different faces of dementia

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Different faces of Dementia Neeraj Gupta & Pallavi Dham OPMHS, Glenside

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Different faces of Dementia. Neeraj Gupta & Pallavi Dham OPMHS, Glenside. Basic Neuroanatomy Dementia overview Differential diagnosis Types of dementia Approach to differentiating Dementias. What is Cognition?. - PowerPoint PPT Presentation

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Page 1: Different faces of Dementia

Different faces of Dementia

Neeraj Gupta & Pallavi DhamOPMHS, Glenside

Page 2: Different faces of Dementia

> Basic Neuroanatomy> Dementia overview> Differential diagnosis> Types of dementia> Approach to differentiating

Dementias

Page 3: Different faces of Dementia

What is Cognition?

> The term cognition (Latin: cognoscere, "to know", "to conceptualize" or "to recognize") refers to a faculty for the processing of information, applying knowledge, and changing preferences.

> These processes include attention, memory, producing and understanding language, solving problems, and making decisions, higher order motor and sensory functions.

Page 4: Different faces of Dementia

Brain areas and cognition

Cortex> Frontal Lobe- executive

functions, speech, movement

> Parietal Lobe- associated with movement, perception of stimuli, orientation, recognition,

> Occipital Lobe- associated with visual processing

> Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech

Page 5: Different faces of Dementia

Subcortical areas> Limbic system

(amygdala, hippocampus, Thalamus, hypothalamus and pituitary): Emotions, memories

> Basal ganglia, Cerebellum: movement and coordination

> Brain stem: vital functions

All parts are interconnected. Impairment in one area can influence another

Page 6: Different faces of Dementia

What is dementia?

> Dementia (taken from Latin, originally meaning "madness", from de- "without" + ment, the root of mens "mind")

> Differentiated from “madness” by Emil Kraepelin

> Diagnosis made on clinical observations

Page 7: Different faces of Dementia

DSM IV TR definition of Dementia

> The essential feature of a dementia is the development of multiple cognitive deficits that include memory impairment and at least one of the following cognitive disturbances:• aphasia, apraxia, agnosia, or a disturbance in

executive functioning.

> The cognitive deficits must be sufficiently severe to cause impairment in occupational or social functioning and must represent a decline from a previously higher level of functioning

Page 8: Different faces of Dementia

Metabolic

Endocrine

Infection

Drugs &Toxins

Tumour

Trauma

Other neurological

Miscellaneous

Vascular

Neuro-degenerative

Dementia

Page 9: Different faces of Dementia

Clinical Presentation in Dementia

Page 10: Different faces of Dementia

Symptoms of Dementia

> Memory impairment • refers to the inability to learn new information

or to recall previously learned information. Does he have difficulty remembering recent

conversations? Is he frequently repetitive? Is he aware of current events? Does he misplace or lose things? Does he forget to turn off the stove?

Page 11: Different faces of Dementia

Cognitive impairment contd

> Aphasia, or language impairment• Does he have difficulty finding correct word?• Is it sometimes difficult for others to

understand him?• Does he have difficulty remembering names? • Does he have difficulty maintaining or initiating

conversations?

Page 12: Different faces of Dementia

Cognitive impairment contd

> Apraxia, or • impaired ability to carry out motor activities

despite intact motor function Does he have difficulty using familiar objects? Does he have difficulty performing simple tasks

at home? Does he have trouble performing previously

acquired skills (i.e., knitting, woodworking)? Is there any difficulty in dressing, bathing, or

feeding?

Page 13: Different faces of Dementia

Cognitive impairment contd

> Agnosia• failure to recognize or identify objects despite

intact sensory function, Does he have difficulty recognizing people,

objects or places? Does he lack insight into his own impairment?

Page 14: Different faces of Dementia

Cognitive impairment contd

> Impairment in executive functioning • refers to disturbances in planning, organizing,

sequencing, and abstracting. > Does he have difficulty relating to

newspapers or television?

> Is he still able to manage finances, the checkbook, medications or taxes?

> Does he or she show problems in judgment or problem solving?

> Does he have difficulty remembering short lists for shopping?

> Does he need assistance with ADL’s?

