Dr. John Puxty

Dementia: Overview

Learning Objectives

The learner will be to

Appreciate difference between normal aging change in memory

and dementia.

Describe the diagnostic criteria for dementia.

Appreciate key components of assessment of individual with

possible dementia

Demonstrate knowledge of the common causes of dementia

and how they differ from Alzheimer’s Disease.

Appreciate importance of early identification of early caregiver

support strategies

Function

Age

Definite AD

Dementia

Probable AD

Mild cognitive impairment

Normal

Model of Continuum of Cognition with Aging

Dementia

What are Normal Age-related Changes?

Rate of information processing

Acquisition performance (learning)

Early retrieval of new information

Delayed recall (forgetting)

Distractibility

Self reported memory loss

Mild Cognitive Impairment

Memory complaint

Objective memory impairment

Normal general cognitive function

Intact activities of daily living

10-20% per year progress to dementia

At 10 years 20% NOT demented

CIND Prevalence Over Age 65

CIND

(N=861)

Dementia

n=1132

65 to 74 yrs 11.0% 2.4%

75 to 84 yrs 24.0% 11.2%

> 85 yrs 30.3% 34.7%

Overall 16.8% 8.0%

Graham J et al: Lancet 349:1793-1796, 1997

Definition of Dementia (DSM IV)

The diagnostic criteria include the presence of :

memory impairment plus at least one other of following features:

aphasia, apraxia, agnosia or executive dysfunction

associated with a decline from previous cognitive functioning and

functional impairment (this differentiates dementia from MCI),

usually affecting IADLs (Instrumental Activities of Daily Living

Its important that other cause of worsening cognition are

considered before making a diagnosis of dementia. Depression

and delirium are important differentials to consider.

A new case worldwide every 7 seconds.

A new case in Canada every 4 minutes (100,000 new cases per year), the prevalence will increase from now (450,000) to 750,000 by 2025.

3rd most expensive disease in the Canadian Healthcare System.

1 in 4 Canadians has a family member with dementia.

1 in 2 Canadians knows someone with dementia.

Ontario has 100,000 demented drivers.

It is estimated that by 2016 Ontario will spend $27.3 billion on dementia care compared to $3.8 billion in 1991.

Dementia: The Silent Epidemic

8

Changing Demographics of Dementia

Severity of AD in Community and LTC

Sources: Statistics Canada, General Social Survey, 2002. Reference: http://www.statcan.gc.ca/pub/89-519-x/2006001/t/4122067-eng.htm

Why Try to Make an Early Diagnosis of Dementia?

Helps family understand and make sense of the changes

they have seen

Early link of patient and family with informal and formal

supports

To prepare patient and family for future course of the illness

With mild dementia possibility of involving the patient in

advanced care planning e.g. POA, living wills etc

Opportunity to modify risk factors e.g.. DM, BP, etc

Impact of non-pharmacological therapies probably greater

e.g. cognitive and physical exercise

Cholinesterase Inhibitors can delay symptomatic progression

of dementia

Alzheimer’s Society 10 Warning Signs for Caregivers

1. Memory loss that affects day-to-day function

2. Difficulty performing familiar tasks

3. Problems with language

4. Disorientation of time and place

5. Poor or decreased judgment

6. Problems with abstract thinking

7. Misplacing things

8. Changes in mood and behaviour

9. Changes in personality

10. Loss of initiative

What arouses our suspicion for dementia?

Family reports concerns re memory or function or behavior

Change in personality, appearance or behavior

Missed appointments

New problems with medication compliance

Forget to bring in their medications and can’t tell you what

they’re taking

Presence of risk factors (family history, vascular risk factors,

previous head injury or stroke)

Estimating the risk for dementia

Vascular risk factors (each vascular risk factor

generally doubles the risk of

dementia)

Hypertension

Diabetes

Smoking

Hyperlipidemia

Atrial fibrillation

Hyperhomocysteinemia

Obesity

Other risk factors:

Age (over 65)

Head injury

Family history

• 1 parent = 2x risk

• 2 parents = 10x risk

Apo E4 status

Lower education level

Adapted from: Canadian Consensus Conference on Dementia, Patterson et al. Canadian Journal of

Neurological Science 2001: 28: Suppl. 1 S3-S16.

Impact of Early AD

Impact of Moderate AD

Impact of Late AD

Progression of ADL loss in Alzheimer

Dementia

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9

MM

SE

Years

Impaired instrumental ADLs

Impaired in 1 or more basic ADLs

Requires assistance for most basic ADLs

Mild AD

Moderate AD

Severe AD

Palliative AD

Social interaction

Dependent in all ADLs

Impact on Caregivers

Mismatch between capacity and expectations

Mismatch in present and past roles of individual

Failure of individual affected to recognize or appreciate issues

Behaviors and actions that challenge historical relationships

Guilt of caregiver regarding need for help

68.8

100.5

113.4120.0

0

20

40

60

80

100

120

140

Mild Mild-to-moderate Moderate Severe

Ho

urs

per

mo

nth

sp

ent c

arin

g fo

r A

D p

atie

nts

AD Caregiver Time by Disease Severity

Hux et al. CMAJ, 1998.

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Mild

Mild

-to-m

odera

te

Moder

ate

Sever

e

Ca

na

dia

n d

olla

rs (

19

96

) Nursing home stay

Community services

Medications, physician

fees

Unpaid net supervision

time

Unpaid direct care time

Mean Annual Cost of AD by Disease

Severity

Hux et al. CMAJ, 1998.

