1. Dementia in Clinical Practice Mary Ann Forciea MD Clinical Prof of Medicine Division of Geriatric Medicine UPHS Photo: Nat Geographic

2. Who has dementia? 78 yr old retired librarian Lives alone, children visit on holidays Family concerned about ‘clutter’ in house, hygiene, unpaid bills 68 yr old child care worker Lives with her husband, drives, in charge of ‘house money’ “Forgot” a child in classroom at end of day

3. Who has dementia (2) ? 84 yr old urology inpatient –Post op day 1: hostile Attempts to strike nurse with cane Refusing blood draw Pulled out catheter 70 yr old homebound patient –Bedbound, mute –Family caregivers –Oral intake decreasing

4. Terms Dementia –Chronic, progressive –Impairment in >1 domain of cognition Mild cognitive impairment –Impairment in 1 domain of cognition –? “pre-dementia” Delirium –Short term

5. What do we know about Brain Function? Cell structure –Microscope (biopsy, cell culture) –PET scans Brain regions –imaging “Domains” of cognition –Imaging –Psychological testing

6. Cell structure: Neurons NetworksGrey matter/white matter

7. Brain regions Regions have different activities

8. Domains of cognition Memory Calculation Language Orientation Spatial construction Executive function (judgment)

9. Mapping Memories Natl Geographic

10. What is wrong in dementia? Theories Neurons: waste products, shape of cells, signaling, genetic flaws Regions: biochemistry, structure Domains: communication We don’t yet know.

11. Clinical observations All patients with dementias are not alike. –Age of onset –Family history –Initial symptom –Most troublesome symptom –Rate of progression –Response to treatment Is dementia a symptom, not a disease?

12. Dementia Subtypes Alzheimer’s Disease Fronto-temporal dementia (formerly Pick’s Disease) – 15% Corticobasilar dementias Dementia with Lewy Bodies – 20% –Distinguished from Parkinson’s Disease with dementia Vascular disease

14. Alzheimer’s type dementia Gradual onset Global impairment in cognition –Usually memory impairment predominant Increased risk in siblings –Apo e allele risk Slow progression (5-7 years) –Predictable course (global deterioration scores)

15. AD - pathology Imaging Neuropathology – quantity and location –Senile plaques White matter Amyloid core –Neurofibrillary tangles Tau protein abnormalities –Initial concentrations highest in hippocampus and temporal lobes

18. What clinical problems do patients with Alzheimer’s Dementia Encounter? Diagnosis Symptom Management End of life care

19. Case 1 NC 64 yr old retired OR nurse Referred for evaluation of impaired memory –Birthdates, telephone numbers –Impaired job performance for 1-2 yrs prior –Inability to ‘balance checkbook’ Gradual decline over 5 years Died of pneumonia

20. Diagnosis Largely on history Exclude other conditions Role for imaging in near future Staging –Mental status testing (MMSE, MOCA, Mini- Cog) –Functional status staging (FAST, GDR)

21. FAST The FAST scale has seven stages: 1 which is normal adult 2 which is normal older adult 3 which is early dementia 4 which is mild dementia 5 which is moderate dementia 6 which is moderately severe dementia 7 which is severe dementia

22. AD - treatment Improve all co-existing conditions! Specific treatments –Cholinesterase inhibitors Donepazil, rivastigmine –Adrenergic stimulants Memantine Treatment of associated symptoms –Agitated behaviors Non pharmacologic, environmental drugs

23. End of life issues Should be anticipated –Advance Directives, conversations with proxies Goals of care –Nutrition –Hospitalization –Caregiver burdens –Hospice involvement

24. Summary “Dementia” is a symptom complex We are in the early stages of understanding the pathology, and discovering effective treatment Optimal care requires advance planning, caregiver involvement, and a team of professionals