Assessment and Diagnosis of Dementia Dr Alison Haddow

Dementia Dementia is the word used to describe a collection of symptoms which may be caused by a variety of disease processes

Dementia Multiple brain functions are affected: Memory Thinking Orientation Comprehension Calculation Language Ability to learn Judgement

What is Dementia? Consciousness is clear Emotional control may be disturbed Social behaviour may change Motivation levels may alter Personality may be affected

Risk factors for Alzheimer’s Disease Age Sex Genetic Factors Education Vascular factors (cholesterol, hypertension) Smoking Head injury Thyroid disease Exposure to electromagnetic fields

Risk Factors for Dementia – Genetic (1) Family History of : Family History of : –Dementia (about 40%) –Parkinson ’ s Disease –Down Syndrome Concordance Rate for monozygotic / dizygotic twins is 43 / 8 % Concordance Rate for monozygotic / dizygotic twins is 43 / 8 %

Genetics Familial Autosomal Dominant AD, single mutated gene causes the disease in each family member carrying the mutation Genes on the chromosome 1, 14 & 21) Associated with the early-onset form of the disease < 5% of cases Gene for Amyloid Precursor protein (APP) is on the long arm of Chromosome 21

Genetics Fourth gene associated with Alzheimer’s Disease is Apolipoprotein E gene (ApoE). Chromosome 19 – People : 1 copy of the gene (E4) have 3 times AD than people without E4 – People : 2 copies of the gene (E4) have 8 times AD than people without E4 Common but no routine testing

Education Many studies show that more highly educated people less likely to develop dementia, especially AD ?? Effects of education delaying AD ?? Intelligence masks AD

Assessment of Dementia ? Medical cause of cog. Impairment? ? Effect of medication ? Neurological condition causing dementia ? Treatable condition

Assessment of Dementia Clinical history – Medical Hx (inc. vascular ) – Medication – Family history Detailed history – patient and carer/s – Social Hx; ADL’s Mental State psych symptoms Sleep disorder

Assessment of Dementia Cognitive Examination MMSE; MOCA; Frontal tests Neuropsychology

Investigations Blood tests – FBC, U&E’s, LFT’s, Ferritin, folate, Vit B12, TFT’s, Calcium, Glucose. (VDRL) ? Vit D Brain imaging – CT, SPECT, CT/SPECT ECG; CXR if indicated *Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementia- not done clinically.

Differential Diagnosis Primary Etiology – Alzheimer’s dementia – Lewy body dementia – Frontotemporal dementia (Pick’s)

Differential Diagnosis Secondary Etiology – Vascular dementia e.g. cva, tia – Infections e.g. Hiv, syphyllis – Inflammatory e.g. SLE – Alcohol – Traumatic e.g. head injury

Differential Diagnosis Neurodegenerative – Multiple Sclerosis – Huntington’s Chorea – CJD (prion) – Wilson’s Disease – other

Management of Dementia Non pharmacological Pharmacological

Pharmacological Management Cholinesterase inhibitors NMDA (memantine) Medications for disruptive behavior: BPSD Antidepressants for comorbid disorders

Cholinesterase Inhibitors Galantamine Donepezil (Aricept) Rivastagmine (Exelon) Patch

Kaplan-Meier plot of time to nursing home admission among patients with Alzheimer's disease (A) taking and (B) not taking CEIs. Lopez O L et al. J Neurol Neurosurg Psychiatry 2002;72: ©2002 by BMJ Publishing Group Ltd

When to Prescribe AChEI’s In: – Alzheimer’s disease – Mixed AD & vascular dementia – Lewy Body Dementia – Parkinson’s disease dementia At earliest possible opportunity After a discussion with the person with dementia and their families

Vascular Dementias Hypertension Cerebrovascular disease Hyperlipedemia Aspirin/clopidogrel

When to review? Post Diagnostic support for one year. Information and advice given Monitor medication –Compliance –Adverse effects

Non Pharmacological Cognitive Stimulation Therapy