APPROACH TO DEMENTIA IN PRIMARY CARE

1. APPROACH TO DEMENTIAIN PRIMARY CARE HÜLYA AKAN, MD Assocc Prof of FamilyMedicine

3. DEFINITION • A syndrome, not a diagnosis • An acquireddegeneration of intellectual and cognitive abilities, which persists at least several months or takes chronically worsening course leading to major impairment in the patient’s everyday life • Is not a normal process of aging

4. PREVALENCE • Prevalence doubles every 5 years after age 60. • Over 85 years,it is about %25-45 • The percentage of geriatric population is increasing all over the world. It shows that with increasing geriatric population, the number of dementia patients will increase • It is the 6th leading cause of death in elderly population in the USA Approximately 2/3 of dementias are Alzheimer type dementia.

5. Is it a community health problem? • Geriatric population is increasing all over the world • Only 10% of dementia is reversible, of these most of them to some extent • Median life expectancy for AD patients 3-15 years • Needs continous care at home and after than at an instituty • As many as 90% of patients with dementia are eventually institutionalized. Median time to nursing-home placement is 3-6 yrs after diagnosis. (what about in Turkey?)

6. What is Cognition? The operation of the mind by which we become aware of objects of thought or perception; it includes all aspects of perceiving,thinking and remembering • Memory • Orientation • Language • Judgement • Perception • Attention • Ability to perform tasks in order

7. What is normal cognitive change in elderly? • Cognitive changes seen in normal aging - Age Associated Memory Impairement (AAMI) - Aging-Associated Cognitive Decline (AACD) • Mild cognitive impairement (MCI) • Dementia : usually complaint of relatives not the patient

8. Cognitive changes seen in elderly • Perform more slowly on timed tasks • Slower reaction time • Subjective problems such as difficulty recalling names or where an object placed • The persons often remembers information later • Intact learning • Any deficits in memory function are subtle, stable and do not cause functional impairement

9. Mild Cognitive Impairement • Not within normal limits for the patient’s age and education but not severe enough to qualify as dementia • Subjective memory complaint • Objective memory impairement in the context of normal abilities on most other cognitive domains (language,executive function); and intact functional status • May represent very early form of AD. Among patients with MCI; 10-15% per year convert to AD compared with 1-2% of age-matched controls • They may progress to other types of dementias or remain stable-FOLLOW UP

10. Dementia • Most severe type of cognitive disorders • Diagnosis requires multiple deficit in multiple domains of cognitive functioning • Memory + At least one another that represent a significant change form baseline and that are severe enough to cause impairement in daily functioning

11. Causes of Dementia

13. Most Common Types of Dementia • Alzheimer Disease 40-50% • Mixed AD/Vascular dementia 15-20% • Lewy Body dementia 10-20% • Pick’s type (frontotemporal) 5-10% • Vascular dementia 5-10% • Other 5%

14. Reversible Causes of Dementia • Toxic affects of medications or drug interactions (especially elderly people use lots of drugs prescribed or unprescribed) • Hydrocephalus-brain tumor • Infection • Electrolyte imbalance • Malnutrition • Endocrine and metabolic disorders

16. ALZHEIMER DISEASE • Most common type of dementia DSM IV Diagnostic Criteria • Developement of gradual cognitive deficits manifested both - impaired memory - aphasia, apraxia,agnosia, disturbed executive function • Significantly impaired social, occupational function • Gradual onset, continuing decline • Not due to CNS or other physical conditions (e.g,parkinson, delirium) • Not due to axis I disorder (eg. Schizophrenia)

17. RISK FACTORS OF ALZHEIMER KNOWN • Age • Specific mutations on chromosomes 1,14,21 • Family history • Down syndrome • Apolipoprotein E ε4 genotype PROBABLE • Low education level • Women • Depression • Brain trauma

18. How Does Alzheimer Patient Apply to the Physician? • Usually the complaint of family or caregivers not patient him/herself • In early dementia patient usually apply to the physician for other reasons • Patient aim to deny the illness – no in-sight • Family members usually aim to relate the symptoms to other reasons- loss of partner, aging, recent operation etc

19. How to Diagnose Alzheimer Disease Probable Diagnosis( usually clinical diagnosis) • History • Physical examination • Cognitive tests • DSM IV Criteria Definite Diagnosis - Brain biopsy

20. COMMON COGNITIVE DISORDERS IN AD • Memory Loss - Diffuculty in learning - Short term memory loss • Disorientation - Time disorientation - Place confusion • Aphasia -Anomia: naming of objects -Difficulty in finding words -Meaningless, undirected speech -Difficulty in understanding

