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EVALUATION OF THE PATIENT WITH DEMENTIA

EVALUATION OF THE PATIENT WITH DEMENTIA. Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center. DEMENTIA. A syndrome characterized by acquired , progressive cognitive impairment

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EVALUATION OF THE PATIENT WITH DEMENTIA

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  1. EVALUATION OF THE PATIENT WITH DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center

  2. DEMENTIA • A syndrome characterized by acquired, progressive cognitive impairment • Affects 10% of individuals over 65 • Caused by at least 80 different diseases, many reversible • Unfortunately, the most common diseases (85 – 90%) are irreversible • Diagnosis will have prognostic and treatment implications • All demented patients need a work-up • …and it’s mostly a good history

  3. PRIMARY SYMPTOMS • ATTENTION • MEMORY • POSTROLANDIC (“COGNITION”) • EXECUTIVE (FRONTAL/SUBCORTICAL) • INSIGHT

  4. PRIMARY SYMPTOMS • ATTENTION: clouded sensorium, delirium • MEMORY: forgetfulness • POSTROLANDIC: aphasia, apraxia, getting lost • EXECUTIVE: poor judgment, disinhibition, abulia, urge incontinence • INSIGHT: anosognosia, catastrophic reactions

  5. TWO TYPES OF DEMENTIA • Postrolandic • Frontal/subcortical

  6. POSTROLANDIC Memory deficits Aphasia Apraxia Agnosia Personality more or less preserved MMSE valid FRONTAL/SUBCORTICAL Memory deficits Loss of behavioral plasticity and adaptability, judgment Personality changes Disinhibition Abulia Urge incontinence MMSE useless

  7. THE REST OF THE HISTORY • Time course • Depressive symptoms • Past medical history • Medical and psychiatric conditions • Family Hx • EtOH • Medications (including OTC, OPM)

  8. THE REST OF THE EXAM • Physical exam • Neurologic exam • Mental status exam

  9. THE FOLSTEIN MMSE • Most studied and used of the standardized exams • Quick and easy to administer • Excellent inter-rater reliability • Accurately measures the severity and progression of Alzheimer’s disease • Does not detect executive deficits at all

  10. BEYOND THE MMSE • ATTENTION: digit span or “DLROW” • MEMORY: 3 word recall, orientation • POSTROLANDIC: naming, praxis, calculations, intersecting pentagons • EXECUTIVE: contrasting programs, Luria figures, go-no go, controlled word fluency, frontal release signs

  11. LURIA’S RECURSIVE FIGURES

  12. LURIA’S RECURSIVE FIGURES

  13. LURIA’S RECURSIVE FIGURES

  14. THE GERIATRIC DEPRESSION SCALE (GDS) • Good screen for most patients • Easy to administer and score • Face-valid, so patients can “fake good” or “fake bad” • Valid for demented patients with an MMSE above about 12 • Use DMAS or Cornell scale for severely demented patients

  15. THE REST OF THE WORK-UP • Basic labs • Thyroid function tests • B12 (methylmalonic acid and homocysteine if borderline) • Serology • HIV, drug screen, others, as indicated • Neuroimaging study, usually • LP or EEG, rarely

  16. PLEASANT SURPRISES • Depression • Iatrogenic (anticholinergics, sedatives, narcotics, H2 blockers, multiple meds) • Hypothyroidism • B12 deficiency • Neurosyphilis • Alcoholic dementia • Normal pressure hydrocephalus • Subdural hematoma • Others

  17. POSTROLANDIC DEMENTIAS • Alzheimer’s disease • Diffuse Lewy body disease

  18. ALZHEIMER’S DISEASE • Slowly, insidiously progressive postrolandic dementia; executive sx’s much later • Neurologic exam, labs, neuroimaging studies unremarkable • Often familial, especially in younger patients

  19. ANTI-DEMENTIA DRUGS • May improve cognitive function, ADL’s to a modest extent; often ineffective • Dechallenge if no meaningful benefit • Possibly delay nursing home placement • Cholinesterase inhibitors may cause nausea, diarrhea, weight loss • Memantine occasionally causes agitation • THESE AGENTS DO NOT SLOW THE RATE OF DECLINE

  20. A TYPICAL STUDY

  21. BEWARE!

  22. DIFFUSE LEWY BODY DISEASE • Second most common dementia in autopsy studies • Characterized by Lewy bodies throughout the cortex • Non-familial • 2:1 male:female ratio

  23. CLINICAL FEATURES • Postrolandic dementia • More rapidly progressive than AD • Fluctuation, episodes of “pseudodelirium” common • Mild parkinsonism • Tremor often absent • Poor response to antiparkinsonian meds • Shy-Drager sx’s common • Prominent psychotic sx’s, esp visual hallucinations • SEVERE NEUROLEPTIC INTOLERANCE

  24. FRONTAL/SUBCORTICAL DEMENTIAS • Vascular dementia • Frontotemporal dementia and Pick’s disease • Alcoholic dementia • Huntington’s disease, Wilson’s disease, progressive supranuclear palsy, late Parkinson’s disease • AIDS dementia complex, neurosyphilis, Lyme disease • Normal pressure hydrocephalus • Most head injuries • Anoxia, carbon monoxide • Multiple sclerosis • Tumors • ANY ADVANCED DEMENTIA

  25. TYPES OF VASCULAR DEMENTIA • Multi-infarct dementia • Small vessel disease • Lacunar state (gray > white) • Binswanger’s disease (white) • Hemorrhagic vascular dementia • Strategic infarct dementia • Dementia due to hypoperfusion

  26. SMALL VESSEL DISEASE • At least 50% of all vascular dementia • Often coexists with MID • Usual vascular risk factors, especially HPT • Steady, not step-wise deterioration • Relatively more abulia than disinhibition

  27. FRONTOTEMPORAL DEMENTIA • Relatively uncommon, non-familial illness • Prominent (macroscopic) atrophy of frontal and anterior temporal cortex • Symptoms include executive deficits, Klüver-Bucy syndrome • About 25% of pts have Pick bodies

  28. MANAGEMENT

  29. BEHAVIORAL PROBLEMS IN DEMENTIA • Present in 80% of cases • Major source of caregiver stress, institutionalization • Common at all stages of the disease • Much more treatable than the underlying dementia • Poorly described in the literature

  30. OTHER MEDS WOOF.

  31. THREE BASIC PRINCIPLES • Simplicity • Limited goals • The “no-fail” environment

  32. “THE CUSTOMER IS ALWAYS RIGHT!”

  33. DEPRESSION • 20-30% incidence in Alzheimer’s disease, often early in the course of the illness • Most important treatable cause of excess disability • Responds very well to treatment

  34. ACUTE BEHAVIOR CHANGE • I atrogenic • I nfection • I llness • I njury • I mpaction • I nconsistency • I s the patient depressed?

  35. AGITATION • Present in up to 80% of patients • Up to 34% of patients are combative • Few predictors • Probably a very heterogeneous problem • Cornerstone of treatment is nonpharmacologic

  36. EMPIRICALLY EFFECTIVE MEDS FOR AGITATION • Atypical neuroleptics (best when agitation is clearly related to delusions or hallucinations) • Anticonvulsants • Trazodone • Beta-blockers • Buspirone • Benzodiazepines • Others

  37. THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one) WHEN IN DOUBT, GET RID OF MEDICATIONS!

  38. DON’T FORGET SAFETY ISSUES! • DRIVING • FIREARMS • POWER TOOLS • SMOKING IN BED • POISONS, MEDICATIONS • FALL RISK

  39. GOOD LUCK! OTHER MEDS WOOF!

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