Page 15: Different faces of Dementia

Neuropsychiatric symptoms

• Not required for the diagnosis of dementia. • Commonly co-occur with dementia• Often the cause of greatest caregiver distress.• Neuropsychiatric Inventory (NPI) evaluates 12

neuropsychiatric disturbances: Delusions, hallucinations, agitation,

dysphoria, anxiety, apathy, irritability, euphoria, disinhibition, aberrant motor behavior, night-time behavior disturbance, and appetite and eating abnormalities.

Page 16: Different faces of Dementia

PSYCHOSIS OF ALZHEIMER'S DISEASE COMPARES WITH SCHIZOPHRENIA IN THE

ELDERLY

Psychosis of AD Schizophrenia

• Bizarre or complex delusions Rare Frequent• Misidentifications of caregivers Frequent Rare• Common form of hallucinations Visual Auditory• Schneiderian first-rank Rare Frequent• Active suicidal ideation Rare Frequent• Past history of psychosis Rare Frequent• Eventual remission of Frequent Uncommon

psychosis• Need for long-term treatment Uncommon Very common

with antipsychotics• Mean optimal daily dose of 15–25% of that in a 40–60% of that• antipsychotics young adult with in a young

schizophrenia adult withschizophrenia

Page 17: Different faces of Dementia

http://www.youtube.com/v/9iXPHhfk_7E

Page 18: Different faces of Dementia

Normal ageing MCI Dementia

Some cognitive decline expected for the age/education

Cognitive decline, more than expected for age/education

Definite cognitive decline

Subjective complaint with little objective findings

Objective deficits

Objective deficits

Little impairment in functioning

Little impairment in functioning

Impaired functioning

Page 19: Different faces of Dementia

Is it Delirium , Dementia or Depression?

Delirium Dementia

Onset Rapid (hours/days); rapid decrease in MMSE score.

Slow (months, years); slow decline of 2 to 3 MMSE points over a period of years.

Symptoms Fluctuate over the course of the day.

Relatively stable.

Duration Days to weeks. Years.

Orientation Disorientation and disturbed thinking are intermittent.

Persistent disorientation.

Level of consciousness

Fluctuates, with inability to concentrate.

Alert, stable.

Sleep/wake cycle

Sleep/wake cycle may be reversed.

Sleep may be fragmented.

Depression

Subacute onset- weeks to months, pseudodementia

Persistent and pervasive

Weeks to months

Oriented

Alert, stable

Early morning awakening

Page 20: Different faces of Dementia

Types of dementia

Response to

treatmentEtiology

Cognitive Profile

ReversibleIrreversible

AlzheimersOther

medical conditions

Cortical SubcorticalVascular

Page 21: Different faces of Dementia

Reversible dementias

Irreversible Dementias

> Infection: HIV, syphilis, encephalitis

> Tumours> Trauma: SDH> Toxins: heavy metal,

alcohol, cancer chemotherapy

> Metabolic: B12,thiamine, Niacin deficiency

> Endocrine: thyroid, diabetes

> Normal pressure hydrocephalus

> Sub classified based on pathology and areas of the brain effected

> Alzheimer's Dementia> Vascular dementia> Lewy body dementia> Fronto-temporal

dementias> Traumatic brain injury> Mixed etiology> Others

•Correcting the underlying reversible cause may improve dementia

Page 22: Different faces of Dementia

Characteristics Cortical D Subcortical D

Language Aphasia -early Late

Memory Recall & recognition Recall>recognition

Attention impaired impaired

Visuospatial impaired impaired

calculation early late

Executive function Proportionate to other deficits Disproportionate

Speed of cognition fine Slowed

personality unconcerned apathetic

mood euthymic depressed

speech articulate dysarthric

posture upright Bowed/extended

coordination preserved impaired

Adventitious movements absent Tremor, chorea, tics

Page 23: Different faces of Dementia

Types of dementias- DSM-IV and ICD 10

DSM IV> Alzheimers dementia> Vascular dementia> Due to general

medical conditions: HIV, picks, brain injury, tumours,etc

> Substance induced persisting dementia

> Due to multiple etiologies

ICD 10> Alzheimers D> Vascular D> Dementia in other

diseases: Picks, Creutzfeldt jacob, huntingtons disease, parkinsons disease, HIV, others

