw test havebeen described, pre-drawing a four inch circle on asheet of paper and instructing the patient to "draw aclock" with the time set at 10 minutes after 11. Scores are classified as normal, almost normal, orabnormal. When a patient is able to draw a clock normally andcan remember all 3 objects, dementia is unlikely. When a patient fails this simple screen, furthercognitive evaluation with the Folstein Mini MentalState Exam (MMSE) or other instruments iswarranted. 10. It is common for a cognitively impaired elder to face aserious medical decision and for the clinicians involved inhis care to ascertain whether the capacity exists to makethe choice. There are five components of a thoroughassessment: (1) ability to express a choice (2) understanding relevant information about the risks andbenefits of planned therapy and the alternatives, in thecontext of ones values, including no treatment (3) comprehension of the problem and its consequences (4) ability to reason (5) consistency A patients choice should follow rationally from anunderstanding of the consequences. 11. Cultural sensitivity must be used in applyingthese five components to people of variouscultural backgrounds. Decision-making capacity varies over time: A delirious patient may regain his capacity afteran infection is treated, and so reassessments areoften appropriate. The capacity to make a decision is a function ofthe decision in question. A woman with mild dementia may lack thecapacity to consent to coronary artery bypassgrafting yet retain the capacity to designate a 12. Signs and Symptoms The clinician can gather important information aboutthe type of dementia that may be present by askingabout: (1) the rate of progression of the deficits as well astheir nature (including any personality or behavioralchange) (2) the presence of other neurologic symptoms,particularly motor problems (3) risk factors for HIV (4) family history of dementia (5) medications, with particular attention to recentchanges. Work-up is directed at identifying any potentiallyreversible causes of dementia. However, such casesare indeed rare. 13. AD typically presents with early problems in memoryand visuospatial abilities (eg, becoming lost in familiarsurroundings, inability to copy a geometric design onpaper), yet social graces may be retained despiteadvanced cognitive decline. Personality changes and behavioral difficulties(wandering, inappropriate sexual behavior, agitation)may develop as the disease progresses. Hallucinations may occur in moderate to severedementia. End-stage disease is characterized bynear-mutism; inability to sit up, hold up the head, ortrack objects with the eyes; difficulty with eating andswallowing; weight loss; bowel or bladderincontinence; and recurrent respiratory or urinaryinfections. 14. "Subcortical" dementias (eg, the dementia of Parkinson disease, and some cases of vascular dementia) are characterized by psychomotor slowing, reduced attention, early loss of executive function, and personality changes. 15. Dementia with Lewy bodies may be confused with delirium, as fluctuatingcognitive impairment is frequently observed. Rigidity and bradykinesia are the primarysigns, and tremor is rare. Response to dopaminergic agonist therapy ispoor. Complex visual hallucinationstypically of peopleor animalsmay be an early feature that canhelp distinguish dementia with Lewy bodies fromAD. These patients demonstrate a hypersensitivity toneuroleptic therapy, and attempts to treat thehallucinations may lead to marked worsening ofextrapyramidal symptoms. 16. Frontotemporal dementias are a group of diseases that include Pickdisease, dementia associated with amyotrophic lateralsclerosis, and others. Patients manifest personality change(euphoria, disinhibition, apathy) and compulsivebehaviors (often peculiar eating habits orhyperorality). In contrast to AD, visuospatial function is relativelypreserved. Dementia in association with motor findings, such asextrapyramidal features or ataxia, may represent aless common disorder (eg, progressive supranuclearpalsy, corticobasal ganglionicdegeneration, olivopontocerebellar atrophy). 17. Physical Examination The neurologic examination emphasizesassessment of mental status but should alsoinclude evaluation for sensory deficits, possibleprevious strokes, parkinsonism, or peripheralneuropathy. The remainder of the physical examination shouldfocus on identifying comorbid conditions that mayaggravate the individuals disability. 18. Laboratory Findings Laboratory studies should include a completebloodcount, electrolytes, calcium, creatinine, glucose, thyroid-stimulating hormone (TSH), and vitaminB12 levels. HIV testing, RPR (rapid plasma reagin)test, heavy metal screen, and liver biochemicaltests may be informative in selected patients butshould not be considered part of routine testing. 