Dementia

Samuel Heery

Normal Aging

Mild Cognitive Impairment (MCI)

Major Neurocognitive Disorder 2/2 Alzheimer’s Dementia

  • Mild decline in working memory
  • More effort/time needed to recall new info
  • New learning slowed but well compensated by lists, calendars, etc.
  • No impairment in social & occupation functioning
  • Subjective complaint of cognitive decline in at least one domain
  • Cognitive decline is noticeable and measurable
  • No impairment in social & occupation functioning
  • Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains
  • Causes significant impairment in social & occupation functioning
  • Other medical & psychiatric conditions, including delirium, have been excluded
  • Insidious onset and gradual progression of impairment in at least two cognitive domains
Cognitive domains: learning/memory, language, executive function, complex attention, perceptual motor, social cognition

Major Neurocognitive Disorder Due to:

Alzheimer’s Disease

Vascular Dementia

Lewy Body Dementia

Frontotemporal Dementia

OnsetGradualSudden or stepwiseGradualGradual (age < 60)
Cognitive Domains & SymptomsMemory, language, visuospatialDepends on location of ischemiaMemory, visuospatialExecutive dysfunction, personality changes, disinhibition language, +/- memory
Motor SymptomsRare early; Apraxia laterCorrelates with ischemiaParkinsonism (memory loss typically precedes)None
ProgressionGradual (over 8-10 years)Gradual or stepwise with further ischemiaGradual, but faster than Alzheimer’s diseaseGradual, but faster than Alzheimer’s disease
ImagingPossible global atrophyCortical or subcortical on MRIPossible global atrophyAtrophy in frontal & temporal lobes

Rare causes of dementia: Parkinsonian’s disease dementia, posterior cortical atrophy, CJD, corticobasal degeneration, neurosyphilis, NPH, autoimmune dementias (eg, NMDA)

Evaluation

MINI-COG: Screening test for cognitive impairment (highly sensitive)

MOCA: Montreal Cognitive Assessment

  • Lengthier test of cognition (but highly specific for cognitive impairment), MUST be done by someone who is certified 
  • Useful for detecting subtle deficits as in MCI
  • Training and Certification is mandatory for proper use.
  • Scores:
    • 18-25: Mild 
    • 10-17: Moderate 
    • <10: Severe 
  • Rule out reversible causes of dementia-like symptoms: DEMENTIA
    • Drugs
    • Emotional (depression)
    • Metabolic (CHF, COPD, CKD, OSA)
    • Endocrine (hypothyroidism, hyperparathyroidism, hyponatremia)
    • Nutrition (B12 deficiency)
    • Trauma (chronic SDH)
    • Infection (RPR)
    • Arterial (vascular)
    • Consider referral for Neuropsychiatric testing for unclear diagnosis. MRI brain with contrast is tier 1 testing as workup for cognitive behavioral syndrome. 

Management

  • Targeting Cognitive Impairment
    • - Cholinesterase Inhibitors Donepezil, rivastigmine, galantamine (Reference)
      • Indicated for any stage of AD, PDD, LBD, Vascular Dementia (avoid in FTT)
      • Does not prevent dementia
      • SE: GI (nausea, diarrhea), bradycardia, orthostasis
  • NMDA Antagonists: Memantine (Reference)
    • Indicated in moderate to severe AD alone or in combination with cholinesterase inhibitors
    • Fewer SE than cholinesterase inhibitors
  • Anti-amyloid Modulators: lecanemab and donanemab
    • FDA approved for MCI or mild AD
    • Reduce brain amyloid levels: 27-40% slower rate of cognitive decline
    • SE: cerebral edema
    • Requires referral to neurology at VUMC 
  • Targeting Behaviors
    BPSD: Behavioral and psychological symptoms of dementia
    1. Non-pharmacologic management (best evidence): treat underlying cause, hydration/nutrition, orient, mobilize, manage pain, engage family, sleep
    2. Depression: Antidepressants (SSRI’s)
    3. Sleep Disturbance: Mirtazapine or Trazodone
    4. Agitation: SSRIs or mood stabilizers (manic-type behaviors), Depakote
    5. Consider antipsychotics (black box warning increased risk of death for older adults with dementia-related psychosis) for behaviors that threaten safety 

See “Delirium” section in Psychiatry for inpatient management recommendations.  

For patients with driving concerns: “Driving Solutions of Tennessee" 615-806-0012 

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