Name:PROF[DR] SURESH R M,

HEAD OF THE DEPARTMENT

Brief Introduction

Photo • MD [INTERNAL MEDICINE],ACME

• DEPARTMENT OF GENERAL MEDICINE, HIMS, HASSAN,KARNATAKA
• NODAL OFFICER,ANTI RETROVIRAL THERAPY CENTRE
• NODAL OFFICER,NON-COMMUNICABLE DISEASES ,HASSAN
• CO-ORDINATOR FOR BOARD OF PG CLINICAL STUDIES,RGUHS[2021]
• TEACHING EXPERIENCE OF 25 YEARS
• NMC ASSESOR FOR UG AND PG SINCE 10 YEARS
• 15 PUBLICATIONS IN NATIONAL AND INTERNATIONAL JOURNALS
DEMENTIA-UPDATE
 CONTENTS

• INTRODUCTION
• EPIDEMIOLOGY
• CLINICAL FEATURES
• MANAGEMENT
• LATEST ADVANCES IN THE MANAGEMENT
• NATIONAL PROGRAMMES RELATED TO DEMENTIA
• CONCLUSION
 DEMENTIA: DEFINITION

• Dementia is a disorder that is characterized by a decline in cognition

involving one or more congnitive domains[learning and
memory,language,executive function,perceptual motor,social cognition].

• The deficits must represent a decline from previous level of function and
be severe enough to interfere with daily function and independence.
DSM 5 CRITERIA FOR MAJOR NEUROCOGNITIVE
DISORDER[PREVIOUSLY DEMENTIA]

Evidence of significant cognitive decline from a previous level of performance in

one or more cognitive domains
a.Learning and memory
b.Language
c.Executive function
d.Perceptual motor
e.Social cognition

The cognitive deficits interfere with independence in everyday activities.

DSM 5

The cognitive deficits donot occur exclusively in the context of a delirium

The cognitive deficits are not better explained by another mental disorder[eg, major
depressive disorder,schizophrenia]
 EPIDEMIOLOGY

• As per 2011 census,India is home to about 65 million people of age 65

and above constituting 5.5% of the total population.

• Prevalence of dementia in India is reported to be 2.7% .

• As age increase,prevalence of dementia increases.

• Mean age of presentation is relatively younger at 66.3 years in

India ,about 10 years lesser than in developed countries.
 Prevalence of different dementing
diseases
• Pure AD – 35%

• Vascular- AD (MIXED) – 15%

• DLB – 15%

• Pure VaD – 10%

• FTLD – 5 %
 SCREENING
• Screening of asymptomatic older adults for cognitive impairment is not
routinely recommended.
• The initial step in the evaluation of a patient with suspected dementia
should focus upon the history.
• Family members or other informants who know the patient well are
invaluable resources for providing adequate history
• Drug history is particularly important as many medications may impact
cognition in older patients.
 CLINICAL FEATURES
• Forgetfulness is the most common chief complaint; in addition ,they also
have difficulty with one or more of the following
a.Retaining new information
b.Handling complex task
c.Reasoning
d.Spatial ability and orientation
e.Language
f.Behaviour
 REVERSIBLE DEMENTIA – INDIAN STUDY

• A prospective study of reversible dementias: Frequency, causes, clinical

profile and results of treatment.
• Out of 124 dementia patients – 24 (18%) had reversible causes.
Neuroinfection – 11
NPH – 8
B12 def -5
• Most had subcortical pattern of involvement and substantial improvement
after treatment.

(Srikanth S et al, Neurology India;2005)

• Although degenerative and vascular etiologies from a major group of
dementias in elderly ,quite a few of them do present with reversible causes.

• A great deal of clinical suspicions is needed to identify them.

• Nutritional deficiencies,NPH,endocrine problems are the most common

common causes of reversible dementia.

-D chari et al,psychiatry India 2015

 Practice AAN guidelines
Evidence supports the following tests in the routine evaluation of the
demented patient:
• Complete blood cell count
• Serum electrolytes
• Glucose - BUN/creatinine
• Serum B12 levels
• Depression screening
• Liver function tests
• Thyroid function tests
 STRUCTURAL IMAGING
• The AAN practice parameter recommends, either CT or MRI ,be
performed at the time of initial assesment.
• While this recommendation was primarily suggested to exclude
reversible and treatable causes of dementia.
• MRI provides a much higher resolution than CT and has proven very
useful in the differential diagnosis and as a biomarker of
neurodegeneration in AD dementia.