21. COMMON COGNITIVE DISORDERS IN AD • Apraxia: -Ideamotor apraxia: Difficulty in turning an idea into movement (brushing teeth) -Extremity-kinetic apraxia:Difficulty in determining the place of own body parts in space (putting dress, sitting on chair) • Complex Visual dysfunction - Agnosia: difficulty in recognizing - Visual spatial dysfunction

22. COMMON COGNITIVE DISORDERS IN AD • Disorder in applying -Disorder in planning -Disorder in judgement • Disorder in abstract thinking • Disorder in solving problem - Disinhibition • Anosognozi - Unawareness of the disorder - Denial of the disease

23. Common Noncognitive Signs in AD • Personality Changes - Passive - Self-oriented - Agitated/irritable • Apathy - Difficulty in beginning - Insufficiency to continue effort • Depression • Anxiety

24. Common Non-cognitive Signs in AD • Delusions - Paranoia - Misidentification • Hallucinations • Agitation - Nonspecific motor behaviours - Verbal agressiveness - Physical agressiveness • Sleep disturbances - Circadian lapse - Insufficient sleep

25. How to approach a patient presenting with cognitive problem • First step : Is it a disturbance of level of conciousness (acute confusional state, coma) or content of conciousness (wakefullness preserved) • Second step: Determine the cognitive function and the degree of cognitive impairement, decide dementia • Third step: Differantiate reversible and irreversible dementia and also pseudodementia (e.g. depression) • Check prescribed, unprescribed drugs and also herbal drugs and substance abuse (e.g,alcohol)

26. Consider neurologic and neurophysciatric consultation Consider the treatment of reversible causes of dementia Consider treatment of dementia Consider daily activities scalas, determine the care needs of the patient Counselling of the patient, family and caregivers Consider treatment of behavioural disorders

27. HISTORY TAKING • Most important part of the diagnosis • Altough it may be unreliable, first try to take the history from the patient. • Asking questions about past and present social life and medical history gives lots of information about recent and remote memory. Don’t forget patient may feel uneasy with lots of questions and aim to deny self memory problem (no insight) • Since patient has memory problem, you must confirm history by some one accompanying her/him. This also gives some clues about the degree of the problem.

28. HISTORY TAKING • Most of cognitive problems can be recognized and tested during history taking • You may begin with asking “What do you like to do in your free times?” (Measure abstract thinking.For a meaningful response the patient must remember a list of activities and how they are organized). Alzheimer patients typically aim to answer with generalized terms (like reading). In this case clinician may specify by asking “What are you reading recently?” If patient has difficulty, the clinician must go into more detailed tests by saying “It seems you have difficulty in remembering some things. Maybe we better to do some more detailed tests.”

29. HISTORY TAKING • Special attention to drug use: Most of geriatric patients use lots of unprescribed and prescribed drugs having anticholinergic effects. Another problem is that the patient may forget and aim to take drugs several times a day.Ask for drug use and if possible ask for a written list and check with the patient and caregiver. • Special attention to hearing and visional problems. These are also very common in elderly people. Undiagnosed problems may interfere with cognitive tests and may lead to lower scores.

30. HISTORY • Duration of symptoms and nature of progression of symptoms • Presence of specific symptoms related to: -Memory (recent and remote) -Language (word finding problems, diffuculty expressing self) - Visuospatial skills (getting lost) - Executive functioning (calculations,planning, carrying out multistep tasks) - Apraxia (not able to do previously learned motor tasks eg:slicing of bread) - Behaviour or personality changes -Psychiatric symptoms (apathy,hallucinations,delusions,paranoia)

31. HISTORY • Functional assesment (ADLs, IADLs) • Social support assesment • Medical history, comorbidities • Through medication review, including over-the-counter medications, herbal products • Family history • Review of systems including screening for depression and alcohol/substance abuse

32. PHYSICAL EXAMINATION • Cognitive examination • General physical examination with special attention to: - Neurologic examination, looking for focal findings, extrapyrimidal signs, gait and balance assessment - Cardiovascular examination - Signs of abuse and neglect • Screen for impairments in hearing and vision

33. Cognitive Examination • Rapid cognitive test • MMSE • Clock Draw Test

34. Rapid Cognitive Test • Most of the items can be performed during history taking and physical exam. • Normal healthy adults usually finish this test in 5 minutes or less. • It can show if there is need more detailed tests.

35. Rapid Cognitive Test 1- Abstract Thinking: “What do you like to do in your free times?” A: If the answer is appropiate and well constructed or if there is no cognitive or behavioral signs, it may not needed further asssesment. B: If the answer is very concrete, suspicious or not including details, go on item 2.

