DementiaA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2

Kendall L. Stewart, MD, MBA, DLFAPAMay 17, 2013

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.

Why is this important?

1Risk factors include being female, having a first-degree relative with the disorder and a history of head injury.2Alzheimer’s progresses gradually but steadily to death within 3 to 9 years of diagnosis.

• About 1.5-percent of people over age 65 have dementia.

• And 16 to 25-percent of those over 85 do.

• About 50 to 60-percent of patients with dementia have Alzheimer’s disease.1

• Patients with Alzheimer’s disease occupy more than 50-percent (or 2 million) nursing home beds.

• Since our population is aging, the number of these cases will increase.

• The financial and emotional tolls extracted are enormous.

• After mastering the information in this presentation, you will be able to– Identify the other diagnoses in

this category,– Identify the diagnostic criteria

for dementia,– Specify three disorders that may

produce dementia,– Describe the evaluation of the

patient with dementia,– Discuss a differential diagnosis,– Write a typical treatment plan,

and– Explain some of the typical

treatment challenges.

What other disorders are included in this category?

• Delirium• Dementia

– Alzheimer’s Early Onset– Alzheimer’s Late Onset– Vascular Dementia– Due to HIV– Due to Head Trauma– Due to Parkinson’s– Due to Huntington’s– Due to Pick’s– Due to Creutzfeldt-Jakob Disease– Due to a General Medical Condition Substance-Induced,

Persisting– Not Otherwise Specified (NOS)

• Amnestic Disorders• Other Cognitive Disorders

How do these patients present?1,2

1Family members living with the patient usually provide the best histories.2View yourself as their consultant; they are the real experts.

• This is a 70 year-old retired barber.

• “I just can’t remember things like I used to.”

• “He’s not himself.”• “He doesn’t pay attention to his

appearance like he used to.”• “He gets irritable and mad over

nothing.”• “He’s real suspicious of other

people for no reason.”• “He keeps asking me the same

question over and over.”

• “He loses his keys and blames it on me.”

• “He misunderstand things and gets upset.”

• “He gets lost in the store.”• “He gets more confused at

night.”• “He remembers things from

years ago just fine, but he can’t remember something that happened this morning.”

• “Sometimes he doesn’t recognize his grandkids.”

• “He’s getting worse.”

What are the diagnostic criteria for Alzheimer’s dementia?

1Good-natured confabulation is fairly common.2“What’s my name?”

• Multiple cognitive deficits manifested by both– Memory impairment1,2

– One or more of• Aphasia (language disturbance)• Apraxia (impaired motor

activity)• Agnosia (failure to recognize

objects)• Disturbance in executive

functioning (planning, organizing, sequencing, abstracting)

• Cognitive impairments reflect deterioration and cause impairment

• Course is characterized by gradual onset and continuing decline

• Cognitive deficits not due to– Other central nervous system

conditions that cause dementia– Other systemic conditions that

cause dementia– Substance-induced conditions

• Deficits do not occur exclusively during a delirium

• The disturbance is not better accounted for by another Mental Disorder (Schizophrenia, Major Depressive Disorder)

What are some of the many disorders that produce dementia?1,2

• Alzheimer’s disease• Vascular dementia• Drugs and toxins• Intracranial masses• Anoxia• Trauma• Normal-pressure

hydrocephalus• Neurodegenerative

disorders– Parkinson’s disease– Huntington’s disease

• Infections– Creutzfeldt-Jakob– AIDS

• Nutritional disorders– Thiamine deficiency– Folate deficiency

• Metabolic disorders– Dialysis dementia– Hypothyroidism

• Chronic inflammatory disorders– Lupus– Multiple sclerosis

1Every psychiatrist memorizes such a list for Board exams.2My hung-over examiner drilled me on these, then gave up and sent me out early.

How should you evaluate the patient with dementia?

