2. What are the investigations?

3. Dementia: Investigations History taking Clinical examination Neuropsychological assessment: - Episodic or short term memory Language, particularly word fluency Executive functioning

5. Dementia: investigations Laboratory assessment:- Full blood count ESR Thyroid function test Serum electrolytes and calcium Serum glucose Serum BUN/creatinine B12 and folate Liver function test Syphilis serology HIV serology

6. Dementia: Investigations Medical imaging X- Rays, ECG CT or MRI scan of the brain

7. How do you want to manage this patient?

8. Dementia of Alzheimer’s type Treat the cognitive deficits Treat the neuropsychiatric symptoms

9. Neurotransmitter system altered in Alzheimer’s disease Decreased Acetylcholine Serotonin Noradrenaline Dopamine GABA Somatostatin Vasopressin Substance P Neuropeptide Y Increased Monoamineoxidase B galanin

10. Neurotransmitter systems altered in Alzheimer’s disease Ach Major neurotransmitter for memory Severely affected in Alzheimer’s disease Acetylcholinesterase destroys Ach in the brain to control amount of Ach Possible to block this enzyme

11. Drug therapy in cognitive deficits Mode of action Acetylcholinesterase inhibition Precursors loading Neurotransmitter release Muscarinic agonists Examples Tacrine, donepezil, ENA 713, metrifonate, galanthamine Choline, lecithin Besipiridine Milameline, xanomeline

12. Acetylcholinesterase inhibitors registered in Australia Donezepil (Aricept) Rivastigmine (Exelon) Galatamine (Reminyl) S/e – diarrhoea, nausea, vomiting, muscle cramps, insomnia, fatigue, and loss of appetite

13. precursors Ac CoA + choline Ach N M2M2 Increase release Choline + acetate Cholinesterase inhibitors M1M1 Selective M 1 agonists Site of action of cholinergic agonists

14. Drug therapy in neuropsychiatric symptoms Indications: Mood, usually depression, rarely mania Perception with hallucinations and misindentifications Thought content with delusions and paranoid ideas Behaviour, with aggressions, wandering, sexual disinhibition

15. Drug therapy in neuropsychiatric symptoms Neuroleptic Indications – agitation, aggression, delusions and hallucinations Haloperidol, olanzepine, thioridazine and risperidone S/e – extrapyramidal, decreased cognitive performance Antidepressants Selective serotonin uptake inhibitors (eg: sertraline) Atypical antidepressants (trazodone) Monoamineoxidase inhibitors (moclobemide, selegiline)

16. Treatment of vascular dementia Drug therapy Antiplatelet therapy (e.g aspirin 75 – 325mg) Other antiplatelet agent (e.g ticlopidine) Surgical Carotid endarterectomy

17. Non drug treatment Better information for carers Reinforcement of day and time given regularly Behaviour modification Patient and family support Role of GP