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Evaluation of Dementia in Geriatric Psychiatry

Comprehensive guide on diagnosing dementia, including symptoms, history, exams, and treatments such as anti-dementia drugs, with focus on Alzheimer's and Lewy body disease.

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Evaluation of Dementia in Geriatric Psychiatry

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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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