• A thorough history and physical1

• Vital signs• Mental status examination• Mini-Mental State Examination (MMSE)• Consider using the faster mini-cog test.• Review of medications and drug levels• Blood and urine screens for alcohol, drugs and heavy

metals• Physiological workup• Chest radiograph• Electrocardiogram• Neurological workup• Neuropsychological testing if indicated2

1A careful evaluation is critical for ruling out treatable forms of dementia.2Very bright people are aware of cognitive challenge; a tenured professor was certain he had a learning disability!

Slide 1 of 2

How should you evaluate the patient with dementia?1,2

• Physiological workup (if indicated)– Serum

electrolytes/glucose/Ca2+/Mg– Liver, renal function tests– Serum chemistry profile– Urinalysis– Complete blood count with

differential– Thyroid function tests

including TSH– RPR (serum screen)– FTA-ABS (if CNS disease is

suspected)– Serum B12

– Folate levels

Slide 2 of 2

– Urine corticosteroids– ESR– ANA, C3C4, anti-DS, DNA– Arterial blood gases– HIV screen– Urine porphobilinogens

• Neurological workup (if indicated)– CT or MRI scan of the head– SPECT– Lumbar puncture– EEG

1If you are a consultant, you will need to obtain copies of previous exams and studies.2This is a hassle, but do not take the patient’s word that appropriate studies were done; some repetition may be needed.

What are some of the psychiatric differential diagnoses?

• Delirium• Amnestic Disorder• Vascular Dementia• Dementia due to General

Medical Conditions• Substance Intoxication• Substance Withdrawal

• Substance-Induced Persisting Dementia

• Dementia NOS• Mental Retardation• Schizophrenia• Major Depressive Disorder• Malingering• Factitious Disorder• Normal aging

What is the treatment?

• Psychosocial Therapies1

– Make sure the diagnosis is correct.

– Consider behavioral treatment of problematic symptoms

– Stimulation-oriented therapies have modest support from clinical trials and embody a common sense, humane approach.

– Supportive counseling may help patients and their families deal with a sense of loss early in the illness.

– Cognitive-orientated interventions are unlikely to be helpful; they are more likely to be annoying.

• Pharmacotherapy– Treat underlying conditions

appropriately.– Taper and discontinue offending

medications.– Use sedatives, antidepressants and

antipsychotics sparingly since they can make matters much worse.

– Consider cholinesterase inhibitors in patients with mild to moderate cognitive impairment• Donepezil (Aricept) 5-10 mg/day

– Vitamin E may slow the rate of progression

– Selegiline may prevent further decline but Vitamin E is safer and just as effective.

– Ergot mesylates cannot be recommended.– Benzodiazepines, atypical antipsychotics,

mood stabilizers and antidepressants are somewhat helpful with agitation and combativeness.

1While in widespread use, few of these interventions are truly evidence-based.

What are some of the typical treatment challenges?• These diagnoses are hard to hear;

always offer to arrange for another opinion at any world-class center of their choosing.1

• Patients and families need to confront the driving issue before they have to.

• It is much easier to obtain a power of attorney than to try for guardianship later.

• Families typically put off nursing home placement too long.

• When patients are institutionalized, specialized Alzheimer’s units produce no better outcomes.

• Walking the razor’s edge between agitation and sedation is the preferred path; this walk is easier if the family understands the challenge.

• Nursing homes prefer sedation.• Chemical and physical restraint

should be minimized, but both—properly administered and supervised—still have their place.

• Preparing families for what is to come and how to cope with it is the physician’s greatest gift to loved ones.

• Assisting daughters (particularly) with identifying and dealing with unreasonable guilt can be liberating.2

1A daughter insisted that the neurologist had told them that her mother “most certainly did not have dementia.”2In our culture, women tend to feel much more responsible—particularly when helpless—than men do.

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any additional

questions I may have.• Make a follow up appointment.• Communicate with my other physicians.

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of my problems and

concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

How can you access the OU-HCOM psychiatry flash cards online?

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Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008.

You can read this text online here.• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition,

March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

Are there other questions?

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