Dementia

Normal Aging

Mild Cognitive Impairment

Alzheimer’s Dementia (DSM V Diagnostic Crit.)
  • 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

Alzheimer’s Disease

Vascular Dementia

Lewy Body Dementia

Frontotemporal Dementia
Onset Gradual Sudden or stepwise Gradual Gradual (age < 60)
Cognitive Domains & Symptoms Memory, language, visuospatial Depends on location of ischemia Memory, visuospatial Executive dysfunction, personality changes, disinhibition language, +/- memory
Motor Symptoms Rare early; Apraxia later Correlates with ischemia Parkinsonism (memory loss typically precedes) None
Progression Gradual (over 8-10 years) Gradual or stepwise with further ischemia Gradual, but faster than Alzheimer’s disease Gradual, but faster than Alzheimer’s disease
Imaging Possible global atrophy Cortical or subcortical on MRI Possible global atrophy Atrophy in frontal & temporal lobes

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

Evaluation

  • MINI-COG: Screening test for cognitive impairment (highly sensitive)
    • Word Recall: Ask pt to remember three words (banana, sunrise, chair). Ask pt to repeat immediately
    • CDT: Ask pt to draw clock. After numbers are on the face, ask pt to “set hands to 10 past 11”
    • Correct is all numbers in right position AND hands pointing to the 11 and the 2
    • Ask pt to recall the three words

MOCA: Montreal Cognitive Assessment

  • Lengthier test of cognition (but highly specific for cognitive impairment)
  • Useful for detecting subtle deficits as in Mild Cognitive Impairment (MCI)
  • Training and Certification is mandatory for proper use.
  • Scores:
    • 18-25: Mild cognitive impairment
    • 10-17: Moderate cognitive impairment
    • <10: Severe cognitive impairment
  • Rule out reversible causes of dementia-like symptoms: DEMENTIA
    • Drugs o Emotional (depression)
    • Metabolic (CHF, COPD, CKD, OSA)
    • Endocrine (hypothyroidism, hyperparathyroidism, hyponatremia)
    • Nutrition (B12 deficiency)
    • Trauma (chronic SDH)
    • Infection (RPR, HIV testing in at-risk patient groups)
    • Arterial (vascular- consider MRI brain)
    • Consider referral for Neuropsychiatric testing if diagnostic pattern unclear. Consider MRI brain with contrast if concerned for inflammatory or infectious causes.

Management

  • Targeting Cognitive Impairment
    • Cholinesterase Inhibitors: Donepezil, rivastigmine
      • Indicated for any stage of AD, PDD, LBD, Vascular Dementia (avoid in FTD)
      • No role in dementia prevention
      • SE: GI (nausea, diarrhea), bradycardia, orthostasis
  • NMDA antagonists: Memantine
    • Indicated in moderate to severe AD in combination with cholinesterase inhibitors
    • Fewer SE than cholinesterase inhibitors
  • Targeting Behaviors
    • BPSD: Behavioral and psychological symptoms of dementia
    • Non-pharmacologic management has the best evidence of effectiveness
    • treat underlying cause, hydration/nutrition, orient, mobilize, manage pain, environmental modification, eliminate devices, engage family, sensory restoration, sleep protocol
      • Depression: Treat with antidepressants (SSRI’s)- (citalopram 10mg or sertraline 25mg = starting doses
    • Sleep Disturbance: Mirtazapine (7.5 mg nightly) or Trazodone (25 mg nightly)
    • Agitation: SSRI (typically first line)- see above; mood stabilizers (manic-type behaviors)- Depakote 125mg q12 = starting dose (serum level 50-100 mcg/mL therapeutic)
      • Consider antipsychotics (black box warning increased risk of death for older adults with dementia-related psychosis) for behaviors that threaten safety of patient or staff and use lowest dose possible
      • See “Delirium” section in Psychiatry for inpatient management recommendations
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