-BRADLEY AND DAROFFS NEUROLOGY

Mild Cognitive Impairment : Predictors of
Progression

• APOE4 Carrier

• Atrophic Hippocampi on MRI

• CSF increased Tau and decreased aA (beta) levels

 Aims of treatment of dementia

(a) Disease modifying treatment

(b) Improving activities of daily living
(c) Psychotropic agents
(d) Care - givers management
(e) Risk reduction & other non pharmacological treatment
 DIPS: a structured approach to management of Dementia

• Dementia: treat the cause where possible

• Illness: treat concurrent illness

• Problem list: tackle each major problem

• Support the supporters: care for the carers

 CATEGORIES OF DEMENTIA
PHARMACOLOGY

• Symptomatic treatment of memory disturbance

• Symptomatic treatment of behavioral disturbance

 OBJECTIVES FOR THE MANAGEMENT OF
PROGRESSIVE DEMENTIAS-

– Preserving function, including physical, social, and self care skills

for as long as possible.

– Accessing preserved long-term memory for enjoyment and

validation.

– Maintaining patients in the security and familiarity of their own

homes for as long as possible.
 COCHRANE REVIEWS
• Donepezil [5-10 MG]– Review of 16 published trials suggest
clinical efficacy.

• Rivastigmine [1.5-6 MG] – Review of 7published trials suggest that

it appears beneficial in mild to moderate AD.

• Galantamine [4-12MG]– Review of 7 published trials suggest

beneficial effect in mild to moderate AD.
• Current evidence suggests the three Cholinesterase Inhibitors -have
similar efficacy at maximum recommended doses

• Patients with dementia of mild to moderate severity may be the most

likely to derive clinical benefit, which is typically modest and must
be balanced with the risk of adverse effects.

• Decisions should be individualized in patients with very advanced

dementia (eg, MMSE <5) at the time of diagnosis.

• The choice among donepezil, galantamine, and rivastigmine can be

based upon ease of use, individual patient tolerance, cost, and
clinician and patient preference, as efficacy appears to be similar.
 COCHRANE REVIEWS
MEMANTINE [5-20mg]
• Published data suggest a small beneficial effect at 6 months in
moderate to severe AD.

• Effect in mild to moderate AD is unknown.

• Beneficial effect on cognition in VD, not discernible at 6 months.

 REEVALUATE AT 6 MONTHS INTERVALS
1.Repeat scales performed at baseline.
2.Indicators to continue ACEI
a) patient improved or stable on current agent.
3.Indicators to switch to other agent
a)decline in MMSE(>2 POINTS)
b) decline in ADL or IADL.
4.Indicators to discontinue ACEI
a) persistent decline in MMSE and ADL or IADL.
b) intolerable side effects.
c)MMSE < 10 with dependency in all ADLs.
 VASCULAR DEMENTIA
• Cholinesterase inhibitors- The available evidence suggests that
this treatment may have a slight benefit on cognitive outcomes
that is of uncertain clinical significance.

• Memantine-Two studies have compared memantine 20 mg/day

with placebo in patients with mild to moderate VaD. These were
of short duration, 28 weeks. Benefit was seen on cognitive scales
but not on clinical global impression or activities of daily living.
• Agents that have inconclusive evidence of benefit in the prevention of cognitive
decline in VaD include nimodipine, ergot alkaloids, cerebrolysin , ginkgo
biloba, xanthine derivatives, cytidinediphosphocholine, and piracetam.

• Actovegin is licensed for poststroke cognitive impairment in some countries in

Europe and Asia, based on a trial showing more improvement in the ADAS-
Cog at six months.

• None of these therapies are recommended at this time.

 PARKINSONS DISEASE DEMENTIA

• Cholinesterase inhibitors-Most, but not all, studies of

cholinesterase inhibitors in PDD have noted a mild to moderate
benefit but an increased risk of side effects, including worsened
tremor and nausea.