Page 24: Different faces of Dementia

Alzheimer's Dementia

Page 25: Different faces of Dementia

Prevalence-

accounts for up to 90% of the dementia cases. 2/3 have concomitant pathologies prevalence increases exponentially every 5

years Sex differences- females>males

Page 26: Different faces of Dementia

Aetiology

> Exaggeration of normal aging process> Genetic

• Amyloid precursor protein (APP), • Presenilin-1 (PS-1),.• Presenilin-2 (PS-2),.• Apolipoprotein E-e4 (APOE4), • Other risk factors: Lifestyle and heart health

Page 27: Different faces of Dementia

Plaques and Tangles: The Hallmarks of AD

The brains of people with AD have an abundance of two abnormal structures:

An actual AD plaque An actual AD tangle

• beta-amyloid plaques, which are dense deposits of protein and cellular material that accumulate outside and around nerve cells

• neurofibrillary tangles, which are twisted fibers that build up inside the nerve cell

AD and the Brain

Slide 16

Page 28: Different faces of Dementia

The Changing Brain in Alzheimer’s Disease

No one knows what causes AD to begin, but we do know a lot about what happens in the brain once AD takes hold.

Pet Scan of Normal Brain

Pet Scan of Alzheimer’s Disease Brain

AD and the Brain

Slide 19

Page 29: Different faces of Dementia

AD- Brain areas and cognitive deficits

> Initial memory deficits

> Global deficits> Impairment in

functioning

Page 30: Different faces of Dementia

AD- BPSD

> Anosognosia- unaware of the illness/impact

> Passivity-apathy -70%, 2years prior to the diagnosis

> Psychosis-later on> Depression, anxiety, catastrophic

reactions> Aggression> Sun downing

Page 31: Different faces of Dementia

AD- course and outcome

> Gradual progressive decline> Average survival time -4-6 years > Life expectancy reduced by 50%

Page 32: Different faces of Dementia

Vascular Dementia

Page 33: Different faces of Dementia

Vascular dementia

> Temporal correlation between :• Cognitive decline• Cerebrovascular disease: neurological

deficits or vascular damage evident on brain imaging

Page 34: Different faces of Dementia

VD:

> Account for about 17% of all dementias> Males> Females> Overall prevalence is increasing with

ageing population> Risk factors: hypertension, diabetes,

hypercholesterolemia, obesity, smoking, cardiovascular disorders

Page 35: Different faces of Dementia

VD- types

> Subcortical ischemia- frontal lobe and basal ganglia: executive dysfunction, slowed processing

> Multi-infarct: disjointed deficits> Strategic infarcts: areas related to

cognition> Mixed alzheimers and VD

Page 36: Different faces of Dementia

Course and prognosis

> Step ladder pattern of cognitive decline> Shorter life expectancy compared to

Alzheimer's. Yet it is variable and depends on the age and underlying risks

Page 37: Different faces of Dementia

Lewy Body Dementia

Page 38: Different faces of Dementia

Dementia Lewy Body (DLB)

> Recognised as the second most common type of neurodegenerative dementias after Alzheimer's Disease

> Lewy bodies- protein deposits in neurons and glia

Page 39: Different faces of Dementia

DLB- clinical presentation

> Shares features of Alzheimer's and Parkinson's disease

> Cognitive deficits: visuospatial, executive, memory-benefits from cueing

> Parkinson's features :bradykinesia, tremor, rigidity, autonomic instability

> Additional features: detailed visual hallucinations, fluctuations, day time drowsiness

> Depression and anxiety

Page 40: Different faces of Dementia

Diagnostic criterion- DLBCentral feature> Progressive dementia - deficits in attention and executive function are typical.

Prominent memory impairment may not be evident in the early stages. Core features: > Fluctuating cognition with pronounced variations in attention and alertness. > Recurrent complex visual hallucinations, typically well formed and detailed. > Spontaneous features of parkinsonism. Suggestive features:> REM sleep behavior disorder (RBD), which can appear years before the onset of

dementia and parkinsonism. > Severe sensitivity to neuroleptics occurs in up to 50% of LBD patients who take

them. > Low dopamine transporter uptake in the brain's basal ganglia as seen on SPECT

and PET imaging scans. (These scans are not yet available outside of research settings.)

Supportive features: > Repeated falls and syncope (fainting). > Transient, unexplained loss of consciousness. > Autonomic dysfunction. > Hallucinations of other modalities. > Visuospatial abnormalities. > Other psychiatric disturbances.

