Dementia

Related Subjects: | Dementias |Abbreviated Mental Test Score (AMTS) |Alzheimer disease | Dementia with Lewy bodies | Frontotemporal dementia | Corticobasal degeneration | Creutzfeldt Jakob disease | Vascular Dementia | Primary progressive aphasia | Anti Dementia Drugs | AIDS Dementia Complex | Normal Pressure Hydrocephalus | Acetylcholinesterase inhibitors | Mental Capacity Act 2005 | Behavioural and Psychological Symptoms of Dementia

Because people with dementia are vulnerable to abuse and neglect, all health and social care staff supporting them should receive information and training about, and abide by the local multi-agency policy on, adult protection.

About

• Dementia is a progressive and largely irreversible clinical syndrome
• Global loss of cortical function but memory usual modality most affected early.

Findings

• Mood and Language impairment, Personality changes
• Memory loss, Judgement, Behaviour, Global functioning
• Visuospatial ability, calculation, problem-solving
• Mental health issues: Anxiety, Depression, withdrawal, hallucinations

Causes of a Dementia syndrome: Some* are reversible

• Alzheimer disease (AD) 50-70%
• Dementia with Lewy Bodies 15%
• Vascular Dementia (VD) 10%
  • Repeated strokes
  • Severe small vessel disease
  • CADASIL
  • Vasculitis
• Mixed Alzheimer disease and Vascular Dementia 10%
• Alcoholism
  • Thiamine deficiency*
  • Falls and head injuries
• Parkinson's disease
  • Dementia with Lewy Bodies
  • Parkinson's disease with Dementia
• Frontotemporal dementias
  • Corticobasal degeneration - alien limb on side contralateral to cortical atrophy, apraxia, stiff jerky limb movements
  • Behavioural variant FTD
  • Primary progressive aphasia - deficits in speech grammar and reading/writing predominate. Fluent (semantic dementia) and non-fluent forms.
  • Motor neurone disease type dementia - may precede diagnosis of MND. Usually men less than 65.
• Chronic Head trauma
• Deficiencies
  • Thiamine
    • Alcoholism
    • Pregnancy Hyperemesis
  • Folate
  • B12 deficiency
  • Nicotinic acid deficiency
• Mental health disease
  • Depression 5-10%
  • Schizophrenia
  • Conversion syndromes
• Endocrine
  • Hypothyroidism *
  • Addison disease
  • Cushings disease
  • Hypo/hyperparathyroidism
• Organ failures
  • Liver failure
  • Renal failure
  • Respiratory failure
  • Cardiac failure
• Infections
  • HIV
  • Syphilis
  • PML
  • Tuberculosis*
  • Whipples disease
• Neurodegeneration
  • Huntington's chorea
  • Multiple sclerosis
  • Multisystem atrophy
  • Subacute sclerosing panencephalitis (children)
  • Downs syndrome and Alzheimer Disease
• Space occupying lesion and Structural disease
  • Slow growing Glioma
  • Slow growing meningioma
  • Metastases
  • Hydrocephalus
  • Normal pressure hydrocephalus*
  • Chronic subdural haematoma*
• Prion diseases
  • Creutzfeldt Jacob disease
  • Gerstamann Strausslet Scheinker disease
• Immune mediated*
  • Paraneoplastic encephalitis
  • Limbic encephalitis
  • Hashimotos encephalitis
• Others
  • Sarcoidosis

Clinical assessment

• Symptoms onset and duration
• Cognitive, psychiatric, behavioural and personality changes
• Past medical history and functional baseline and family history Mental state examination
• Interaction, mood, thought content and processing
• Insight, judgement, orientation, attention, psychosis

Physical examination

• Neurological, chest, heart looking for AF, Hypertension, Stroke disease
• Murmurs, hypothyroid, liver disease

Screening Assessment tests

• Mini Mental State Examination (MMSE)
• Montreal Cognitive Assessment (MOCA)

General Features	Dementia	Depression
FHx	DAT	Affective dis
Duration	Long	Short
Progression	Slow	Rapid
Prev. depression	No	Yes
c/o poor memory	No	Yes
Hx	Vague	Detailed
Effort at tests	Good	Poor
Response	Pleased	Picks on faults
Somatic Sx	+++	+
Behaviour	Compatible	Contrary
Orientation	Poor	"don't know"
Apraxias	Present	Absent
Word intrusions	Present	Corrects
Test performance	Always	poor Variable
Pattern of performance	VIQ>>PIQ	Nil specific

Cortical vs Subcortical

• Cortical
  • Normal attention and concentration, Normal speed mental processing
  • Poor language and orientation
  • Causes
    • Alzheimer's Disease, Frontotemporal dementia, Creutzfeldt-Jakob disease
• Subcortical
  • Parkinsonism, Orientated, Impaired concentration and attention
  • language quite well preserved e.g. naming
  • Causes
    • Progressive supranuclear palsy, Vascular dementia/CADASIL
    • Huntington disease, Normal pressure hydrocephalus, Corticobasal Degeneration

Investigations

• FBC, ESR
• Glucose, CRP, LFT, TFT, Ca, ALP
• B12 folate
• ECG, CXR
• HIV, Syphilis serology
• Brain Imaging by CT or MRI: MRI usually preferred. Structural imaging should be used in the assessment of people with suspected dementia to exclude other cerebral pathologies and to help establish the subtype diagnosis. MRI is preferred.

Additional Investigations

• Lumbar puncture and CSF analysis in rare cases e.g Creutzfeldt-Jakob disease or other forms of rapidly progressive dementia are suspected.
• PET scanning if frontotemporal dementia considered
• EEG if a diagnosis of delirium, frontotemporal dementia or Creutzfeldt-Jakob disease is suspected, or in the assessment of associated seizure disorder in those with dementia.
• Brain biopsy for diagnostic purposes should be considered only in highly selected people whose dementia is thought to be due to a potentially reversible condition that cannot be diagnosed in any other way.

Medical Management [NICE Guidance]

• Specific Drug Treatment should be initiated by specialists alone. Carers views should be considered.
• Alzheimer disease: donepezil, galantamine and rivastigmine are recommended as options for managing mild to moderate Alzheimer's disease. Memantine is recommended as an option for managing Alzheimer's disease for those with moderate Alzheimer's disease who are intolerant of or have a contraindication to AChE inhibitors or severe Alzheimer's disease.
• Vascular dementia: acetylcholinesterase inhibitors and memantine should not be prescribed for the treatment of cognitive decline, except as part of properly constructed clinical studies.