SECONDARY PREVENTION STRATEGY

EARLY DETECTION & TREATMENT OF

DEMENTIA
SENSITIZATION OF PHYSICIANS & SPECIALISTS

Prof DR.B.P.SHELLEY,MBBS,MD,DM,FRCP Edin

DEPARTMENT OF NEUROLOGY
FATHER MULLER MEDICAL COLLEGE

AT A GLANCE - OVERVIEW
Why sensitisation of physicians & specialists? Physician
Awareness Studies
Dementia syndromes : (1) Is it dementia? (2) If it is dementia,
what sort of dementia is it? (3) Which specific dementia is it?
MCI clinical concept
Clinical Assessment & Brief Cognitive Testing
Treatment Issues
Learning Points

PHYSICIAN AWARENSS STUDIES

Can Fam Physician 2009; 55:506-507. e1-5
Knowledge, Attitude, Behaviour-related barriers

Can Fam Physician 2009; 55:508-509. e1-7

Low Diagnostic confidence; Management of dementia: suboptimal

Arch Intern Med 2000; 160:2964-2968

Recognition rate-33%; Knowledge, Attitude, Behaviour-related barriers

Fam Practice 2007; 24:616-621

GP Diagnostic confidence: 58%

Great variation in Adherence International/European guidelines

Wide gap: guidelines and practice; early diagnosis of dementia not a reality

DEMENTIA SYNDROME
Operational Criteria

Dementia is NOT memory complaints alone

Multiple Cognitive Domains involved
Cognitive dimension
Non-Cognitive/Neurobehavioural Domain: Non-Cognitive
Behavioural Symptoms/ BPSD
Functional Domain: ADLs/ QOL
Decline in occupational, social functioning
Exclude delirium
NEVER ALZHEIMERIZE DEMENTIA: The diagnosis of
dementia is a complicated enterprise

DSM IV CRITERIA FOR DEMENTIA

IS IT DEMENTIA?

WORRIED WELL
DEPRESSION / PSYCHIATRIC DISORDER
PRIMARY NEURODEGENERATIVE DEMENTIA
MILD COGNITIVE IMPAIRMENT
AMNESTIC & NON AMNESTIC
MULTIPLE COGNITIVE
MISCELLANEOUS GROUP
EARLY ONSET DEMENTIA
RAPIDLY PROGRESSIVE DEMENTIA
REVERSIBLE DEMENTIAS
SECONDARY DEMENTIAS
NEUROLOGICAL DISORDERS
MEDICAL DISORDERS

IS IT DEMENTIA?
MEMORY COMPLAINTS
& DEMENTIA WORKUP
DELIRIUM

PSEUDO
DEMENTIA

MCI

DEMENTIA

IF IT IS DEMENTIA,WHAT SORT OF DEMENTIA IS IT?

CORTICAL
DEMENTIA

SUBCORTICAL
DEMENTIA

DEMENTIA CATEGORIZATION
CLASSIFICATORY SYSTEMS
Burden of
neuropathology

Age of Onset

Cortical dementia (AD,

FTD)

EOD /YOD
(age<65yrs)

Subcortical dementia
(HIV dementia, HD,
PDD, PSP)

LOD
(age>65yrs)

Mixed dementia DLB,

CBS, FTLD, VaD
(VaD +AD, DLB +AD)

Aetiology
Primary dementia
Neurodegenerative dementia
Potentially Reversible dementias
Secondary dementia:
(a) Associated with general
medical disorders
(b) Associated with other
neurological disorders
Depression associated dementia

WHICH DEMENTIA IS IT?