36. Rapid Cognitive Test 2-Focal Cortical function a: Learning:” I want you to repeat and keep in mind these three words, umbrella, rose, afraid” b: Memory/counting assessment: “If I give you one lira, five kuruş, ten kuruş and twenty five kuruş, how much money I would have given to you?” c: Naming:”Please tell me the name of the things I show you (shirt, jacket,pen etc)”

37. Rapid Cognitive Test d: Temporaparietal tests 1- “Show how you nail on with your right hand” 2- Show how you use key when you are opening the lock with your left hand” 3- “Show how you slice a loaf of bread by using your both hands” 4-Touch your left ear with your right hand” 5- “Use your left hand to show my left hand” 6- “Before showing the ceil please show the door.” e: Drawings: 1- “Draw a clock and put the numbers in it and show the time 08:20.” 2- “Please draw the same of this figure”

38. Rapid Cognitive Test f: Memory: “Please tell me the words that I have told you to memorize few minutes ago.” How to interprate? A: If the patient performs the tests in section 2, assess again in 6-12 months B: If patient can’t success in 2 or more parts of section 2 , consider more detailed assesment.

39. Clock Draw Test Instructions • “Draw the face of the clock, putting the numbers in the correct position. I’ll then ask you to indicate a time after you are done.” • Ask the patient to draw in the hands at ten minutes after eight.” Scoring • Draw a closed circle: 1 point • Place numbers in correct position: 1 point • Includes all 12 correct numbers: 1 point • Correct indication of time: 1 point

40. Clock Draw Test Interpration • CTD 4: approximates MMSE nearly 30 or MCI • CDT 2: puts the patient in moderate cognitive impairement, MMSE about high teens • CTD 1 reflects moderate to low scores on mmse- low teens • Clinical judgement MUST be applied • Abnormal results needs further assesment

41. MMSEMini – Mental State Exam • Not “ gold standart”, but most commonly accepted • 30-point scale to evaluate orientation, concentration, verbal and visual spatial skills • Subject to level of educational attainment, language barrier and vision/hearing requirements • Scoring: Early stages: 21 - 30 Moderate stages: 11 - 20 Late stages: 0 - 10

42. LABORATORY • CBC • Electrolytes, Glucose, BUN/Cr.,Ca, LFTs • Thyroidfuntiontests • Vit B12 • VDRL (Syphilis),HIV (AIDS) • ESR, Urineanalysis • Toxicologyscreen, 24 hoururineforheavymetals • EEG (optional) • Neuroimaging (optional) -CT: toruleoutotherdx -MRI: toruleoutotherdx • PET, SPECT (optional) • CSF fluids: Hightauandlow beta amyloid

43. Is It Needed Neuroimaging? • Routine brain imaging in the diagnostic evaluation of a patient with cognitive impairement dementia is controversial. • If there is oppurtunity, uncontrasted CT or MRI is advised.

44. New developments in diagnosis • Functionalimaging: FDG(fluorodeoxyglucose) PET- reduced use of glucose (sugar) in brain areas important in memory, learning and problem solving • Molecularimagingtechnologies : highligtsamiloidplaques in PET Pittsburgh compound B (PIB) 18F flutemetamol (flute) Florbetapir F 18 (18F-AV-45) Florbetaben (BAY 94-9172)

46. How To Differentiate AD and Depression (Pseudodementia) • Depression is common in dementia patients, also in elderlies. • Clinically when they are found together it may be very diffucult to differentiate. • In every patient you think dementia, try to differentiate pseudodementia- depression. • Treatment of depression may improve cognitive problems.

47. How To Differentiate AD and Depression (Pseudodementia)

48. When To Refer To Neurology • Abrupt onset • Extrapyrimidal symptoms or focal neurologic symptoms other than cognitive symptoms • Abnormal neurologic examination except cognitive impairement • Rapid deteriotion • During follow-up new neurologic signs or symptoms unrelated to AD • If you are not sure of the diagnosis

49. When to Counsel for Neuropsychologic Tests? Neuropyschologic tests consist in-depth battery of standardized examinations that test multiple cognitive domains including intelligence,memory,language, visuospatial abilities,attention, reasoning and problem solving as well as other executive functions and applied by neurophysciatrists. • Patients who have early or mild syptoms (diffuculty in diagnosing or differentiating) • High premorbid intelligence • Patients with low intelligence/educational level

50. Is it needed Genetic Counselling? • Late- onset AD (>60-65 yrs):Is associated with genes that increase the risk of AD but not in autosomal dominant fashion. ε4 increase AD 2-3 times, ε2 protective, but absence of ε4 does not rule out diagnosis. So it is not needed in practical means. • Early-onset AD (<65 yrs, usually between 40-50 yrs): Familial.Inherited autosomal dominant. It is not needed in practical means, but if children of the patient wish to know whether they have inherited the gene, the family shoud be referred for genetic counselling.