Dementia

From Anvita Health Wiki

Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 History 6 Clinical-manifestations 7 Laboratory 8 Diagnostic-procedures 9 Radiology 10 Complications 11 Differential-diagnosis 12 Management 13 More General Terms 14 Additional Terms 15 References

More Specific Terms

• dementia pugilistica
• familial British dementia (cerebral amyloid angiopathy ITM2B-related type 1, CAA-ITM2B1)
• familial Danish dementia (cerebral amyloid angiopathy ITM2B-related type 2, CAA-ITM2B2, heredopathia ophthalmo-oto-encephalica)
• frontal-subcortical dementia
• frontotemporal dementia (FTD)
• mixed dementia
• Parkinson's dementia
• rapidly progressive dementia
• vascular dementia

Introduction

• A group of acquired mental disorders involving general loss of intellectual abilities, including memory, language, judgment, & abstract thinking, such as to interfere with activities of daily living. There may be associated poor impulse control &/or personality change. Dementias may be progressive, reversible, or static & have a variety of causes.

Etiology

• Alzheimer's disease
• vascular dementia & mixed dementia

• high incidence of cerebral emboli (not from carotids) [23]

• parkinsonism

• Parkinson plus syndromes
• diffuse Lewy body disease

• Huntington's disease
• Pick's disease
• progressive supranuclear palsy
• corticobasal ganglionic degeneration
• progressive ataxic syndromes
• infections

• neurosyphilis
• Creutzfeldt-Jakob disease
• HIV, AIDS dementia complex, possibly latent CMV [15]

• hydrocephalus: normal pressure hydrocephalus
• mass lesions

• frontal & temporal lobe tumors
• chronic subdural hematoma

• metabolic & endocrine disorders, toxins
• head trauma
• also see CAIDE
• also see causes of dementia & NIH consensus statement [8])

Epidemiology

• 35-50% of population > 85 years of age
• 60-70% of dementia is due to Alzheimer's disease
• 15-25% of dementia is due to Lewy body dementia
• 15-20% of dementia is due to vascular dementia often coexisting with Alzheimer's disease
• 2-5% of dementia due to reversible causes [21]

History

• time course of intellectual decline
• functional assessment -> activities of daily living
• education level
• medication history
• associated medical conditions
• substantiation from spouse or family member
• mental status examination

Clinical-manifestations

• insidious onset (see subjective memory problems in the elderly)
• stable course of a period of 24 or more hours
• clear consciousness
• attention is normal except in severe cases
• cognition is globally impaired

• memory impairment
• language impairment
• disorder of abstract thinking
• loss of constructional abilities

• decline in social & occupational skills
• loss of activities of daily living
• getting lost
• hallucinations are usually absent

• generally visual hallucinations when they do occur [8]

• persecutory delusions (generally plausible)

• stolen belongings
• spouse infidelity

• orientation is usually impaired
• psychomotor activity is usually normal
• patient has difficulty in finding words & often perseverates
• behavioral disturbances (80-100%) [8]

• may result from

• mood disorders: depression, anxiety, apathy
• agitation resulting in verbal & physical aggression
• wandering, pacing, rummaging
• disinhibition

• especially prominent with moderate to severe dementia
• most patients show 2 or more behavioral disturbances

• involuntary movements are generally absent
• often no underlying physical illness or drug toxicity
• cortical dementia:

• aphasia
• agnosia
• apraxia

• frontal-subcortical dementia:

• psychomotor slowing
• apathy
• impaired executive function
• difficulty with information retrieval

• clues to potentially reversible dementia [3]

• rapid or abrupt onset
• fluctuating severity
• hypersomnolence
• inattention
• tremulousness
• gait unsteadiness
• hallucinations

• triad of gait ataxia, urinary incontinence & dementia suggests normal pressure hydrocephalus
• final stages of dementia are characterized by pneumonia, dypsnea, fevers, eating problems [19]

Laboratory

• (Laboratory Evaluation of Dementia)
• routine

• complete blood count ( CBC)
• comprehensive metabolic panel

• electrolytes
• serum Ca+2 & serum albumin
• liver function tests
• renal function tests

• thyroid function tests
• serum vitamin B12 &/or serum methylmalonic acid ( vitamin B12 deficiency)
• urinalysis

• optional testing

• HIV testing
• serology for Lyme disease
• serologic test for syphilis ( VDRL, RPR) [8]
• low serum folate levels associated with dementia
• low serum homocysteine associated with dementia
• lumbar puncture ( CSF evaluation)

• prion-related disorders ( CJ disease)
• teriary syphilis
• meningeal carcinomatosis
• CNS vasculitis