Predictors of nursing home placement in AD include:

Worsening dementia

Cognitive impairment

Functional impairment

Troublesome behaviours

Increased caregiver burden

Despite the burden, most families prefer to care for patients at

home as long as possible

Nursing home care is the largest component of direct AD

healthcare costs

Geldmacher et al. J Am Geriatr Soc, 2003, Karlawish et al. Neurology, 2000. , Hux et al.

CMAJ, 1998.

Nursing Home Placement in AD

Impact on Formal Caregivers

MD’s typically underestimate

caseload by 50%

MDs less likely be comfortable re

issues of non-AD, driving, co-

morbidities, BPSD and accessing

community supports

Formal Caregivers report

behaviors such as aggression,

calling out and disruptive behavior

typically less well tolerated

Clinician role in Dementia

careful assessment, identification of all contributory factors and

probable diagnosis

Diagnosis of AD

Adapted from Patterson C et al. Can J Neurol Sci, 2001.

Progressive decline in cognition and/or

function:

History from patient and reliable informant

Mental and functional status assessments

Physical examination

Laboratory tests

Alzheimer’s disease 1. Disclose diagnosis to patient and family, and

inform about the disease

2. If mild-to-moderate: initiate therapy as per

treatment guidelines

3. Treat other symptoms

4. Educate and support both patients and

caregivers; refer families to support

organizations

Other dementia Assess further or refer

• Onset & duration

• Evolution of symptoms

• Precipitating factors

• Family history

• Medication history

• Rule out Depression/Delirium

Cognitive and Functional Activities

Assessment

Rule out:

• Adverse drug effects

• Neurological disease

• Metabolic or systemic illness

• CBC, TSH, electrolytes,

calcium, glucose

• CT or MRI in specific cases

+

+

+

26

Examples of Office Cognitive Assessment

Tools

Possible Dementia

Dementia Quick Screen

Folstein MMSE

Montreal Cognitive Assessment (MOCA)

Clock

Trail Test

Dementia Quick Test

3 item recall (2/3 is normal)

4-legged animals in 1 minute (<15 abnormal

Clock drawing (hands at 10 past 11)

If one or more of the screening tests are positive, the person and an “informant” should be asked if there have been any memory or functional changes over the last 6 – 12 months, and formal cognitive tests should be done (MMSE, MOCA, etc.).

Cognition assessment: MMSE The annotated Mini-Mental State Examination (MMSE) is a brief instrument commonly used to assess patients with dementia

The MMSE is scored out of 30 points; a total score of 23 or less suggests dementia (although the cut-off varies with age and education)

Limitations include poor sensitivity in detecting MCI, and if conducted late during the course of many dementias, the test has a “floor effect”

Guidelines for managing Alzheimer’s disease: Part I. Jeffrey L. Cummings, MD et al. American Family Physician, June 15, 2002.

28

Physical Findings and Dementia

Progression of ADL loss in Alzheimer

Dementia

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9

MM

SE

Years

Impaired instrumental ADLs

Impaired in 1 or more basic ADLs

Requires assistance for most basic ADLs

Mild AD

Moderate AD

Severe AD

Palliative AD

Social interaction

Dependent in all ADLs

Functional Assessment and Dementia

In assessing a patient with dementia, it is critical to determine the impact on functional abilities.

Typically the first functional areas affected are the instrumental ADLs (IADLs) –mnemonic: SHAFT

S Shopping

H Housework

A Accounting

F Food preparation

T Transportation

Other areas of function affected early include driving, medication management, using the telephone and doing laundry.

Investigations

All Most Some

HB and CBC Serum B12 MRI

Electrolytes RBC Folate SPECT or PET

Glucose Calcium EEG

TSH CT Scan Lumbar

Puncture

LFTs HIV

Clarfield criteria for CT:

age < 70

new onset dementia , < 1 year

atypical presentation

rapid unexplained deterioration

unexplained focal signs, symptoms

head injury

incontinence, gait ataxia

need for reassurance of patient, family

1.Clarfield, CMAJ, (1991), vol.144(7), 851-853

2.Patterson et al., (1999) CMAJ, vol.160,(Supp.12),S1-15

Atrophy of the brain in AD: Medial temporal lobes are

affected first and most severely

Atrophy in Alzheimer’s disease

SPECT scan of normal control vs AD

Differential Diagnosis Considerations

Depression

Delirium

Drug side effects

Decompensated Chronic Disease

B12 Deficiency

Thyroid Dysfunction

Hypercalcemia

Tumour/Subdural

Normal Pressure Hydrocephalus

Differentiating Depression and Dementia

Differentiating Delirium and Dementia

SUMMARY: Main Dementia Subtypes

AD: short term memory, word finding, way finding.

VaD: vascular history, focal findings, +ve imaging.

Mixed AD/VaD: clinical, radiologic +ve imaging.

LBD: fluctuations, hallucinations, Parkinsonism.

FTD: behaviour, social tactlessness, language.

Clinician role in Dementia

careful assessment, identification of all contributory factors and

probable diagnosis

communicating the findings and diagnosis and discussing probable

natural history and treatment options

responding to common questions and concerns

optimizing of cognitive, medical and functional status and reduction

of ongoing risk factors,

an anticipatory care plan sensitive to ethico-legal issues that

includes monitoring, mobilization of patient and caregiver supports

and adjustment of strategies

Use of ACEI’s

collaboration with other health providers and community agencies

identification of psychiatric co-morbidities

monitoring for and anticipating common issues and concerns

(driving, delirium, depression, disruptive behaviors, sleep disruption

etc)

consultation with specialist services as needed