TYPES OF DEMENTIA

Late onset dementia: Lobo A

Neurology 2000; 11 Suppl 5:S4-9

EOD/YOD
Young onset dementia: Harvey RJ JNNP 2003;74:1206-9

EOD vs. LOD

PATTERN RECOGNITION
SPECIFIC TYPES OF DEMENTIA
International
Criteria

Surrogate markers:
Neuroimaging markers
Biomarkers

Neuropathologic
Criteria

PATTERN RECOGNITION & CRITERIA BASED

SPECIFIC DEMENTIAS
AD: Episodic memory (Medial temporal lobe) + Parietal deficits, LOD:
NINDS-ADRDA Criteria
VaD: Abrupt onset, stepwise decline, dysexecutive deficits, CVD, VRF,
EOD/LOD: NINDS-AIREN; HIS
FTLD: Behavioural dementia, Frontal dysexecutive defiicts, Language related
dementia; EOD: Neary, Lund Manchester Consensus Criteria;
Work Group on FTD & Picks Disease
DLB: (Between AD, delirium, PD); Delirium like picture (Fluctuating levels of
consciousness, Fluctuating cognitive deficits, EPS, Hallucinations, Systematized
delusions), Syncope, Unexpected falls, Neuroleptic hypersensitivity):

McKeiths DLB Consortium Criteria

REVERSIBLE DEMENTIAS
How to identify them?
Imperative for clinicians to differentiate potentially
treatable, reversible dementia from the largely untreatable
neurodegenerative dementias
Potentially reversible- may not be cured, but can be
modified addressing the underlying aetiologies
The reported frequency of reversible dementia in literature
varies from 2 to 30% . Recent studies: 8% from Brazil,
Indian estimates:18 to 38%
A heightened awareness of reversible dementia would
provide focus for its early detection

REVERSIBLE DEMENTIAS

Potentially reversible dementias: 9%

Vitamin B 12 deficiency; NPH

Hypothyroidism; HIV-associated dementia;
ARD; Neurosyphilis

RAPIDLY PROGRESSIVE DEMENTIAS

SECONDARY
DEMENTIAS

MCI CONCEPT
MCI REVISED CRITERIA
Presence of cognitive complaints from either the subject
and/or family member
Decline in any area of cognitive function, demonstrable
deficit on cognitive tasks [>1.5 SD below normal; matched
for age/level of education]
Absence of dementia
A change from normal functioning
Preserved overall general function but possibly with
increasing difficulty in the performance of ADL

MCI- TRANSISTION STAGE

CLINICAL
APPROACH

FOCUSSED EXAMINATION TO
POSSIBLE DEMENTIA
History taking
Multiple cognitive deficits = Memory PLUS (aphasia,
apraxia, agnosia, dysexecutive deficits). EXCLUDE
delirium
Focussed neurological/physical examination; Screening for
BPSD/NCBS; Screening for ADLs
Formal Cognitive assessment: Problem-oriented screening
approach / Non-problem oriented screening
Rating Scales (MMSE, ACE, ADL, NPI, HADS, GDS)
International Criteria
Evidence based/Practice guidelines: Investigation protocol

HISTORY

SECONDARY DEMENTIA
NEUROLOGICAL EXAMINATION

SECONDARY
DEMENTIA
SYSTEMIC CLUES

ABC; DEMENTIA ASSESSMENT

COGNITIVE TESTING
ADL
FUNCTIONAL
DOMAIN
CDR
BADL
IADL
EASI

BPSD/NCBS
BEHAVIOURAL
DOMAIN
HADS
GDS
NPI
CBI

COGNITIVE
DOMAIN

MMSE
ACE
WMS
RAVLT

BRIEF COGNITIVE TESTING

Orientation (Time & Place)
Attention: Digit Span: Forward & Backward; Serial 7s;
Months of the year backwards
Language: Spontaneous speech; Comprehension, Naming;
Reading; Writing
Memory (Verbal & Visual)
Praxis: Meaningful and meaningless gestures, Luria 3 step
test (fist-edge-palm)
Visuospatial: Clock drawing, and overlapping pentagons
Executive function: Letter fluency; Abstraction, Similarities,
Interference, Inhibition (Go-No-Go test), Set shifting,
Cognitive estimates

MMSE

ADDENBROOKES COGNITIVE
EXAMINATION
MMSE TEST ITEMS
MEMORY
Anterograde & Retrograde memory, Free Recall,
Recognition memory
VERBAL FLUENCY
Letter & Animal fluency
LANGUAGE
Repetition, Naming, Comprehension, Reading
VISUOSPATIAL

INTERSECTING PENTAGONS & CLOCK DRAWING

TESTS: AD PROFILE

CDT

CDT & INTERSECTING PENTAGONS

MMSE 29/30

MMSE 12/30

LABORATORY & IMAGING

INVESTIGATIONS

MRI; DEMENTING SYNDROMES

EEG
PRIONOPATHY: CJD

KF SYNDROME

HD

DOES HE HAVE AD?

