Dementia Jaqueline Raetz, M.D.

Dementia vs Normal Cognitive Changes With Aging Dementia: Memory loss and impairment of one other cognitive domain that progresses over time and impairs function. Normal changes: Slowed information processing. Occasional memory impairment such as misplacing car keys or forgetting names of acquaintances. Many patients come to their primary care physicians to ask about early signs of dementia. It is important to be able to speak about normal cognitive changes that occur with aging. Remember that while dementia is very common, is not a normal part of aging. Slowed information processing and learning does occur with aging. Older actors take longer to memorize their lines. It is not abnormal to occasionally forget where the car keys are or to forget the name of an acquaintance.  It is abnormal to get lost in your own neighborhood, forget the names of close family, or place clothes on in the wrong order. Substantial short-term memory loss is not a normal part of aging. A dementia diagnosis requires documentation of memory loss and impairment of one other cognitive domain (language, perception, visual-spatial function, calculation, judgment, abstraction, problem-solving ability) that progresses over time, impairs function, and is not caused by another medical disease.

Types of Dementia Alzheimer Dementia 70% Vascular Dementia 17% Others 13% including: Lewy Body Dementia Frontotemporal Dementia Overall incidence: 37% by age 90 Simmons 2011 Incidence varies depending on what studies and references you look at. Risk factors: age, family history of dementia, apolipoprotein E4 genotype, cardiovascular comorbidities, chronic anticholinergic use, and lower educational level. (Simmons) Persons 71 to 79: prevalence 5%.

Alzheimer Dementia Key Early Features: Key Later Features: Recent event memory loss. Language dysfunction Visuospacial skills Key Later Features: Immediate and long term memory impairment Difficulty performing learned motor tasks Neuropsychiatric symptoms Personality changes occur later, preserved in early disease. Simmons 2011, Grabowski 2013 Usually decline 3 -3.5 points per year on the mini mental status exam but can decline much faster. Alzheimer disease affects 5.3 million Americans, and is the sixth leading cause of death. Median survival time after diagnosis of dementia is 4.5 years. (Simmons)

Lewy Body Dementia Key features: Second most common dementia Fluctuating cognition Visual hallucinations Parkinsonism Neef 2010 Lewy Body Dementia is second most common 1:5 dementias. Key features include fluctuating congnition (very similar to delirium), visual hallucinations and Parkinsonism. Sleep disorder is also very common. Executive functioning difficulties more common than in Alzheimers so you may see more problems on the clock face test which involves planning than on the MMSE. Cholineserase inhibitors are more effective in pts with Lewy Body dementia than in those with Alzheimer’s. They do very poorly with antipsychotics. It really represents a spectrum of disease from Alzhiemers to Parkinsons. (Neef)

Vascular Dementia Key features: Presents in a variety of ways. Underlying cause is cerebrovascular disease. Memory impairment may occur later. Wright 2013. Patients may have significant disability before the meet the criteria for dementia because memory may be impaired later in the course of the disease. The terminology for vascular dementia has evolved a great deal and “vascular cognitive impairment” is the newest terminology. Cevebrovascular disease may be from small artery infarcts, large artery infarcts, chronic ischemia or a combination of more than one type. Symptoms depend on what parts of the brain are affected. The course may be gradual, stepwise and some fluctuation may occur. It may progress slowly or quickly.

Frontotemporal Dementia Key features: Behavior changes Personality changes Aphasia Cardarelli 2010 Frontotemporal Dementia: Behavior or personality changes and or aphasia as opposed to memory loss are key features. (Cardareelli) Patients may have inappropriate disinhibition. (Simmons)

References Cardarelli R. Frontotemporal Dementia:A Review for Primary Care Physicians. Am Fam Physician. 2010 Dec 1;82(11):1372-1377. Grabowski T. Clinical Manifestations and Diagnosis of Alzheimer Disease. UpToDate October 2013. Accessed 11/5/13 www.uptodate.com Neef D. Lewy Body Dementia: An Emerging Disease. Am Fam Physician. 2010 Dec 1;82(11):1372-1377. Simmons B. Evaluation of Suspected Dementia. Am Fam Physician. 2011 Oct 15;84(8):895-902 Wright C. Etiology, clinical manifestations and diagnosis of vascular dementia June 27, 2013. UpToDate Acessed 11/4/13: www.uptodate.com