• urine toxin screen
• apolipoprotein E

• occasionally helpful tests

• parathyroid function: serum PTH
• adrenal function: cosyntropin-stimulation test
• urine heavy metals
• erythrocyte sedimentation rate (ESR)

Diagnostic-procedures

• Folstein mini-mental status examination is standard

• Sweet 16 simpler & faster

• other cognitive assessment

• time & change test

• neuropsychologic testing

• high-functioning patients
• patients with mental retardation
• patients with low levels of education

• occasionally helpful tests

• electroencephalogram ( EEG)
• brain biopsy

Radiology

• magnetic resonance imaging ( MRI) of the brain

• imaging modality of choice
• may be more useful for patients with suspected vascular dementia
• T2-weighted white matter changes are generally unrelated to dementia

• computed tomography (CT) of the brain (without contrast)
• positron emission tomography ( PET) or SPECT [10]
• indications for neuroimaging

• onset before 60 years of age
• cognitive decline < 6 month duration
• focal signs/symptoms or papilledema
• new onset seizures
• ataxic or apraxic gait
• marked personality change

• angiogram of the brain may be helpful
• chest X-ray (optional testing0)
• no consensus that all patients with insidious onset of symptoms after age 60 should have imaging study

Complications

• pneumonia is common cause of mortality in patients with advanced dementia
• increased risk of hospitalizations [22]
  
• disease interaction(s) of dementia with urinary incontinence
• disease interaction(s) of pneumonia with dementia

Differential-diagnosis

• delirium (see dementia vs delirium)
• psychosis
• depression (see depressive pseudodementia)

• depression is common in demented patients

• apathy

• apathy is common in demented patients & affects ADLs beyond the level of cognitive impairment

• minimal cognitive impairment

Management

• general

• depends upon underlying etiology

• screen for depression

• treat underlying cause when possible
• manage associated behavioral & affective disorders

• environmental strategies
• pharmacologic agents (start low, go slow)

• antidepressants with minimal anticholinergic effects

• trazodone
• selective serotonin reuptake inhibitors ( SSRI)
• nortriptyline
• patients generally tolerate discontinuation of SSRIs without recurrence of symptoms initiating treatment [24]

• carbamazepine
• haloperidol
• benzodiazepines may result in paradoxical agitation agents used to manage hypersexuality in men [4] - cimetidine, SSRI, medroxyprogesterone, estrogens, GNRH analogues ( leuprolide)
• periodically evaluate need for continued therapy

• maximize functional skills of the patient
• address legal & financial issues at the time of diagnosis
• monitor the needs of the caregiver

• increased incidence of depression
• increased incidence of stress-related illnesses

• pharmaceutical agents

• see Alzheimer's disease ( Alzheimer's agents)
• see drugs to avoid in patients with dementia
• no effective pharmacotherapy to prevent mild cognitive impaitment or slow its transition to dementia [3]

• bright light +/- melatonin may reduce cognitive decline & improve physical function [18]
• dementia is a reportable disorder & must be reported to the heath department

• see dementia, driving & California state law

• prognosis (see prognosis for patients with dementia)
• prevention: see cognitive impairment

More General Terms

• sign/symptom
• mental disorder
• chronic neurologic disease

Additional Terms

• ACE inhibitors & dementia
• cardiovascular risk factors, aging, & dementia (CAIDE) trial
• causes of dementia
• cognitive impairment
• cortical versus frontal-subcortical dementia
• dementia vs delirium vs depression
• dementia, driving & California state law
• depressive pseudodementia
• diagnostic criteria for dementia (DSM III/IV)
• drugs to avoid in patients with dementia
• neuropsychological battery for dementia evaluation
• prognosis for patients with dementia
• screening for dementia

