1. A neurology primer

2. Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)

3.  18 million cases of Alzheimer’s disease worldwide  Up to 50% of persons > 85yrs are demented  Majority of long-term care residents suffer from dementia Grossberg GT J Gerontol Med Sci 2003

5.  Dementia is an inevitable part of aging  Dementia is synonymous with Alzheimer’s disease  Dementia cannot have an acute onset  Dementia is an untreatable disorder  Dementia cannot be accurately diagnosed without autopsy

6.  Dementia is a “global” disorder of cognitive function  Dementia is only a memory problem  Dementia always impairs insight into cognitive deficits  Dementia is only a cognitive & not a behavioral disorder

7.  Primary care physicians see large numbers of patients with dementia  Dementia can be accurately diagnosed and managed in a primary care setting  General medical health is closely related to late life cognitive function

8.  Failure to recognize symptoms of dementia  Negative attitudes towards treatment and therapeutic nihilism  Limited time  Lack of confidence in establishing a particular diagnosis

9.  Planning for the future  Identify patients at high risk of complications  Early treatment may delay progression  Refer to community based resources

10.  Decreased speed and efficiency of learning  Difficulty inhibiting irrelevant information  Troubles with “working memory”  No true language dysfunction  No more rapid forgetting when controlling for initial learning

11.  Troubles finding words, coming up with names  Difficulty understanding conversations  Getting lost  Troubles recognizing people or objects  Repeating conversations  Difficulty managing medications, appointments, finances  Personality changes, withdrawal, apathy

12.  Troubles managing medications  Difficulty providing detail in medical interview  Repetitive questions  New onset personality or mood changes  Family members expressing concerns over memory or behavior  Episodes of delirium after surgery or during hospitalization

13.  Acquired disorder of memory and at least one other cognitive domain (language, visuospatial function, executive functions)  Occurs in the setting of a clear sensorium  Affects occupational and social functioning

14.  Over 100 illnesses cause dementia  Majority of cases are Alzheimer’s disease  Non-AD dementias account for ~50% ◦ Vascular dementia ~15% ◦ Dementia with lewy bodies ~20% ◦ Frontotemporal dementias ~5% ◦ Other (NPH, syphillis, HIV, Parkinson’s disease dementia, vasculitis, etc.)

16. Delirium Acute onset Marked fluctuations Poor attention Changes in alertness Marked circadian disturbances Dementia Gradual Less fluctuation Generally attentive Generally alert Mild circadian disturbance

17. Cortical  Normal speed of thought  Aphasia  Amnesia  Visuospatial dysfunction  Normal gait  Paratonic rigidity Subcortical  Bradyphrenia  No aphasia  “Forgetful”, poor recall  Visuospatial dysfunction  Impaired gait, posture  Movement pathology

18.  Development of cognitive deficits manifested by both  impaired memory  aphasia, apraxia, agnosia, disturbed executive function  Significantly impaired social, occupational function  Gradual onset, continuing decline  Not due to CNS or other physical conditions  Not due to an Axis I disorder (e.g., schizophrenia)

19.  Age  Family history  CV risk factors (hypertension, diabetes, elevated homocysteine, cholesterol?)  Late onset depression  Delirium  Fewer years of education  Head injury

20.  NSAIDs  Statins  Antihypertensives  Antioxidants  Exercise

21.  Complete blood count  Thyroid function test (TSH)  Vitamin B-12 level/folate  Complete metabolic panel (BUN/Cr, glucose, calcium, LAEs, electrolytes)  Neuroimaging should be done at least once ◦ Non-contrast CT ◦ MRI brain without contrast

22.  Mini Mental Status Exam  Clock-drawing tests  Blessed-dementia rating scale  Mini-cog  7-minute screen

23.  Attention  Language  Memory  Visuospatial/perceptual functions  Executive functions  Praxis  Calculations

24.  Look for extrapyramidal dysfunction  Asymmetric findings  Pyramidal tract findings and pathologic reflexes  Gait dysfunction  Coordination  Sensation

25.  Erythrocyte sedimentation rate  RPR  Lumbar puncture  HIV  Serial neuroimaging  Functional neuroimaging (PET, SPECT)  Full neuropsychological testing

28.  Poor short term memory  Difficulty learning and retaining new information  Mild word-finding difficulties  Naming problems  Problems with organization, and complex planning

29.  Worsening memory problems  Remote memory becomes involved  More obvious language problems  Visuospatial and topographical orientation  Getting lost, unable to find way back home  Behavioral changes (delusions, aggression, irritability, anxiety)

30.  Aphasia (unable to comprehend language other than simple commands)  Agnosia (difficulty recognizing objects, people, etc.)  Apraxia (inability to perform skilled movements despite intact motor/sensory skills)

31.  Slow or delay progression  Correct exacerbating factors/conditions  Treat and prevent concomitant CVD  Treat behavioral and psychiatric problems  Treat functional problems

32.  Acetylcholinesterase inhibitors ◦ Donepezil (Aricept) ◦ Rivastigmine (Exelon) ◦ Galantamine (Reminyl)  N-methyl-D-aspartate inhibitors ◦ Memantine (Namenda) ◦ May be used in conjunction with CHEIs

33.  Approved for mild-moderate AD  Aricept just approved for severe AD  Start as early as possible  Continue as long as possible  Use maximum dose tolerated  Failure to respond to one does not preclude response to another

34.  Most AD patients decline by 3-4 points on MMSE per year  Treatment generally may delay progression by ~ 6 months  Behavior and function may improve in addition to cognition

35.  ChEI treatment is the standard of care for mild to moderate AD  Improvement, stabilization, or slowed decline represent treatment success ◦ Evaluate treatment response in the context of progressive decline ◦ Inform patient and caregiver that stabilization is desirable ◦ Use follow-up visits to reinforce realistic expectations  Aricept has proven benefits on cognitive, functional, and behavioral symptoms ChEI = cholinesterase inhibitor.

36.  Detect and diagnose early  Provide early and persistent treatment  Evaluate treatment response in the face of progressive decline  Manage physician, patient, and caregiver expectations of disease course and treatment response

37.  Dementia is a major public health problem  Dementia is under recognized in all settings  Dementia is a disorder of cognition, behavior and function  Effective treatments exist that may improve or help preserve all 3 domains