lecture 7_Dementia the basics (intro).pptx
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The document provides a comprehensive overview of dementia, covering its definition, types, early symptoms, and management approaches. It differentiates between normal aging-related cognitive decline and various forms of dementia, including Alzheimer's disease and vascular dementia, and emphasizes the importance of diagnosis based on cognitive functional impairments. Additionally, it discusses treatment options, including medications and non-pharmacological strategies, and highlights the growing prevalence of dementia among the elderly population.
lecture 7_Dementia the basics (intro).pptx
- 1. Dementia: the basics Dr Doha Rasheedy Professor of Geriatrics and Gerontology Ain Shams University
- 2. objectives • The definition of dementia and other types of cognitive impairment • Treatable causes of dementia • To differentiate types of dementia • To identify Early symptoms and signs of dementia • Management approach for cognitive decline
- 3. Introduction We need to answer 3 important questions first Is it all about memory? Can other cognitive domains be affected in dementia? If yes what is meant by cognitions and cognitive domains? Is memory impairment normal in older adults? If no then what is normal aging process in memory?? Are all dysfunctions in cognition considered dementia? If no what other types of cognitive impairment we can deal with in older adults?
- 4. First Q Is it all about memory? Can other cognitive domains be affected? If yes what is meant by cognitions and cognitive domains?
- 5. What is cognition?? What are the cognitive domains?? Cognition: the collection of mental processes and activities used in perceiving, learning, remembering, thinking, understanding and the act of using these processes Complex attention Executive function Learning and memory Language Perceptual motor Social cognition
- 6. •Normal ageing is associated with cognitive decline but not dementia. •What are the age related changes? •How to differentiate from dementia? Q2 Is memory impairment normal in older adults? If no then what is normal aging process in memory??
- 7. AGING of COGNITION Structural changes of CNS Altered cognitive performance Cognitive abilities stay about the same until the late 50s or early 60s, at this point they begin to decline, but to only a small degree. The effects of cognitive changes are not usually noticed until the 70s and beyond
- 8. Structural changes Clinical impact CNS • ↓ loss of cells in certain areas with morphologic cellular changes (brain atrophy) • changes in hormonal neurotransmitters ( ACH) ↓ • ↓synaptic transmission esp. cholinergic Leading to • ↓ nerve conduction velocity • ↓ in speed of reaction time ↓Cognitive functions • ↓Divided attention • ↓Short term (working memory) • ↓Fluid intelligence • ↔ Or crystallized ↑ intelligence. ↑ Motor response time ↓percepto- motor performance
- 9. Q3 Are all dysfunctions in cognition considered dementia? If no what other types of Cognitive impairment we can deal with in older adults?
- 10. Check these scenarios first!
- 11. You are always misplacing your glasses, lecture notes, and your keys. You always struggle to find them. Sometimes you end finding your glasses on your eyes, your lecture notes left behind at the photocopy office, and if you were lucky your keys would be left in the fridge as usual…………………… Do you have dementia??? What is wrong with you??? How you can be assured you are ok???
- 12. Your father seems to misplace objects, forget which day is today. He always remembers these things very soon. He is a successful engineer currently working on a huge challenging project with successful results. Does your father have dementia? Does he have to worry?
- 13. Your friend’s father who works as an accountant started to have problems with parking his car a year ago, he started to use calculators more often, he had to work extra hours to compensate his delayed performance caused by fatigue and stress, last week the bank management discovered many serious problems in his work after which he had a car accidents for the third time this year. Does he have dementia? What if you know his memory is perfect? Does he have to worry?
- 14. The spectrum of cognitive decline in elderly Dementia Mild cognitive impairment Subjective memory loss Normal ageing of cognition
- 15. Age related cognitive decline Much milder symptoms Not substantially progressive Does not impair function Normal Aging Does Not Impair Elderly Functions But Dementia Does
- 16. Mild cognitive impairment (MCI) It represent a transitional state between normalcy and dementia. 10-15% progress to dementia each year Either amnestic or non-amnestic MCI No functional impairment • Some cases may not progress to Dementia.