FTLD

WM DISEASE

VaD

B12 Leucoencephalopathy

WILSONS DISEASE

GOALS OF TREATMENT
Pharmacological treatment of cognitive symptoms
Non-pharmacological treatment of non-cognitive behavioural
symptoms (NCBS / BPSD): Bio psychosocial Model
Pharmacological treatment of non-cognitive behavioural symptoms
Caregiver Issues: Caregiver education/training programs; support
groups; respite; reducing caregiver burden
Strategy of treatment: To improve cognitive symptoms; To
ameliorate non cognitive problem/ disruptive behaviours; To
improve overall functional performance & QOL
Reinforce primary preventive strategies & life style modification

TREATMENT: end points

Outcome Measures: Instruments to measure
TREATMENT OUTCOME with respect to
Cognition = ADAS Cog; MMSE; ACE
Behaviour = ADAS Non Cog; NPI; CBI
Functional domain = BADL+IADL ; EASI
= CIBIC; Caregiver
= CIBIC Plus
= CGI-S; CGI-I
= GDS

ChEI - INDICATIONS

Specific Types: AD, VaD, DLB

MMSE < 24; With treatment MMSE should not < 12
Improvement to ChEIs: ADAS-Cog 4 points; MMSE 2 points
Regular assessments every 6 months
Optimize doses of ChEIs
Adequate duration of treatment
Switching therapy
Moderate to Severe AD (MMSE < 12): Donepezil + Memantine
combination therapy

BEHAVIOURAL PROFILE

TREATMENT: BPSD

NON-PHARMACOLOGICAL
MUSIC THERAPY
SOCIAL INTERACTION
VIDEOTAPES (FAMILY
MEMBERS)
BRIGHT LIGHT
WALKING/LIGHT EXERCISE
AROMATHERAPY
MULTISENSORY
STIMULATION
ANIMAL-ASSISTED THERAPY
MASSAGE

PHARMACOLOGICAL
ChEIs
ATYPICAL ANTIPSYCHOTICS
BLACK BOX WARNING
VALPROATE,
CARBAMAZEPINE
GABAPENTIN
SSRIs

REINFORCE
PRIMARY PREVENTIVE STRATEGIES

Timing of Primary preventive strategies: MID-LIFE

Vascular risk factors (VRF): Hypertension, Diabetes
mellitus, Visceral Obesity, Metabolic syndrome
Life style risk factors: Increase physical activity;
regular exercise; Increase cognitive activity; Increase
social engagement; Healthy dietary modifications;
Treatment of Depression

Multivariate mixed random

effects regression model of
MMSE progression over time
in patients with AD without
CVD

PREVENTIVE NEUROLOGY
Shifts in thinking about classification of dementia- AD
& VaD: Continuum of cognitive impairment with
similar risk factors; common coexistence and probable
interaction of cerebrovascular and Alzheimer disease
on the moving background of aging

LEARNING POINTS
Dementias: Spectrum of heterogeneous, multifaceted syndrome
of cognitive, non cognitive behavioural, functional decline
Pattern recognition: Familiarity with International Criteria
It is worth remembering that EOD is gaining recognition, in
addition to the strongly age- related LOD
Early detection & Recognition by Physicians & Specialists:
National Dementia Strategy; Clinical Practice Guidelines
Dementia: NCBS / BPSD (Awareness, Recognition,
Management)
Outcome measures: Cognition, Behaviour, Functional
Familiarity with MCI concept & operationalisation

LET US NOT FORGET THE FORGETFUL;

THERE IS HOPE