• Memantine-One randomized controlled study found that patients

treated with memantine performed better on the primary outcome
assessment measure, the clinical global impression of change, but
not on other secondary outcome measures
 DEMENTING DISEASE INTERVENTION

ALZEIMERS DISEASE AChE – Is, antioxidants

VASCULAR DEMENTIA Antihypertensive, AchE I , stroke prevent

FRONTOTEMPORAL DEMENTIA SSRIs ?

DEMENTIA WITH LEWY BODIES AChE Inhibitors, Antiparkinsonian

medications

PARKINSONS DISEASE DEMENTIA AChE Inhibitors, Antiparkinsonian

medications

WILSONS DISEASE Pennicillamine, Zinc

HUNTINGTONS DISEASE Phenothiazines, tetrabenzaine

DEMENTIA DUE TO INFECTIONS Appropriate antibiotics

TOXIC DEMENTIA Limitation of exposure to toxins

HEAVY METAL POISONING Chelation, removal of source

METABOLIC DEMENTIAs Treatment of underlying ds

DEMENTIA OF DEPRESSION Antidepressants, ECT

HYDROCEPHALIC DEMENTIA Shunt

POST TRAUMATIC DEMENTIA Surgery for SDH

NEOPLASTIC DEMENTIA Surgery, chemo or radiotherapy

MULTIPLE SCLEROSIS Interferon beta, glatiramer

 NATIONAL PROGRAMME FOR HEALTH
CARE OF THE ELDERLY[NPHCE]

• The ministry of health and family welfare had launched the NPHCE
during 2010-11 to address various health related problems of elderly
people.

• The population over the age of 60 years has more than 60 years has more
than tripled in last 50 years in India.
 EXPECTED OUTCOMES OF NPHCE
• Establishment of Department of Geriatric Medicine in selected 19 Medical Colleges
Sanctioned as Regional Geriatric Centres (RGC) with a dedicated Geriatric OPD and
30-bedded Geriatric ward for management of specific diseases of the elderly,
conducting trainings of health personnel in geriatric health care and pursuing
research.

• Post-graduation in Geriatric Medicine (two seats) in each of the 19 Regional

Geriatric Centres.

• District Geriatric Units with dedicated Geriatric OPD and 10-bedded Geriatric ward
Rehabilitation/Physiotherapy Services in all District Hospitals.
• OPD Clinics/Rehabilitation units including domiciliary visits at CHC, PHC & HWC.

• Health & Wellness Centres/Sub-centres provided with equipment for community
outreach services for Elderly.

• Training of Human Resources of Public Health Care System for provision of quality
Geriatric Care.

• Convergence with National Rural Health Mission, AYUSH and other line
departments like Ministry of Social Justice and Empowerment
 ALZHEIMERS DISEASE SOCIETY OF
INDIA [ARDSI]
• Kerala became the first state to launch a state wide dementia initiative in
2014.

• The society used a public-private partnership model linking various

government departments with ARDSI.

• It has several components including creating dementia awareness among

all sections of society,establishing memory clinics ,opening care homes
and day care centres in all districts for dementia and so on.
 CURRENT STRATAGIES
• Community based primary health care approach including domiciliary
visits by trained health care workers.

• Dedicated services at PHC/CHC level including provision of machinery,

equipment,training, additional human resources (CHC), IEC, etc.

• Dedicated facilities at District Hospital with 10 bedded wards, additional

human resources, machinery & equipment, consumables & drugs,
training and IEC.
• Strengthening of Regional Geriatric Centers to provide dedicated tertiary
level medical facilities for the Elderly, introducing PG courses in
Geriatric Medicine, and in-service training of health personnel at all
levels.
• Information, Education & Communication (IEC) using mass media, folk
media and other communication channels to reach out to the target
community.
• Continuous monitoring and independent evaluation of the Programme
and research in Geriatrics and implementation of NPHCE.
 CONCLUSION
• The first step in management of dementia is accurate diagnosis.

• It is important to limit polypharmacy and avoid medications that can

affect cognition.

• Medications list should be reviewed periodically for necessity and

new drugs should be prescribed with caution.

• To focus on the objectives of NPHCE to facilitate better geriatric care

 REFERENCES
• Harrisons principles of internal medicine 21st edition.
• Bradley and Daroff neurology in clinic al practice 8th
edition.
• Uptodate.
• AAN guidelines.
• National health portal.
THANK YOU……