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DEMENTIA
NOOR HAFIZAH BT HASSAN 2007287236
REFERENCES:
1. Kaplan & Sadock’s Synopsis of PsychiatryBehavioral Sciences/Clinical Psychiatry10th edition
2. Clinical Practice Guidelines For Management of DementiaMinistry of Health Malaysia
INTRODUCTION
• Definition: progressive impairment in cognitive function with normal consciousness
• Essential features: intellectual impairment– Memory– Thinking– Attention– Comprehension
• Other mental function may affected mood / judgement / social behaviour
DSM IV DIAGNOSIS
EPIDEMIOLOGY
• 5 % of population > 65 years old are demented.• Prevalence ↑ with increasing age.• Dementia shortens life expectancy by 5-9.3 years.• M:F equally affected• Alzheimer’s disease: 50-60 %• Vascular dementia: 15-30 %
AETIOLOGY
DEMENTIA OF ALZHEIMER’S TYPE
• Insidious onset• Gradual progression• Definitive diagnosis: neuropathological examination– Senile plaques– Neurofibrillary tangles
• Pathophysiology:– Genetic: 40% has family history– Neuropathology: amyloid deposition– Neurotransmitter: ↓ Ach and norepinephrine
SENILE PLAQUES
NUEROFIBRILLARY TANGLES
Diffuse cerebral atrophy with enlargement of the ventricle seen on CT scan and MRI
DIFFERENTIATING FEATURES
ALZHEIMER’S DISEASE
VASCULAR DEMENTIA
ETIOLOGY• Genetic• Neuropathology• Neurotransmitter
• Hypertension• Other cardiovascular risk
AGE OF ONSET Usually > 65 y/o Less common in those > 75 y/o
ONSET OF SYMPTOMS Insidious Abrupt
COURSE OF ILLNESS Steady progression in function decline Worsening dementia
PATTERN OF COGNITIVE DEFICIT Global
Patchy: depending on the area of the brain
affected
RADIOLOGICAL FINDINGS
Diffuse cerebral atrophy with
ventricle enlargement
Multifocal infarcts
ASSESSMENT OF DEMENTIA
HISTORY:- Patient’s history:
o memory: past and recent
- Caregiver’s history:o pre-morbid personalityo attitudeo social functioningo interesto self-care
PHYSICAL EXAMINATION:
- To exclude treatable and reversible causes of dementia
MENTAL & COGNITIVE STATE EXAM:
-Mini mental state exam (MMSE)- Clock drawing test
CLOCK DRAWING TEST1. In the space below,
please draw the face of a clock and put the numbers in the correct position
2. Now, draw in the hands at ten minutes after eleven
SUMMARY OF MANAGEMENT
Non pharmacologicalintervention
Pharmacological treatment
General principles
1. Set treatment goals 2. Involve patient and family members in
decision making3. Treat the main distressing problem first4. Set a frame time: monitor cognitive &
non cognitive symptoms5. Assess success/failure of the
intervention
SUMMARY OF MANAGEMENT
Non pharmacologicalintervention
Pharmacological treatment
General principles
GENERAL PSYCHOSOCIAL:• educate the pt and family• optimize function & QOL• address family issue: financial, emotional• related ethical issue
SPECIFIC PSYCHOTHERAPY:• behaviour-oriented• emotion-oriented• cognition oriented• stimulation oriented
SUMMARY OF MANAGEMENT
Non pharmacologicalintervention
Pharmacological treatment
General principles
1. COGNITIVE IMPROVEMENT:- Cholinesterase inhibitor: Donepezil / Rivastigmine / Galantamine- NMDA antagonist: Memantine
2. BEHAVIOURAL & PSYCHOLOGICAL SYMPTOMS:- psychosis & agitation- depression- sleep disturbance
CHOLINESTERASE INHIBITOR
Donepezil (Aricept) 5-10 mg OD- For all stages of Alzheimer’s disease
Rivastigmine (Exelon) 6-12 mg BD- For mild to moderate Alzheimer’s disease
Galantamine (Reminyl) 16-24 mg BD- For mild to moderate Alzheimer’s disease
NMDA INHIBITOR
• Memantine (Ebixa) 5-20 mg BD
• M.O.A: inhibit glutamate activity
• Effective in moderate to severe dementia, including vascular dementia and HIV dementia
THANK YOU