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.

 
Diagnostic Criteria for Dementia
  • Acquired impairment of short- and long-term memory and at least 1 of the following:
    • Abstract thinking
    • Judgment
    • Language
    • Praxis
    • Visual recognition
    • Constructional abilities
    • Personality
  • Severe enough to interfere with daily function
  • Gradual decline and progression (ie, absence of delirium)
Should We Screen for Dementia?
  • Under current Medicare Pay for Performance: “Whether or not patient (> 65 yo) was screened for cognitive impairment using a standardized tool”
  • Affordable Care Act will require clinicians to assess for cognitive impairment as part of annual wellness.
    www.healthcare.gov/law/full/index.html

 

Potential Benefits of Screening
  • Clarify advance directives while patient still competent.
  • Begin discussion about alternatives to driving, housing alternatives.
  • Prevent financial victimization or self-neglect; remove firearms.
  • Participate in research.
“Average” Dementia Evaluation
  • History, PE, mental status testing, comprehensive neuropsychological testing
  • CBC, CMP, TSH, VDRL, B12, folate, calcium, U/A
  • Genetic testing
  • Brain imaging (CT or MRI)
Incidence and Causes of Dementia
  • Record review of 560 consecutive patients newly diagnosed with dementia
  • No cases of reversible dementia due to NPH, subdural hematoma, B12 deficiency, hypothyroidism, or neurosyphilis
  • Conclusion: “None of the patients with dementia reverted to normal with treatment of the putative reversible cause.”
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 Memory loss plus 1 or more: Aphasia, Apraxia, Agnosia, Executive Dysfunction
• Usually few motor signs apparent early
• Subtle behavioral and personality changes early
Minor Neuro-cognitive Disorder  
“Pseudodementia” (Dementia Syndrome of Depression)  
Vascular Dementia Stepwise progression, prior strokes, focal neuro symptoms/signs
Preserved personality
Diffuse Lewy Body Dementia Dementia + Parkinsonism + Visual hallucination
Frontotemporal Dementia Behavioral problems early
Normal Pressure Hydrocephalus Wacky, Wobbly, and Wet
Creutzfeldt-Jakob Disease Rapidly progressive
Myoclonic jerks