Dementia in Clinical Practice

1. Dementia in Clinical Practice • Mary Ann Forciea MD • Clinical Prof of Medicine • Division of Geriatric Medicine • UPHS • Photo: Nat Geographic

2. Who has dementia? • 78 yr old retired librarian • Lives alone, children visit on holidays • Family concerned about ‘clutter’ in house, hygiene, unpaid bills • 68 yr old child care worker • Lives with her husband, drives, in charge of ‘house money’ • “Forgot” a child in classroom at end of day

3. Who has dementia (2) ? • 84 yr old urology inpatient • Post op day 1: hostile • Attempts to strike nurse with cane • Refusing blood draw • Pulled out catheter • 70 yr old homebound patient • Bedbound, mute • Family caregivers • Oral intake decreasing

4. Terms • Dementia • Chronic, progressive • Impairment in >1 domain of cognition • Mild cognitive impairment • Impairment in 1 domain of cognition • ? “pre-dementia” • Delirium • Short term

5. What do we know about Brain Function? • Cell structure • Microscope (biopsy, cell culture) • PET scans • Brain regions • imaging • “Domains” of cognition • Imaging • Psychological testing

6. Cell structure: Neurons • Networks • Grey matter/white matter

7. Brain regions • Regions have different activities

8. Domains of cognition • Memory • Calculation • Language • Orientation • Spatial construction • Executive function (judgment)

9. Mapping MemoriesNatl Geographic

10. What is wrong in dementia? Theories Neurons: waste products, shape of cells, signaling, genetic flaws Regions: biochemistry, structure Domains: communication We don’t yet know.

11. Clinical observations • All patients with dementias are not alike. • Age of onset • Family history • Initial symptom • Most troublesome symptom • Rate of progression • Response to treatment • Is dementia a symptom, not a disease?

12. DementiaSubtypes • Alzheimer’s Disease • Fronto-temporal dementia (formerly Pick’s Disease) – 15% • Corticobasilar dementias • Dementia with Lewy Bodies – 20% • Distinguished from Parkinson’s Disease with dementia • Vascular disease

14. Alzheimer’s type dementia • Gradual onset • Global impairment in cognition • Usually memory impairment predominant • Increased risk in siblings • Apo e allele risk • Slow progression (5-7 years) • Predictable course (global deterioration scores)

15. AD - pathology • Imaging • Neuropathology – quantity and location • Senile plaques • White matter • Amyloid core • Neurofibrillary tangles • Tau protein abnormalities • Initial concentrations highest in hippocampus and temporal lobes

18. What clinical problems do patients with Alzheimer’s Dementia Encounter? • Diagnosis • Symptom Management • End of life care

19. Case 1 NC • 64 yr old retired OR nurse • Referred for evaluation of impaired memory • Birthdates, telephone numbers • Impaired job performance for 1-2 yrs prior • Inability to ‘balance checkbook’ • Gradual decline over 5 years • Died of pneumonia

20. Diagnosis • Largely on history • Exclude other conditions • Role for imaging in near future • Staging • Mental status testing (MMSE, MOCA, Mini-Cog) • Functional status staging (FAST, GDR)

21. FAST • The FAST scale has seven stages: • 1 which is normal adult • 2 which is normal older adult • 3 which is early dementia • 4 which is mild dementia • 5 which is moderate dementia • 6 which is moderately severe dementia • 7 which is severe dementia

22. AD - treatment • Improve all co-existing conditions! • Specific treatments • Cholinesterase inhibitors • Donepazil, rivastigmine • Adrenergic stimulants • Memantine • Treatment of associated symptoms • Agitated behaviors • Non pharmacologic, environmental • drugs

23. End of life issues • Should be anticipated • Advance Directives, conversations with proxies • Goals of care • Nutrition • Hospitalization • Caregiver burdens • Hospice involvement

24. Summary • “Dementia” is a symptom complex • We are in the early stages of understanding the pathology, and discovering effective treatment • Optimal care requires advance planning, caregiver involvement, and a team of professionals