1. An Approach to Dementia Lisa B. Caruso, MD, MPH Boston University School of Medicine Copyright Boston University Medical Center

2. Overview--Dementia Definition Epidemiology Classification Assessment

3. DEMENTIA: A syndrome of progressive decline that relentlessly erodes multiple intellectual abilities, causing cognitive and functional deterioration

4. DEMENTIA Chronic Confusional State

5. Epidemiology Prevalence: 5 million in U.S. in 2007 with AD; may rise to 16 million by 2050 1 Prevalence rates increase with advancing age 2 : –>65 yrs : about 15% with mild dementia –>80 yrs : maybe >40% with mild dementia 1 Alzheimer’s Association News release, 21 Mar 2007 2 CH Kawas, Ratzman R: Epidemiology of dementia and Alzheimer disease. In Terry RD, Katzman R, Bick KL, et al (eds):Alzheimer Disease, ed 2. Philadelphia, Lippincott Williams & Wilkins, 1999, p. 95.

6. Epidemiology Most common causes of dementia are –Alzheimer’s Disease: 2/3 of dementia cases –Diffuse Lewy body disease –Vascular dementias –Frontotemporal dementias –Subcortical dementias: progressive supranuclear palsy, parkinsonian syndromes,

7. Classification Assess and classify dementia by qualitative differences in the presentation of the patient Most clinically useful distinction is between cortical and sub- or noncortical dementia AD, the most common dementia, presents with cortical features while reversible causes for the most part do not

8. Classification Cortical features (active) –lack of extrapyramidal motor findings –large amts of abnormal speech and behavior Subcortical features (passive) –slowness of thought or action –apathy –extrapyramidal motor findings

9. Classification

10. Assessment: triggers Any concerns about cognitive decline of function from patient or others should trigger initial assessment for dementia. Symptoms that may indicate dementia: learning and retaining new information handling complex tasks reasoning ability spatial ability and orientation language behavior Clinical practice guideline, No. 19. Recognition and initial assessment of Alzheimer’s disease and related dementias. Agency for Health Care Policy and Research, US Dept of Health and Human Services, November 1996.

11. Assessment : focused history Chronology of the problem –mode of onset: abrupt vs. gradual –progression: stepwise vs. continuous decline –duration of symptoms Medical history Family history Social and cultural hx: education, literacy, socioeconomic status, recent life events Medication evaluation for possible drug toxicity

12. Assessment: focused PE Neurological exam including mobility and balance assessment Vision and hearing screening Evidence of cardiac or pulmonary dysfunction Signs of caregiver abuse or self-neglect

13. Assessment: mental status Most commonly used brief screening test is Folstein’s Mini-Mental State Exam 1 (MMSE) <24 suggests dementia; 21-25 less helpful in determining probability of dementia Mini-Cog 2 assessment instrument 1 Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. 2 Borson S, Scanlan JM, Chen P, et al. The mini-cog as a screen for dementia; Validation in a population-based sample. J Am Geriatr Soc 2003;51:1451-54.

14. Assessment: functional status Activities of Daily Living (ADL’s) –transferring, ambulating, bathing, toileting, feeding, dressing Instrumental Activities of Daily Living (IADL’s) –grocery shopping, food preparation, housekeeping, transportation, money management, medication management

15. Assessment: tests Remember that relatively few patients (<15%) are found to have an isolated, potentially reversible condition, so intensity of evaluation should be limited if the likelihood of a reversible condition is low. American Academy of Neurology 2001 –CBC, serum electrolytes with BUN/creatinine and glucose, serum B12 level, liver function tests, thyroid function tests, structural imaging. Petersen RC, Stevens JC, Ganguli M, et al. Practice parameter: Early detection of dementia: Mild cognitive impairment (an evidence-based review). Neurology 2001;56:1133-1142.

16. Assessment: r/o similar sx Minimal Cognitive Impairment Delirium Depression Normal Aging

17. Assessment : interpretation Normal functional and mental status –reassure family and patient –reassess in 6-12 months –OR refer for 2nd opinion Abnormal functional and mental status –tests to r/o medical condition –support and education for caregivers Mixed –more complete neuropsychological testing –consider age, education, and cultural confounders

18. Therapy Supportive care to patients –Safety matters –Daily living routine and environment –Monitoring of medical conditions –Advance care planning

19. Therapy Supportive care to caregivers –Education –Teaching problem-solving skills –Accessing resources –Long-range planning –Emotional support –Respite options

20. Therapy Medications for Alzheimer’s Disease –Acetylcholinesterase inhibitors Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne) –NMDA receptor antagonist Memantine (Namenda)