Dementia

DEMENTIA
• DEFINITION:
– Group of symptoms that can be caused by several
disorders
– Syndrome which refers to progressive decline in
intellectual functioning
– severe enough to interfere with person’s normal
daily activities and social relationships.
 Dementia
– Marked by progressive declines in
• memory.
• visual-spatial relationships
• performance of routine tasks
• language and communication skills
• abstract thinking
• ability to learn and carry out
mathematical calculations.
 Dementia
• A common problem in the US
– 5% of those over 65 have severe dementia,
– 15% have mild dementia
– 20% those over 80 have severe dementia
– One of first distinctions you must make is
reversible from nonreversible.
– Only about 10-15% are reversible
 Dementia
• Two Types:
– Reversible
– Irreversible
• effort must be made to have
intensive medical physical to rule
out reversible types of dementia.
 Irreversible dementias
• Alzheimer's
• Frontotemporal dementia –Picks disease
• Huntington's Disease-Autosomal dominant-
chorea and behavioral disturbance
• Dementia with Lewy bodies
• Vascular (DM, HPT, AFB, PVD)
• Leukoencephalopathies
• Parkinson's
• CJD- Creutzfeldt- Jakob disease-motor
rigidity and myoclonus
 Reversible dementias-examples
• Hypothyroidism
• Thiamine deficiency
• Vitamin B12 deficiency
• Normal-pressure hydrocephalus
• Subdural hematoma
• Chronic infection
• Brain tumor
• Drug intoxication
 Dementia
• Reversible:
– D= Drugs, Delirium
– E= Emotions (such as depression) and
Endocrine Disorders
– M= Metabolic Disturbances
– E= Eye and Ear Impairments
– N= Nutritional Disorders
– T= Tumors, Toxicity, Trauma to Head
– I= Infectious Disorders
– A= Alcohol
 Dementias -psychiatric
• Schizophrenia
• Conversion disorder
• Depression
 Vascular dementia
• Many small strokes
• Divided into two-Multi-infarct dementia and
Diffuse white matter disease (Binswanger’s
disease)
• focal neurologic deficits such as hemiparesis, a
unilateral Babinski sign, a visual field defect, or
pseudobulbar palsy, gait disturbance
• Urinary incontinence and dysarthria in
advanced disease
• Often mixed with Alzheimer’s dementia
Dementia-Lewy Body dementia

• Episodic confusion with intervals of lucidity with at

least one of the following:
1. Visual or auditory hallucinations
2. Mild extrapyramidal symptoms (muscle rigidity, slow
movements
3. Repeated unexplained falls
• Progresses to severe dementia—found at autopsy.
Dementia-FTP-Pick’s disease

 Pick’s bodies in cells.

 Personality changes
 Behavioral dis-inhibition.
 Loss of social or personal awareness.
 Disengagement with apathy
 Maintain ability to draw and calculate well into later
stages
 FTP..
• 25 times rarer than Alzheimer’s dementia
• Frontal lobe clinical features
• behavioral symptoms predominate in the
early stages
• Assymetrical frontal or temporal atrophy
• anatomic hallmark of FTD is a focal atrophy
of frontal, insular, and/or temporal cortex
 Case history: Pick's Disease
This 59 year old woman had a three year history of a
progressive alteration in social behavior which included
apathy and occasional disinhibition. Images reveal severe
focal shrinkage of temporal and frontal lobes bilaterally.
 Alzheimer's Disease
• Estimated that 4,000,000 people in U.S.
have Alzheimer's disease.
• Estimated that 25-35% of people over age
85 have some type of dementia.
• After age 65 the percentage of affected
people, doubles with every decade of life.
• Caring for patient with Alzheimer's disease
can cost $47,000 per year (NIH).
Changes Caused by Alzheimer's
• Diminished blood flow
• Neurofibrillary Tangles
• Neuritic Plaques
• Degeneration of hippocampus, cerebral
cortex, hypothalamus, and brain stem
Atrophic hippocampus in AD
 Compare central sulcus of
Alzheimer’s patient with normal
81 year old woman

From Whole Brain Atlas at http://www.med.harvard.edu/AANLIB/home.html

74 year old AD patient: reduced blood
flow on SPECT in temporal areas
 Normal vs AD Brain

Normal brain Alzheimer’s brain

 AD Prognosis
• Alzheimer’s has a slowly progressive
decline.
Function

Time
 Evaluation –Mini-Mental Status
examination
• The Mini-Mental Status Examination
• 30 Points
• Orientation
• Name: season/date/day/month/year
• Name: hospital/floor/town/state/count
• Identify three objects by name and ask patient
to repeat
• Attention and calculation
• Recall
 Drug treatment in Alzheimer’s
disease-FDA
• Many drugs aim to stimulate the cholinergic
system
• Inhibit acetycholinesterase so as to increase
cerebral acetylcholine levels
• These drugs have limited positive effects and
do not reverse the causes of AD
• Donepezil 10 mg daily
• Rivastigmine 6 mg twice daily
• Galantamine 24 mg daily
• Memantine 10 mg twice daily
 Huntington’s disease
• Huntington’s disease
– Rare: 5 in 100,000
– abnormal ‘exaggerated movements
– chorea
– -autosomal dominant disease
– Affects the basal ganglia
 Basal ganglia
• Caudate
• Putamen Striatum
• Globus pallidus
• Subthalamic nuclei
• Substantia nigra
 Viral dementia: HIV
• 20-60% of HIV patients suffers from
dementia
• Cerebral atrophy may be caused by
microglial nodules
• May result from opportunistic infection or
virus attacking brain cells
 End-stage Dementia
Prognosis < 6 mos:
• Severe dementia with need for total assistance in
ADLs (dressing, bathing, continence), unable to
walk, only able to speak a few words
• Comorbid conditions – aspiration pneumonia,
urosepsis, decubiti, sepsis
• Unable to maintain caloric intake with weight loss
of 10% or more in 6 months
 Complications from dementia
• Delusions in up to 50%, most with paranoia
• Hallucinations in up to 25%
• Depression, social isolation may also occur
• Aggressive behavior in 20-40% (may be related to
above problems, misinterpretation)
• Dangerous behavior – driving, creating fires,
getting lost, unsafe use of firearms, neglect
• Sundowning – nocturnal episodes of confusion
with agitation, restlessness
 Treatment of complications
• Hallucinations, delusions, agitation, sun-downing
may be improved with anti-psychotics like
haloperidol, risperdal
• If any signs of depression, may be beneficial to treat
• Anxiety may respond to benzodiazepines
• Behavioral mod – reinforce good behavior
• Don’t fight aggressive behaviour
• Familiarity (change in environments make things
worse)
• Safety – key locks, knobs off stoves, take away car
keys/cigarettes/firearms…, lights, watch stairs
• Avoid restraints, use human contact/music/pets/
distraction
 Dementia patients are very
sensitive to additional disabilities
• Illness
• Pain
• Medications
• Poor hearing
• Poor vision
Management of depression at end
of life
• Psychotherapy – behavioral, cognitive, and other
supportive approaches by psychologists, licensed
social workers, chaplains, even bereavement
counselors may help
• New coping strategies like meditation, relaxation,
guided imagery, hypnosis may help
• Medications - SSRIs, quetipine
 Other EOL care needs for dementia
• In bedbound, watch out for and prevent decubiti
• Feeding instructions to prevent aspiration – head
up, chin tucked, thick consistency foods like
pudding/jello/ice cream…
• Caregiver stress – difficult care, poor sleep,
education to prevent aggressive behavior, early
bereavement losing loved one before they are
gone, need for support/respite