evaluation of the patient with dementia1747

8/12/2019 Evaluation of the Patient With Dementia1747

1/39

EVALUATION OF THEPATIENT WITH DEMENTIA

Jonathan T. Stewart, MDProfessor in Psychiatry

University of South Florida College of MedicineChief, Geropsychiatry SectionBay Pines VA Medical Center


2/39

DEMENTIA

A s y n d r o m e characterized by acqui red ,progress ive cognitive impairment

Affects 10% of individuals over 65Caused by at least 80 different diseases,many reversible

Unfortunately, the most common diseases (85

90%) are irreversibleDiagnosis will have prognostic and treatmentimplicationsA ll dem ented p at ien ts n eed a wo rk-up

and its mostly a good history


3/39

PRIMARY SYMPTOMS

ATTENTION

MEMORYPOSTROLANDIC (COGNITION) EXECUTIVE (FRONTAL/SUBCORTICAL)INSIGHT


4/39

PRIMARY SYMPTOMS

ATTENTION: clouded sensorium, delirium

MEMORY: forgetfulnessPOSTROLANDIC: aphasia, apraxia, gettinglostEXECUTIVE: poor judgment, disinhibition,abulia, urge incontinenceINSIGHT: anosognosia, catastrophicreactions


5/39

TWO TYPES OF DEMENTIA

Postrolandic

Frontal/subcortical


6/39

POSTROL NDIC

Memory deficits Aphasia Apraxia Agnosia

Personality more orless preservedMMSE valid

FRONT L SUBCORTIC L

Memory deficitsLoss of behavioral plasticityand adaptability, judgmentPersonality changes

Disinhibition Abulia

Urge incontinenceMMSE useless


7/39

THE REST OF THE

HISTORYTime course

Depressive symptomsPast medical history

Medical and psychiatric conditions

Family HxEtOHMedications (including OTC, OPM)


8/39


9/39

THE FOLSTEIN MMSE

Most studied and used of the

standardized examsQuick and easy to administerExcellent inter-rater reliability

Accurately measures the severity andprogression of Alzheimers disease Does n o t detect execut iv e d efic i ts a t

al l


10/39

BEYOND THE MMSE

ATTENTION: digit span or DLROW

MEMORY: 3 word recall, orientationPOSTROLANDIC: naming, praxis,calculations, intersecting pentagons

EXECUTIVE: contrasting programs,Luria figures, go-no go, controlled wordfluency, frontal release signs


11/39

LURIAS RECURSIVEFIGURES


12/39



13/39



14/39

THE GERIATRICDEPRESSION SCALE (GDS)

Good screen for most patients

Easy to administer and scoreFace- valid, so patients can fake goodor fake bad Valid for demented patients with anMMSE above about 12

Use DMAS or Cornell scale for severelydemented patients


15/39

THE REST OF THE WORK-

UPBasic labsThyroid function testsB12 (methylmalonic acid andhomocysteine if borderline)SerologyHIV, drug screen, others, as indicatedNeuroimaging study, usuallyLP or EEG, rarely


16/39

PLEASANT SURPRISES

DepressionIatrogenic (anticholinergics, sedatives,narcotics, H2 blockers, multiple meds)HypothyroidismB12 deficiency

Neurosyphilis Alcoholic dementiaNormal pressure hydrocephalusSubdural hematomaOthers


17/39

POSTROLANDIC

DEMENTIAS Alzheimers disease

Diffuse Lewy body disease


18/39

ALZHEIMERS DISEASE

Slowly, insidiously progressive

postrolandic dementia; executive sxsmuch laterNeurologic exam, labs, neuroimaging

studies unremarkableOften familial, especially in youngerpatients


19/39

ANTI-DEMENTIA DRUGS

May improve cognitive function, ADLs to amodest extent; often ineffective

Dechallenge if no meaningful benefitPossibly delay nursing home placementCholinesterase inhibitors may cause nausea,diarrhea, weight lossMemantine occasionally causes agitationTHESE A GENTS DO NOT SLOW THERA TE OF DECLINE


20/39


21/39

BEWARE!


22/39

DIFFUSE LEWY BODY

DISEASESecond most common dementia in

autopsy studiesCharacterized by Lewy bodiesthroughout the cortex

Non-familial2:1 male:female ratio


23/39

CLINICAL FEATURES

Postrolandic dementiaMore rapidly progressive than AD

Fluctuation, episodes of pseudodelirium common Mild parkinsonism

Tremor often absentPoor response to antiparkinsonian medsShy- Drager sxs common

Prominent psychotic sxs, esp visualhallucinations

SEVERE NEUROL EPTIC INTOL ERA NCE


24/39

FRONTAL/SUBCORTICAL

DEMENTIASVascular dementiaFrontotemporal dementia and Picks disease

Alcoholic dementiaHuntingtons disease, Wilsons disease, progressivesupranuclear palsy, late Parkinsons disease

AIDS dementia complex, neurosyphilis, Lyme diseaseNormal pressure hydrocephalus

Most head injuries Anoxia, carbon monoxideMultiple sclerosisTumorsANY ADVANCED DEMENTIA


25/39

TYPES OF VASCULAR

DEMENTIAMulti-infarct dementia

Small vessel diseaseLacunar state (gray > white)Binswangers disease (white)

Hemorrhagic vascular dementiaStrategic infarct dementiaDementia due to hypoperfusion


26/39

SMALL VESSEL DISEASE

At least 50% of all vascular dementia

Often coexists with MIDUsual vascular risk factors, especiallyHPT

Steady, not step-wise deteriorationRelatively more abulia than disinhibition


27/39

FRONTOTEMPORAL DEMENTIA

Relatively uncommon, non-familial

illnessProminent (macroscopic) atrophy offrontal and anterior temporal cortex

Symptoms include executive deficits,Klver-Bucy syndrome About 25% of pts have Pick bodies


28/39


29/39

BEHAVIORAL PROBLEMS INDEMENTIA

Present in 80% of cases

Major source of caregiver stress,institutionalizationCommon at all stages of the disease

Much more treatable than theunderlying dementiaPoorly described in the literature


30/39

WOOF.

MEDS OTHER


31/39

THREE BASIC PRINCIPLES

Simplicity

Limited goalsThe no -fail environment


32/39

THE CUSTOMERIS ALWAYS

RIGHT!


33/39

DEPRESSION

20- 30% incidence in Alzheimers

disease, often early in the course of theillnessMos t im po rtan t t reatab le caus e ofexc ess d isabi l i ty

Responds very well to treatment


34/39

ACUTE BEHAVIOR CHANGE

I atrogenic

I nfection I llness I njury I mpaction I nconsistency I s the patient depressed?


35/39

AGITATION

Present in up to 80% of patients

Up to 34% of patients are combativeFew predictorsProbably a very heterogeneous problem

Cornerstone of treatment isnonpharmacologic


36/39

EMPIRICALLY EFFECTIVEMEDS FOR AGITATION

Atypical neuroleptics (best when agitation isclearly related to delusions or hallucinations)

AnticonvulsantsTrazodoneBeta-blockersBuspironeBenzodiazepinesOthers


37/39

THE BEST NUMBER OFMEDICATIONS TO USE ISZERO (or sometimes one)

WHEN IN DOUBT, GET RID OFMEDICATIONS!


38/39

DONT FORGET SAFETYISSUES!

DRIVING

FIREARMSPOWER TOOLS

SMOKING IN BED

POISONS, MEDICATIONSFALL RISK


39/39

WOOF!

MEDS OTHER

GOOD LUCK!

evaluation of the patient with dementia1747

Documents