19. Imaging Most patients should receive neuroimaging aspart of the diagnostic work-up to rule out subduralhematoma, tumor, previous stroke, andhydrocephalus (usually normal pressure). Those who are younger and those who havefocal neurologic symptoms or signs, seizures, gaitabnormalities, and an acute or subacute onsetare most likely to yield positive findings and mostlikely to benefit from MRI scanning. In older patients with a more classic picture of ADin whom neuroimaging is desired, a noncontrastCT scan is sufficient. 20. Treatment Soon after diagnosis, patients and families should bemade aware of the Alzheimers Association(http://www.alz.org) as well as the wealth of helpfulcommunity and online resources and publicationsavailable. Caregiver support, education, and counseling canprevent or delay nursing home placement. Education should include the manifestations andnatural history of dementia as well as the availabilityof local support services such as respite care. Collaborative care models and disease managementprograms appear to improve the quality of care forpatients with dementia. 21. Cognitive Impairment Demented patients have greatly diminishedcognitive reserve, they are at high risk forexperiencing acute cognitive or functional declinein the setting of new medical illness. Consequently, fragile cognitive status may bebest maintained by ensuring that comorbiddiseases such as congestive heart failure andinfections are detected and treated. 22. Acetylcholinesterase inhibitors: The majority of experts recommend considering atrial of acetylcholinesterase inhibitors(eg, donepezil, galantamine, rivastigmine) in mostpatients with mild to moderate AD. Memantine In clinical trials, patients with more advanceddisease have been shown to have statisticalbenefit from the use of memantine, an N- methyl-D-aspartate (NMDA) antagonist, with or withoutconcomitant use of an acetylcholinesteraseinhibitor. 23. Behavioral Problems:Nonpharmacologic approaches Behavioral problems in demented patients are oftenbest managed with a nonpharmacologic approach.Initially, it should be established that the problem isnot unrecognized delirium, pain, urinaryobstruction, or fecal impaction. Caregivers are taught to use simple language whencommunicating with the patient, to break downactivities into simple component tasks, and to use a"distract, not confront" approach when the patientseems disturbed by a troublesome issue. Additional steps to address behavioral problemsinclude the discontinuation of all medications exceptthose considered absolutely necessary andcorrection, if possible, of sensory deficits. 24. Behavioral Problems: Pharmacologicapproaches Patients with depressive symptoms may showimprovement with antidepressant therapy. Patients with dementia with Lewy bodies have shownclinically significant improvement in behavioral symptomswhen treated with rivastigmine (36 mg orally twice daily). For those with AD and agitation, no agents, includingacetylcholinesterase inhibitors and antipsychotics, havedemonstrated consistent efficacy. Despite the lack ofstrong evidence, antipsychotic medications have remaineda mainstay for the treatment of behavioraldisturbances, largely because of the lack of alternativeagents. The newer atypical antipsychotic agents(risperidone, olanzapine, quetiapine, aripiprazole, clozapine, ziprasidone) are reported to be better tolerated thanolder agents but should be avoided in patients withvascular risk factors due to an increased risk of stroke and 25. Prognosis Life expectancy after a diagnosis of AD istypically 315 years. Other neurodegenerative dementias, such asdementia with Lewy bodies, show more rapiddecline. Hospice is often appropriate for patients with end-stage dementia. 26. When to Refer Referral for neuropsychological testing may be helpful in the following circumstances: to distinguish dementia from depression, to diagnose dementia in persons of very poor education or very high premorbid intellect, and to aid diagnosis when impairment is mild. 27. Question 1 ___________ is an acquired persistent andprogressive impairment in intellectual function,with compromise of memory and at least oneother cognitive domain. A. Depression B. Dementia C. Delirium D. Immobility 28. B. Dementia 29. Question 2 The clinician can gather important informationabout the type of dementia that may be presentby asking about which of the following, except: A. the rate of progression of the deficits as well astheir nature (including any personality orbehavioral change) B. the presence of other neurologicsymptoms, particularly motor problems C. risk factors for Syphilis D. family history of dementia E. all of the above 30. C. risk factors for Syphilis