assessment and diagnosis of dementia dr alison haddow
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Assessment and Diagnosis of Dementia
Dr Alison Haddow
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Dementia
Dementia is the word used to describe a collection of symptoms which may be caused by a variety of disease processes
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Dementia
Multiple brain functions are affected:• Memory• Thinking• Orientation• Comprehension• Calculation• Language• Ability to learn• Judgement
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What is Dementia?
• Consciousness is clear• Emotional control may be disturbed• Social behaviour may change• Motivation levels may alter• Personality may be affected
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Risk factors for Alzheimer’s Disease
• Age• Sex• Genetic Factors• Education• Vascular factors (cholesterol, hypertension)• Smoking• Head injury• Thyroid disease• Exposure to electromagnetic fields
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Risk Factors for Dementia – Genetic (1) • Family History of :
– Dementia (about 40%)– Parkinson’s Disease – Down Syndrome
• Concordance Rate for monozygotic / dizygotic twins is 43 / 8 %
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Genetics
• Familial Autosomal Dominant AD, single mutated gene causes the disease in each family member carrying the mutation
• Genes on the chromosome 1, 14 & 21)• Associated with the early-onset form of the disease• < 5% of cases
Gene for Amyloid Precursor protein (APP) is on the long arm of Chromosome 21
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Genetics
• Fourth gene associated with Alzheimer’s Disease is Apolipoprotein E gene (ApoE).
• Chromosome 19– People : 1 copy of the gene (E4) have 3 times AD than
people without E4– People : 2 copies of the gene (E4) have 8 times AD than
people without E4
Common but no routine testing
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Education
• Many studies show that more highly educated people less likely to develop dementia, especially AD
• ?? Effects of education delaying AD• ?? Intelligence masks AD
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Assessment of Dementia
• ? Medical cause of cog. Impairment?• ? Effect of medication• ? Neurological condition causing dementia• ? Treatable condition
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Assessment of Dementia
• Clinical history– Medical Hx (inc. vascular )– Medication– Family history
• Detailed history – patient and carer/s– Social Hx; ADL’s
• Mental Statepsych symptomsSleep disorder
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Assessment of Dementia
• Cognitive Examination
• MMSE; MOCA; Frontal tests
• Neuropsychology
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Investigations
• Blood tests– FBC, U&E’s, LFT’s, Ferritin, folate, Vit B12, TFT’s, Calcium,
Glucose. (VDRL) ? Vit D• Brain imaging
– CT, SPECT, CT/SPECT• ECG; CXR if indicated
*Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementia- not done clinically.
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Differential Diagnosis• Primary Etiology
– Alzheimer’s dementia– Lewy body dementia– Frontotemporal dementia (Pick’s)
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Differential Diagnosis• Secondary Etiology
– Vascular dementia e.g. cva, tia– Infections e.g. Hiv, syphyllis– Inflammatory e.g. SLE– Alcohol– Traumatic e.g. head injury
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Differential Diagnosis• Neurodegenerative
– Multiple Sclerosis– Huntington’s Chorea– CJD (prion)– Wilson’s Disease– other
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Management of Dementia
• Non pharmacological• Pharmacological
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Pharmacological Management
• Cholinesterase inhibitors• NMDA (memantine)• Medications for disruptive behavior: BPSD• Antidepressants for comorbid disorders
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Cholinesterase Inhibitors
• Galantamine• Donepezil (Aricept)• Rivastagmine (Exelon) Patch
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Kaplan-Meier plot of time to nursing home admission among patients with Alzheimer's disease (A) taking and (B) not taking CEIs.
Lopez O L et al. J Neurol Neurosurg Psychiatry 2002;72:310-314
©2002 by BMJ Publishing Group Ltd
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When to Prescribe AChEI’s
• In:– Alzheimer’s disease– Mixed AD & vascular dementia– Lewy Body Dementia– Parkinson’s disease dementia
• At earliest possible opportunity• After a discussion with the person with
dementia and their families
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Vascular Dementias• Hypertension• Cerebrovascular disease• Hyperlipedemia• Aspirin/clopidogrel
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When to review?
• Post Diagnostic support for one year.
• Information and advice given• Monitor medication
– Compliance– Adverse effects
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Non Pharmacological
• Cognitive Stimulation Therapy