References

1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1025-27
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
4. Prescriber's Letter 7(10):58 2000
5. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 142-150
6. Role of cholinergic therapy in treatment of Alzheimer's disease and other dementias, Farlow, M et al, 2001
7. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
8. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
9. NIH consensus statement Differential diagnosis of dementing diseases [1]
10. Centers for Medicare & Medicaid. Billing requirements for positron emission tomography (PET) scans for dementia and neurodegenerative diseases. Oct 2004 [2]
11. Costa PT et al, Early identification of Alzheimer's disease and related dementias. Clinical practice guideline, Quick reference guide for clinicians, No. 19, Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1996. AHCPR publication No 97-0703 [3]
12. Ridha B and Josephs KA Young-onset dementia: A practical approach to diagnosis. Neurologist 2006; 12:2 PMID: [4]
13. Purandare N et al, Cerebral emboli as a potential cause of Alzheimer's and vascular dementia: Case-control study. BMJ 2006; 332:1119 PMID: [5]
14. Garrard P, Carroll E. Lost in semantic space: a multi-modal, non-verbal assessment of feature knowledge in semantic dementia. Brain. 2006 May;129(Pt 5):1152-63. Epub 2006 Apr 3. PMID: [6]
15. Aiello A, Haan M, Blythe L, Moore K, Gonzalez JM, Jagust W. The influence of latent viral infection on rate of cognitive decline over 4 years. J Am Geriatr Soc. 2006 Jul;54(7):1046-54. PMID: [7]
16. Holsinger et al, Does this patient have dementia? JAMA 2007, 297:2391 PMID: [8]
17. Prescriber's Letter 15(5): 2008 Pharmacotherapy Choices for Patients with Dementia CHART: Drugs to Avoid in Patients with Dementia COMMENTARY: Efficacy of Dementia Drugs and Guidelines for Use GUIDELINES: American College of Physicians and the American Academy of Family Physicians Clinical Practice Guideline on Current Pharmacologic Treatment of Dementia Detail-Document#: [9] (subscription needed) [10]
18. Riemersma-van der Lek RF et al, Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: A randomized controlled trial. JAMA 2008, 299:2642 PMID: [11]
19. Mitchell SL et al The Clinical Course of Advanced Dementia N Engl J Med 2009, 361:1529 <PubMed> PMID: [12] <Internet> [13]
    - Sachs GA Dying from Dementia N Engl J Med 2009, 361:1595 <PubMed> PMID: [14] <Internet> [15]
20. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of disability in the last year of life. N Engl J Med 2010 Apr 1; 362(13):1173-1180. PMID: [16]
21. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
22. Phelan EA et al. Association of incident dementia with hospitalizations. JAMA 2012 Jan 11; 307:165 PMID: [17]
23. Purandare N et al. Association of cerebral emboli with accelerated cognitive deterioration in Alzheimer's disease and vascular dementia. Am J Psychiatry 2012 Mar 1; 169:300. PMID: [18]
    - Doraiswamy PM. Silent cerebrovascular events and Alzheimer's disease: An overlooked opportunity for prevention? Am J Psychiatry 2012 Mar 1; 169:251. PMID: [19]
24. Bergh S et al. Discontinuation of antidepressants in people with dementia and neuropsychiatric symptoms (DESEP study): Double blind, randomised, parallel group, placebo controlled trial. BMJ 2012 Mar 9; 344:e1566 PMID: [20]
25. NIH Institute and Center Resources [21]
    - Guidelines on the management of patients with dementia Scottish Intercollegiate Guidelines Network (SIGN) [22]
26. Kaiser Permanente, Care Management Institute's Dementia Guidelines Workup [23]
27. National Guideline Clearinghouse [24]
    - Dementia in the long-term care setting. American Medical Directors Association ngc-guideline: [25]
    - (1) Caregiving strategies for older adults with delirium, dementia and depression. (2) Caregiving strategies for older adults with delirium, dementia and depression 2010 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [26]
    - Bathing persons with dementia. ngc-guideline: [27]
    - Dementia care practice recommendations for assisted living residences and nursing homes. (Alzheimer's Association) ngc-guideline: [28]
    - Management of patients with dementia. A national clinical guideline. (Scottish Intercollegiate Guidelines Network) ngc-guideline: [29]
    - Individualized music for elders with dementia. University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. ngc-guideline: [30]
    - Dementia. (Singapore Ministry of Health) ngc-guideline: [31]
    - Detecting depression in older adults with dementia. University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core ngc-guideline: [32]
    - Dementia and movement disorders American College of Radiology ngc-guideline: [33]
    - Practice guideline for the treatment of patients with Alzheimer's disease and other dementias. American Psychiatric Association ngc-guideline: [34]
    - Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. ngc-guideline: [35]
    - Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline. European Federation of Neurological Societies ngc-guideline: [36]
    - Dementia care practice recommendations for assisted living residences and nursing homes: phase 3 end-of-life care. Alzheimer's Association ngc-guideline: [37]
    - Dementia. Diagnosis and treatment. Regione Toscana, Consiglio Sanitario Regionale ngc-guideline: [38]
    - EFNS guidelines on the molecular diagnosis of channelopathies, epilepsies, migraine, stroke and dementias. European Federation of Neurological Societies ngc-guideline: [39]
    - Clinical practice guideline for dementia. Part I: diagnosis & evaluation. Clinical Research Center for Dementia of South Korea ngc-guideline: [40]

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