- 17. Other differential diagnosis (depression, delirium)
- 18. What is Dementia? Dementia is an acquired, persistent, and progressive impairment in intellectual function, with compromise in one or more cognitive domains, not resulting from impairment of level of consciousness. The diagnosis of dementia requires a significant decline in function that is severe enough to interfere with work or social life.
- 19. The most commonly affected cognitive domains include: Learning and Memory (e.g. free recall, cued recall) Aphasia (e.g. word-finding difficulty) Apraxia (inability to perform motor tasks, such as cutting a loaf of bread, despite intact motor function) Agnosia (inability to recognize objects despite intact sensory function) Impaired executive function (poor abstraction, mental flexibility, planning, and judgment).
- 20. Diagnostic Criteria For Major Neurocognitive Disorder (DSM 5) A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual–motor, or social cognition) based on: 1. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. B. The cognitive deficits interfere with independence in everyday activities (that is, at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications). C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder.
- 21. Severity of dementia • Mild: Difficulties with instrumental activities of daily living (e.g., housework, managing money). • Moderate: Difficulties with basic activities of daily living (e.g., feeding, dressing). • Severe: Fully dependent.
- 22. MILD Moderate Severe MMSE 22-26 MMSE10-21 MMSE 0-9 Disoriented to date Disoriented to date and places (get lost in familiar places-wandering) Impaired recent recall Impaired new learning and calculation Impaired remote recall Anomia aphasia Unintelligent verbal output (echolalia,palalalia) Mood,↓insight,irritability ,soci al isolation Agitation, depression anxious Verbal or motor agitation Assisted or independent Assisted or dependent Incontinent Finances problem No cooking or shopping, impaired dressing and grooming Loss of dressing and grooming Can’t copy design
- 23. Progression of dementia: According to type
- 24. How common is dementia??? Dementia affects only 1% of people aged 60 to 64 but affects 30 to 50% of those > 85.
- 25. Classification of dementia syndromes over 70 different causes of dementia reversible, partially reversible and irreversible or treatable and untreatable dementia.
- 26. 1- Degenerative disorders : Cortical (Alzheimer’s disease, pick’s disease). Subcortical (Parkinson’disease ). Cortical and subcortical (Lewy body dementia). 2- Vascular dementias (Lacunar state, Binswanger’s disease). 3- Traumatic conditions . 4- Neoplastic dementias . 5- Inflammatory conditions (vasculitis / sarcoidosis). 6- Toxic conditions (Alcohol, drug abuse, metals). 7- Metabolic disorders (uremia, hepatic encephalopathy, hypothyroideism, B12 deficiency). 8- Infectious dementia (Neurosyphilis, AIDS). 9- Normal-pressure hydrocephalus 10- Depression.
- 27. Potentially Reversible Dementias • Drug Toxicity • Metabolic Disturbance • Normal Pressure Hydrocephalus • Mass Lesion (Tumor, Chronic Subdural) • Infectious Process (Meningitis, Syphilis) • Collagen-Vascular Disease (SLE, Sarcoid) • Endocrine Disorder (Thyroid, Parathyroid) • Nutritional Disease (B12, thiamine, folate) • Other (COPD, CHF, Liver Dz, Apnea…)
- 29. In November 1901 Auguste D., at the relatively young age of 51, had become disturbingly absent-minded, making obvious mistakes in food preparation, neglecting her housework, hiding objects in nooks and crannies around their apartment, wandering aimlessly from room to room, and suffering from intense bouts of jealousy and paranoia. In 1906 Patient passed away. Dr. Alzheimer performed an autopsy, finding a high volume of senile plaques and neurofibrillary tangles in the tissue of her brain. And so, in 122 years we've gone from having one Alzheimer's disease patient, Auguste D., to having more than 50 million worldwide ……………………….. Currently, this is greater than the total population of Spain and is projected to nearly triple by 2050.
