Alzheimer's Dementia


Case Discussion
76-yo woman is brought to see you by her daughter, who is concerned about her failing memory. Six months ago, the daughter took over management of her mother’s checkbook after she failed to pay bills. Her mother seems unable to knit, something she enjoyed for years. She has difficulty finding the right words to complete a thought.

What is your diagnosis?

A. This patient has dementia.
B. This patient is depressed.
C. This patient is delirious.
D. This patient has mild cognitive impairment.

 
Criteria for Alzheimer’s Disease
  • Memory loss plus 1 or more:
    • Aphasia
    • Apraxia
    • Agnosia
    • Executive dysfunction
  • Usually few motor signs apparent early
  • Subtle behavioral and personality changes early
Screening Questions for Alzheimer’s Dementia
  •  Aphasia: can’t come up with words, substitutes words, new words
  • Apraxia: has difficulty using utensils, tools
  • Agnosia: doesn’t recognize familiar people; gets lost in familiar surroundings
  • Executive dysfunction: can’t manage checkbook, use computer
Features Inconsistent with Alzheimer’s Disease
  • Sudden onset
  • Focal neurological findings
  • Seizures, early marked change in personality/behavior
  • Gait disorder early in disease course
Treatment
Summary of Cholinesterase Inhibitor Trials in AD:
  • Nearly 9000 patients in 22 RCT, range 3 to 12 months of donepezil (eg, Aricept), rivastigmine (eg, Exelon), or galantamine (eg, Razadyne)
  • Modest positive benefit in cognitive, behavioral, ADL, and global scales; few side effects; modest side effects (GI) Rare evidence of dose response
  • Clinical outcomes (caregiver burden, nursing home placement, etc) not measured

Memantine

  • Behavioral, ADL, and global scales modestly better in moderate/severe dementia.
  • Clinical outcomes (eg, caregiver burden) not measured.
  • ADR: Falls and agitation.
  • Conclusion: Use in moderate dementia if intolerant of CIs or severe dementia.

Medical Foods

  • Caprylidene (Axona) is a medium-chain triglyceride derived from coconut or palm oil.
  • Theory: Alternative fuel for brain of AD patients (poor uptake of glucose).
  • Small, short-term, manufacturer-sponsored trials show “benefit.”
  • Approximately $90 per month.

Lifestyle and Dementia

  • Bronx Aging Study: Education and cognitive leisure activities “protective” against development of AD (N Engl J Med. 2003;348:2508-2516)
  • 15 minutes aerobic exercise 3x/week reduces likelihood of dementia (Ann Intern Med. 2006;144(2):73-80)

 
Dementia Alzheimer's Dementia
Minor Neuro-cognitive Disorder
“Pseudodementia” (Dementia Syndrome of Depression)
Vascular Dementia
Diffuse Lewy Body Dementia
Frontotemporal Dementia
Normal Pressure Hydrocephalus
Creutzfeldt-Jakob Disease