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Geriatric Dementia
Geriatric Dementia
An 83-year-old woman is brought to the clinic by her husband who was concerned with
his wife’s memory problems. He first noticed some memory decline a few years ago, but
the onset was subtle and did not interfere with her day-to-day activities. Mainly, she has
some difficulty remembering details, is repeating things, and is being forgetful. The
patient’s family noticed her gradually increasing memory problems, particularly over the
past year. She is unable to remember her appointments and relies heavily on written
notes and appointment books. Recently, she got lost while driving and was found by her
family 10 hours later. She was unable to use her cell phone and was unsure about her
home address and phone number. She has also become more reclusive. She does not
enjoy her church activities anymore and prefers to stay at home most of the time. She
does not want to cook, and she is less attentive to her housework. The patient says that
she has always been forgetful. Her medical history is significant for well-controlled
hypertension and a history of mastectomy secondary to breast cancer diagnosed 20
years ago. She has no significant history of tobacco or alcohol use. She is independent
with all activities of daily living, but needs assistance with medication administration,
banking, and transportation. She is up-to-date with her health maintenance and
immunization. Her vital signs and general physical examination are normal.
What laboratory testing and imaging studies are indicated at this time?
ANALYSIS
Objectives
1. Develop a differential diagnosis for dementia.
2. Learn how to appropriately evaluate a complaint of memory loss.
3. Learn about treatment of Alzheimer dementia, the most common specific
diagnosis of dementia.
Considerations
This 83-year-old woman is noted by her family to have progressive decrease in
cognitive function. She is forgetful, gets lost easily, and this has been slowly but steadily
worsening. The most likely diagnosis is dementia; however, other conditions should be
considered in the differential diagnosis such as medications, stroke, thyroid disorders,
chronic syphilis, or other metabolic conditions. Depression can also present as
dementia at times. The workup for this patient includes a careful history and physical
examination, imaging of the brain, and selective laboratory tests such as TSH, vitamin
B12 level, complete blood count (CBC), and comprehensive metabolic panel. Screening
for syphilis should also be considered.
APPROACH TO:
Dementia
DEFINITIONS
EXECUTIVE FUNCTIONS: High-level cognitive abilities that control other, more basic,
abilities. Executive functions include the ability to start and stop behaviors, alter
behaviors to fit circumstances, and adapt behaviors to new situations.
CLINICAL APPROACH
The essential features of the diagnosis of dementia are memory loss and impairment of
executive function. Dementia is a clinical diagnosis that can go unrecognized until it is in
an advanced stage. Patients rarely report memory loss; the informants are usually their
family members. However, relatives may fail to recognize signs and symptoms of
dementia because many have a tendency to think that memory loss can be a part of
normal aging. Studies of aging have shown that nonverbal creative thinking and new
problem-solving strategies may decline with age, but information, skills learned with
experience, and memory retention remain intact.
Clinicians should assess cognitive function whenever cognitive impairment or
deterioration is suspected. These concerns may be based on direct observation, patient
report, or concerns raised by family members, friends, or caretakers. Patients with
dementia may have difficulty with one or more of the following:
Learning and retaining new information (rely on lists, calendars)
Handling complex tasks (banking, bills, payments)
Reasoning (adapting to unexpected situations, unfamiliar environment)
Spatial ability and orientation (getting lost driving, walking)
Language (word finding, repetition, confabulation)
Behavior (agitation, confusion, paranoia)
The evaluation of a patient with suspected dementia should include a mental status
examination. The Folstein MMSE is the most widely used tool in the screening for
dementia. The sensitivity of the MMSE for dementia is as high as 87% and the
specificity is as high as 82%. The interpretation of the score depends on the patient’s
education level. It is most accurate in those with at least a high school education.
Another valuable test that can be used in a busy primary care setting is the Clock
Test. The patient is asked to draw a clock with a specific time. The patient must then
accurately draw the clock face with the “big hand” and “small hand” in the correct
positions. It is quick, easy to administer, and evaluates executive function in multiple
cognitive domains. Other brief cognitive screening tests, such as the Short Portable
Mental Status Questionnaire, modified MMSE, MoCA, and Mini-Cog (three-item recall
combined with clock drawing) can be used in the primary care setting.
In the evaluation of dementia, it is necessary to get information from people who
know the patient well. Useful information can be obtained from informant-based
functional tests, such as the functional activities questionnaire (FAQ), the instrumental
activities of daily living (IADL), and caregiver burden assessments. This information can
be important for physicians and families in making plans for long-term care. See Case
18 (Geriatric Health Maintenance) for more on functional assessment.
ALZHEIMER DISEASE
Alzheimer disease is the most common cause of dementia. Although a definitive
diagnosis can only be made by the presence of neuritic plaques and neurofibrillary
tangles detected on autopsy, clinical diagnostic criteria have been developed (Table
32–1). Common diagnostic criteria include the gradual onset and progression of
cognitive dysfunction in more than one area of mental functioning that is not
caused by another disorder.
No disturbances of consciousness
The initial evaluation includes a detailed history, from both the patient and another
informant (usually a spouse, child, or other close contact) and complete physical and
neurologic examinations to evaluate for any focal neurologic deficit that may be
suggestive of a focal neurologic lesion. A validated test, such as the MMSE, should
be used to confirm the presence of dementia. The results of this test can also be
used to follow the clinical course, as a reduction in score over time is consistent with
worsening dementia.
A focused evaluation to rule out other causes of dementia must be performed as well.