Page 41: Different faces of Dementia

> A clinical diagnosis of LBD can be probable or possible based on different symptom combinations. • A probable LBD diagnosis requires either:

Dementia plus two or more core features, or Dementia plus one core feature and one or

more suggestive features.

• A possible LBD diagnosis requires: Dementia plus one core feature, or Dementia plus one or more suggestive features.

Page 42: Different faces of Dementia

Fronto-Temporal Dementia

Page 43: Different faces of Dementia

Fronto-temporal Dementia (FTD)

> Occurs most commonly in the 50’s (less than 65 years)

> Most common form of pre-senile dementia

> Frontal and temporal lobe atrophy> 1/3 to ½- genetic aetiology> Nature of the pathological changes vary-

pick body/ vacuolisation

Page 44: Different faces of Dementia
Page 45: Different faces of Dementia

FTD- clinical presentation

> Changes in behaviour: • impulsive, apathetic, socially disinhibited, lack

of empathy, judgement or insight, hypersexual, neglect, compulsive behaviours

> Problems with language: • including difficulty making or understanding

speech, often in conjunction with the behavioural type’s symptoms. 

Page 46: Different faces of Dementia

Dementia due to prion disease

> Rapidly progressive neurodegerative disorder

> Abnormal protein called prion> Sporadic, inherited or exposure to

infected material> Rapidly progressive decline, ataxia,

myoclonic jerks

Page 47: Different faces of Dementia

Dementia due to brain damage- other causes

> Head trauma- direct damage and increased predisposition to further degeneration

> Huntingtons disease: familial,hyperkinesia, dementia

> Parkinsons disease> Wilson’s disease> Leukodystrophies> Idiopathic basal ganglia calcification> Dementia due to mixed causation

Page 48: Different faces of Dementia

Evaluation of Dementia

> A thorough history• An assessment of each cognitive domain• Behavioral and neuropsychiatric symptoms• Degree of socio-occupational impairment

> A physical and neurological examination> Mental status examination> Bedside or detailed cognitive testing> Investigations

Page 49: Different faces of Dementia

ASSESSMENT

• Common tools to assist include:

• ADL (activities of daily living) and IADL (instrumental activities of daily living) checklists.

• Cognitive screens (MMSE, RUDAS, KICA – for Indigenous clients).

• Clock drawing test.

• Animal naming (1 Minute).

• Informal tests of frontal lobe functioning

Page 50: Different faces of Dementia

IMPACT ON FAMILY AND CAREGIVERS• Caregivers are at high risk for developing

psychological distress.

• The rates of depression and anxiety are increased compared with the general population.

• Anger and resentment are emotions commonly felt by caregivers.

• Reduced physical and mental health.

Page 51: Different faces of Dementia

MODEL OF EFFECTS OF DEMENTIA ON CAREGIVERS

Page 52: Different faces of Dementia

MANAGEMENT

• Consider both non-pharmacological and pharmacological management strategies.

• Base management on a detailed assessment of specific symptoms and contributing medical, psychological or environmental factors.

• Treat underlying medical causes such as infection, delirium, pain.

• Cease medications that are unnecessary, change medications that may aggravate the specific symptoms.

• Address environmental factors such as under or over stimulation.

Page 53: Different faces of Dementia

Role of medication

> Controversial> Consent> Safety- side effects, stroke, cardiac, Lewy

Body Dementia

Page 54: Different faces of Dementia

SUPPORT AVAILABLE

• Ideally it is best to assist the client to live as independently as possible in familiar surroundings, such as at home, whilst they can be managed with community support.

• Home and Community Care (HACC).

• Department Veteran Affairs (DVA).

• Community Aged Care Package (CACP).

• Extended Aged Care at Home (EACH).

• Extended Aged Care at Home-Dementia (EACH-D).

• Also consider psychosocial rehabilitation, Rapid Intensive Brokerage Service (RIBS) or Transition Care Package (TCP) (needs to be in or avoid hospital for RIBS and in hospital for TCP).

Page 55: Different faces of Dementia

Conclusion

> DEMENTIA is a • Complex neuropsychiatric illness• Multiple etiologies• Varied clinical manifestations• Requires detailed evaluation• Multidisciplinary management

Page 56: Different faces of Dementia