- 30. Risk factors of AD 1. Age; 65-85 years, risk doubles every 5 years. 2. Sex; 2/3 of AD patients are females. 3. Family history. 4. Down’s syndrome; all patients with Down’s syndrome > 35 years age have AD neuropathology. 5. Head trauma. 6. Education; low educational level is associated with increased risk. 7. Depression. 8. Environmental toxins; Aluminum. 9. APOE allele 4 Clinical presentation of AD Gradual onset very slowly progressive Early affects memory, language and visuspatial affection. Non cognitive features • delusions (usually paranoid or persecutory) • hallucinations (commonly visual) • depressive symptoms • agitation or aggression. Incidence age-related: 8% per year by 85 y 1/2-2/3 of the time, the cause of dementia is AD. Ultimate diagnosis based on pathology of plaques and tangles.
- 31. Acetylcholine is the main neurotransmitter that is deficient. Amyloid plaques and neurofibrillary tangles. Cerebral atrophy eventually occurs; however, atrophy is not strongly correlated with clinical severity. Neuronal toxicity by excessive excitatory neurotrasmitters (glutamate).
- 33. Vascular dementia • The second most common type of dementia • Vascular dementia is more common among patients with hypertension or diabetes. • Controlling risk factors for stroke is likely to slow progression of the dementia and improve function. • Many patients with vascular damage also have concomitant manifestations of AD. patterns of vascular dementia Multi infarct, single infarct, lacunar infarct dementia
- 34. Cognitive affection in VD subcortical features: 1. early gait disturbances with falls 2. early urinary difficulties 3. pseudo-bulbar palsy 4. other frontal subcortical deficits, such as abulia, mood changes and emotional lability.
- 35. Multi infarct dementia abrupt onset stepwise cognitive decline each step is characterized by causal relationship to cerebrovascular disease such as a recent stroke (generally within 3 months). Focal neurological signs and symptoms Abrupt onset, stepwise decline
- 37. Modified Hachinski Ischemia Score: Modified Hachinski Ischemia Score: Points Abrupt onset 2 Stepwise progression 1 Fluctuating course 2 Nocturnal confusion 1 Relative preservation of personality 2 Depression 1 Somatic complaints 1 Emotional incontinence 1 History of hypertension 1 History of stroke 2 Focal neurologic signs 2 Focal neurologic symptoms 2 Dementia is not likely to be due to vascular causes if the total score is 4 or less; dementia is likely to be due to vascular causes if the total score is 7 or more.
- 38. Dementia of lewy body The typical clinical picture of diffuse Lewy body disease is distinctive and features a tetrad of symptoms: (Alzheimer's-like dementia, parkinsonian symptoms, prominent psychotic symptoms and, most important, extreme sensitivity to antipsychotic agents). Fluctuation in course is common. , up to 81% of patients with diffuse Lewy body disease have unexplained periods of markedly increased confusion that lasts days to weeks and closely mimics delirium. (This "pseudodelirium" has not been explained). The dementia seen in diffuse Lewy body disease is similar to that of Alzheimer's disease and includes prominent memory loss, aphasia, and apraxia initially and executive deficits (eg, disinhibition, loss of initiative, incontinence) later. It may or may not progress more rapidly than in Alzheimer's disease. The symptoms generally vary a great deal more from one day to the next than do symptoms of Alzheimer's disease
- 39. FTD &PICK’S disease:(and related 1ry progressive aphesia): It is the most common dementia among patients with early-onset disease, with 70% of patients experiencing onset before the age of 65 years. Insidious onset and gradually progressive impairment of behaviour, personality and/or language. Due to behavioural affection that can make it difficult to distinguish from psychiatric disorders.. The behavioural variant is characterized by symptoms such as disinhibition; apathy or inertia, which leads to inactivity and lack of effort; loss of sympathy or empathy; perseverative, compulsive, ritualistic behaviours or stereotypies; and hyperorality and dietary changes. Individuals with the language variant present with primary progressive aphasia: speaking slowly, struggling to make the right sounds when saying a word, getting words in the wrong order, or using words incorrectly. memory problems – these only tend to occur late in the course of the disease.
