Dementia

Leke Ogunmefun, MD

Clinical Assistant Professor

Department of Psychiatry

University of Maryland School of Medicine

Definitions

• Dementia is used as an umbrella term to group all diseases in which there is some form of memory loss.

• Symptoms of dementia emerge slowly, worsen over time and restrict your ability to function.

• Because depression can sometimes affect memory and cognition, it is often difficult to clearly differentiate it from dementia.

The BRAIN

Types of Dementia

• Alzheimers’ Dementia – Commonest type of dementia. Unknown cause, may occur in families, gradual onset

• Vascular Dementia – Caused by changes in blood supply to the brain. Hypertension, stroke, diabetes and high cholesterol may contribute to this

• Lewy-body Dementia – Dementia and Parkinson’s disease

Dementia Subtypes

• Dementia secondary to Gen. Med. Cond.

• Syphilis

• CJD – Mad cow disease

• HIV

• Head Trauma with severe memory loss

• Mixed

Treatable causes

• Less than 5% of a sample of dementia cases have a potentially treatable cause. These include:

• Hypothyroidism • Vitamin B1 (thiamine) deficiency • Vitamin B12, Vitamin A deficiency • Depressive pseudodementia (note: dementia and

depression can coexist in many patients and can be difficult to differentiate.)

• Normal pressure hydrocephalus • Tumor

Alzheimer’s Disease

Alzheimer’s DiseaseAlzheimer’s Disease

First described by Alois Alzheimer, a German physician, in 1907

Observed in a 51-year-old female patient with memory loss, disorientation, and hallucinations

Postmortem studies characterized senile plaques and neurofibrillary tangles (NFTs) in the cerebral cortex

– Senile plaques: Extracellularaccumulation of insoluble fragments of beta-amyloid (A1-42)

– NFTs: Intracellular accumulation of hyperphosphorylated tau strands

First described by Alois Alzheimer, a German physician, in 1907

Observed in a 51-year-old female patient with memory loss, disorientation, and hallucinations

Postmortem studies characterized senile plaques and neurofibrillary tangles (NFTs) in the cerebral cortex

– Senile plaques: Extracellularaccumulation of insoluble fragments of beta-amyloid (A1-42)

– NFTs: Intracellular accumulation of hyperphosphorylated tau strands

Forecast of Alzheimer’s Disease Prevalence in the U.S.Forecast of Alzheimer’s Disease Prevalence in the U.S.

Forecast of Alzheimer’s Disease Prevalence in the U.S.

65-74 Years 75-84 Years 85+ Years

2030 2050

7.7 Million (est) 13.2 Million (est)

2000

4.5 Million (est)

Source: Hebert LE, et al. Arch Neurol. 2003;60:1119-1122.

Normal Brain vs Severe Alzheimer’s Disease BrainNormal Brain vs Severe Alzheimer’s Disease Brain

Normal Brain vs Severe Alzheimer’s Disease Brain

© Peskind, 2000.

Dementia and Depression

• Patients with mild dementia are almost always depressed. >80%

• Elderly depressed patients are sometimes misdiagnosed as Alzheimer’s dementia.

• Demented patients do poorly in testing due to cognitive decline despite excellent motivation.

• Depressed patients do poorly in testing due to decline in motivation despite excellent cognitive skills.

• Both illnesses are under-diagnosed and under-treated.

Real Symptoms

• Memory loss- Recent >Remote initially• Poor night time sleep• Excessive daytime sleepiness• Wandering• Irritable mood because of forgetfulness• Speech impairment• Suspiciousness (Paranoia)• Auditory and/or visual hallucinations• Physical combativeness• Weight loss• DEPRESSION

Fronto-temporal Dementia

Symptoms of Dementia

Marked loss of memory for recent events

-losing items

-getting lost in familiar places

-Missing appointments

-Trouble with cooking, paying bills, driving

-Can’t understand books, movies or news items

Symptoms of Dementia

• Substitution of approximate phrases ("Where is the thing for sweeping?" for ‘broom’)

• Misidentifying people (Confusing sister with [deceased] mother)

• Use of empty phrases ("You know", "That thing")

• Difficulty inhibiting behavior

Behavior Disturbance

• Wandering, especially at night• Physical combativeness• Argumentative with care provider• Refusing medications• Dangerousness- Leaving stove on, forgetting to turn off

faucets, getting lost• Delusions resulting in suspiciousness of care provider,

calling the police, bizarre acts• Disturbed sleep-wake cycle• Incontinence- Bowel and or bladder ***• DRIVING

Diagnostic Tools

• MMSE – at doctor’s office – scored /30

• Clock Drawing

• Animal naming in one minute

• Other tests may be done by the doctor or specialist

Normal Memory Problems

• Occasional memory problems attributable to age-related forgetfulness

• Normal finding or misleading info after age 45• Forgetting keys or where you parked• Incidental occurrence of misplacing items• Declining mental performance which can be

explained by age, stress or medical condition.• Bereavement and depression

Normal Brain in Section

Dementia Brain in Section

Dementia Treatment

• Start early in treatment and continue indefinitely

• Target specific areas: Cognition, Behavior and/or Function

• Cholinesterase inhibitors indicated for mild to moderate disease

• NMDA indicated for moderate to severe

• They can and should be combined

Treatment of Dementia

• Cholinesterase inhibitors:-Aricept-Exelon-Razadyne ER

• NMDA receptor antagonist: -Namenda

• ****These medications DO NOT improve memory, they only SLOW the decline****

Initial Practical Approaches

• Housing: One level, < 3steps; few, large furniture; low bed or floor mattress; burglar alarm turned on at all times

• Healthy finger foods and microwave• Electric stove preferred; with controlled

access to fusebox• Telephone with large numbers and letters• Orientation cues: LARGE calendar, names

and pictures of patient and loved ones

QUESTIONS

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THE END