The physical examination should focus on neurologic deficits consistent with prior
strokes, signs of Parkinson disease (eg, cogwheel rigidity and/or tremors), gait
abnormalities or slowing, and eye movements. Patients with Alzheimer disease
generally have no motor deficits at presentation.
Depression in the elderly can present with symptoms of memory disturbance.
This is known as “pseudodementia.” As depression is common and treatable, a
screening test for depression should be performed when dementia is evaluated.
Similarly, hypothyroidism and vitamin B12 deficiency are common and treatable
conditions that can cause cognitive problems. TSH and vitamin B12 levels should be
performed as a routine part of the workup. Neurosyphilis could present in this fashion,
but is such an uncommon diagnosis that routine screening would not be recommended.
Evaluation for neurosyphilis would be warranted if there were identified high-risk factors,
history of the disease, or if the patient lived in an area with a high prevalence of syphilis.
Neuroimaging with either a noncontrast CT scan or an MRI of the brain is
recommended to rule out other confounding diagnoses. Other testing, such as positron
emission tomography (PET), genetic testing, and spinal fluid analysis are not routinely
recommended. Referral to neurology is appropriate when diagnosis is uncertain.
When the diagnosis of Alzheimer disease is made, a comprehensive care plan should
be initiated. ◦Durable Power of Attorney for Health Care
(documents surrogate decision-maker), usually requires
attorney
Health care proxy – legal form that names your
surrogate decision-maker (no attorney)
Table 32–2 lists the medications that are primarily used in the treatment of Alzheimer
disease. Family members should understand that the medications may delay the
progression of the disease but may not reverse any decline that has already
occurred. For that reason, the medications may be more beneficial if started earlier in
the course of the disease.
Antipsychotic medications have also been used to control hallucinations and agitation
in patients with Alzheimer disease. However, this is an “off-label” use of medication and
data show a higher death rate associated with the use of the newer antipsychotics. The
Food and Drug Administration (FDA) has placed a black box warning against the use of
typical and atypical antipsychotic medications for dementia-related psychosis due to the
increased risk of deaths. Herbal medications such as Ginkgo biloba and huperzine A
have inconsistent evidence for efficacy, but appear to be safe alternatives. These
should not be used with prescription medications due to potential interactions.
Behavioral interventions also may be beneficial. These can include scheduled
toileting in an effort to reduce episodes of incontinence, writing reminder notes, keeping
familiar objects around, providing adequate lighting, and making duplicates of important
objects (eg, keys) in case they get lost. Caregivers also need support and may benefit
from appropriate training, support groups, and periodic respite care.
Unfortunately, even with the best of care, Alzheimer disease is relentless and
progressive. Families may have significant difficulties and conflicts regarding issues
surrounding end-of-life care and placement in assisted living or nursing homes.
Resources such as local chapters of the Alzheimer Association (www.alz.org) may
provide valuable services, information, and support.
VASCULAR DEMENTIA
Vascular dementia, or multi-infarct dementia, is the second most common cause of
dementia. In vascular dementia, there is neuronal loss as a consequence of one or
more strokes. The symptoms are related to the amount and location of the
neuronal loss. Vascular dementia can exist along with Alzheimer disease or other
causes of dementia, resulting in a mixed-dementia syndrome. Unlike Alzheimer
disease, which is a gradually progressive process, vascular dementia often has a
sudden onset and progresses in a stepwise fashion. Patients tend to function at a
certain level and then show an acute deterioration when the initial, or subsequent,
infarcts occur. The risk factors include those for cerebrovascular disease (hypertension,
tobacco use, diabetes, etc). There are no controlled trials showing medication
effectiveness in vascular dementia, so the treatment is aimed at reducing the risk of
further neurologic damage.
DELIRIUM
Delirium is an acute change in mental status that is characterized by fluctuations
in levels of consciousness. It is usually caused by an acute medical illness, the use of
a medication, or the withdrawal from a drug or alcohol. Delirium affects 10% to 30% of
hospitalized patients, with a higher incidence in the elderly, in those with an underlying
dementia, and in those with multiple underlying medical conditions. The treatment of
delirium is treatment of the condition that precipitated it. Delirium is often reversible
if the underlying cause can be found and aggressively managed. Patients with delirium
have significantly longer hospital stays and increased mortality rates.
CASE CORRELATION
COMPREHENSION QUESTIONS
ANSWERS
CLINICAL PEARLS
The presentation of acutely altered mental status (delirium) should prompt an
aggressive workup for an underlying cause, as treatment may result in correction
of the mental status.
Alzheimer disease is a disease of the family, not just the individual. It is critical to
treat the patient while giving support to the caregivers.
REFERENCES
Alzheimer’s Association website: www.alz.org. Accessed November 7, 2015.
American Geriatric Society website: www.americangeriatrics.org. Accessed November 7,
2015.
Cardarelli R, Kertesz A, Knebl JA. Frontotemporal dementia: a review for primary care
physicians. Am Fam Physician. 2010 Dec 1;82(11):1372-1377.
Neef D, Walling AD. Dementia with Lewy bodies: an emerging disease. Am Fam Physician.
2006;73(7):1223-1230.
Seeley WW, Miller BL. Dementia. In: Kasper D, Fauci A, Hauser S, et al., eds. Harrison’s
Principles of Internal Medicine. 19th ed. New York, NY: McGraw-Hill; 2015. Available at:
http://accessmedicine.mhmedical.com. Accessed May 25, 2015.
Simmons BB, Hartmann B, Dejoseph D. Evaluation of suspected dementia. Am Fam
Physician. 2011 Oct 15;84(8):895-902.