- 41. Evaluation of a patient with dementia Alarming signs 1. People with dementia often forget things and never remember them. 2. Asking the same question over and over 3. Difficulty in performing familiar tasks. 4. Problems with language. 5. Time and place disorientation. 6. Misplacing things. 7. Poor judgment Suspect dementia is the first step to diagnose dementia
- 42. Non cognitive features of dementia 1. Depression and dementia often overlap, and about 30% of individuals with dementia have a concomitant depression. 2. behavioural disturbance (for example, psychotic symptoms, mood disturbance, agitation, apathy,
- 43. Perform a comprehensive geriatric assessment including: Review all medications, including OTC medications, for drugs that can adversely affect cognition
- 44. Brief cognitive tests MMSE MOCA SLUM Neuropsychological battery CAM-cog CERAD ACE -III
- 45. Laboratory testing (Don’t miss treatable causes) CBC TSH B12 serum calcium liver and renal function tests Lumbar puncture with cerebrospinal analysis may be useful in cases of suspected neurosyphilis, HIV, or vasculitis.
- 46. Neuroimaging Structural brain imaging using CT scan ,MRI. Functional brain imaging using PET, SPECT, show parietal and temporal deficits in AD
- 47. Treatment Primary goals of treatment are to improve quality of life and maximize functional performance Caregiver suffers too
- 48. Non pharmacological approach 1- In the early stages, the patient is still active, has insight and can use reminder techniques, 2-Educate patient and family about symptoms and stages. 3-Give cognition stimulation exercises. Medications should be monitored especially OTC. Depression should be treated if overt. Driving is risky and should be stopped or evaluated by vehicles department. Advance directives should be completed. Behavioral management, educate the family to deal with different problems. Pharmacologic treatment for AD: 1. Cholinesterase inhibitors, have beneficial effects on behavioral symptoms in some patients and can improve or stabilize cognition and slow decline in mild to moderate AD and may delay nursing home placement, Donepezil : 5-10mg once daily , start at 5mg increase to 10mg after 1 month, Rivastigmine : 6-12mg bid, start at 1.5mg gradually titrate up as tolerated. 2. Memantine, acting on the glutamatergic system by blocking NMDA glutamate receptors. vascular dementia: Control risk factors e,g, smoking, DM, hyperlipidemia. Stroke prevention, by using maintenance antiplatelet therapy.
- 49. New therapies for AD Aduhelm (aducanumab) injection is used to reduce amyloid beta plaque Leqembi (lecanemab)
- 50. Vascular dementia Treatment involves addressing risk factors, e.g., controlling blood pressure, smoking cessation, and lipid control. Although there is no clear evidence of benefit, many physicians prescribe daily aspirin. Although not FDA-approved for treating vascular dementia, cholinesterase inhibitors may be of modest benefit
- 51. FTD: Mainly antipsychotic and speech therapy. Lewy body dementia: Sinemet have minor role
- 52. Pharmacological treatment for the Noncognitive symptoms: Antidepressants Anxiolytics Antiparkinsonian agents Beta-blockers Antiepileptic drugs (for their effects on behavior) Neuroleptics Late stages Care of nutrition. Care of bed ridden. Consider the possibility of nursing home admission.
- 53. Thank you
Editor's Notes
- #11: Stress, sleep deprivation, inattention, preoccupied, anemia some other organic causes Not affect function You can track back your lost items
- #12: May be benign forgetfulness or MCI Remember back Not affect function but 10% may turn alz each year
- #13: Vascular or any subcortical Exclude reversible causes But can progress Not all dementia affect memory