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EVALUATION OF THE PATIENT WITH DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry.

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Presentation on theme: "EVALUATION OF THE PATIENT WITH DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry."— Presentation transcript:

1 EVALUATION OF THE PATIENT WITH DEMENTIA Jonathan T. Stewart, MD Professor in Psychiatry University of South Florida College of Medicine Chief, Geropsychiatry Section Bay Pines VA Medical Center

2 DEMENTIA  A syndrome characterized by acquired, progressive cognitive impairment  Affects 10% of individuals over 65  Caused by at least 80 different diseases, many reversible  Unfortunately, the most common diseases (85 – 90%) are irreversible  Diagnosis will have prognostic and treatment implications  All demented patients need a work-up  …and it’s mostly a good history

3 PRIMARY SYMPTOMS  ATTENTION  MEMORY  POSTROLANDIC (“COGNITION”)  EXECUTIVE (FRONTAL/SUBCORTICAL)  INSIGHT

4 PRIMARY SYMPTOMS  ATTENTION: clouded sensorium, delirium  MEMORY: forgetfulness  POSTROLANDIC: aphasia, apraxia, getting lost  EXECUTIVE: poor judgment, disinhibition, abulia, urge incontinence  INSIGHT: anosognosia, catastrophic reactions

5 TWO TYPES OF DEMENTIA  Postrolandic  Frontal/subcortical

6 POSTROLANDIC  Memory deficits  Aphasia  Apraxia  Agnosia  Personality more or less preserved  MMSE valid FRONTAL/SUBCORTICA L  Memory deficits  Loss of behavioral plasticity and adaptability, judgment  Personality changes  Disinhibition  Abulia  Urge incontinence  MMSE useless

7 THE REST OF THE HISTORY  Time course  Depressive symptoms  Past medical history  Medical and psychiatric conditions  Family Hx  EtOH  Medications (including OTC, OPM)

8 THE REST OF THE EXAM  Physical exam  Neurologic exam  Mental status exam

9 THE FOLSTEIN MMSE  Most studied and used of the standardized exams  Quick and easy to administer  Excellent inter-rater reliability  Accurately measures the severity and progression of Alzheimer’s disease  Does not detect executive deficits at all

10 BEYOND THE MMSE  ATTENTION: digit span or “DLROW”  MEMORY: 3 word recall, orientation  POSTROLANDIC: naming, praxis, calculations, intersecting pentagons  EXECUTIVE: contrasting programs, Luria figures, go-no go, controlled word fluency, frontal release signs

11 LURIA’S RECURSIVE FIGURES

12

13

14 THE GERIATRIC DEPRESSION SCALE (GDS)  Good screen for most patients  Easy to administer and score  Face-valid, so patients can “fake good” or “fake bad”  Valid for demented patients with an MMSE above about 12  Use DMAS or Cornell scale for severely demented patients

15 THE REST OF THE WORK- UP  Basic labs  Thyroid function tests  B12 (methylmalonic acid and homocysteine if borderline)  Serology  HIV, drug screen, others, as indicated  Neuroimaging study, usually  LP or EEG, rarely

16 PLEASANT SURPRISES  Depression  Iatrogenic (anticholinergics, sedatives, narcotics, H2 blockers, multiple meds)  Hypothyroidism  B12 deficiency  Neurosyphilis  Alcoholic dementia  Normal pressure hydrocephalus  Subdural hematoma  Others

17 POSTROLANDIC DEMENTIAS  Alzheimer’s disease  Diffuse Lewy body disease

18 ALZHEIMER’S DISEASE  Slowly, insidiously progressive postrolandic dementia; executive sx’s much later  Neurologic exam, labs, neuroimaging studies unremarkable  Often familial, especially in younger patients

19 ANTI-DEMENTIA DRUGS  May improve cognitive function, ADL’s to a modest extent; often ineffective  Dechallenge if no meaningful benefit  Possibly delay nursing home placement  Cholinesterase inhibitors may cause nausea, diarrhea, weight loss  Memantine occasionally causes agitation  THESE AGENTS DO NOT SLOW THE RATE OF DECLINE

20 A TYPICAL STUDY

21 BEWARE!

22 DIFFUSE LEWY BODY DISEASE  Second most common dementia in autopsy studies  Characterized by Lewy bodies throughout the cortex  Non-familial  2:1 male:female ratio

23 CLINICAL FEATURES  Postrolandic dementia  More rapidly progressive than AD  Fluctuation, episodes of “pseudodelirium” common  Mild parkinsonism  Tremor often absent  Poor response to antiparkinsonian meds  Shy-Drager sx’s common  Prominent psychotic sx’s, esp visual hallucinations  SEVERE NEUROLEPTIC INTOLERANCE

24 FRONTAL/SUBCORTICAL DEMENTIAS  Vascular dementia  Frontotemporal dementia and Pick’s disease  Alcoholic dementia  Huntington’s disease, Wilson’s disease, progressive supranuclear palsy, late Parkinson’s disease  AIDS dementia complex, neurosyphilis, Lyme disease  Normal pressure hydrocephalus  Most head injuries  Anoxia, carbon monoxide  Multiple sclerosis  Tumors  ANY ADVANCED DEMENTIA

25 TYPES OF VASCULAR DEMENTIA  Multi-infarct dementia  Small vessel disease  Lacunar state (gray > white)  Binswanger’s disease (white)  Hemorrhagic vascular dementia  Strategic infarct dementia  Dementia due to hypoperfusion

26 SMALL VESSEL DISEASE  At least 50% of all vascular dementia  Often coexists with MID  Usual vascular risk factors, especially HPT  Steady, not step-wise deterioration  Relatively more abulia than disinhibition

27 FRONTOTEMPORAL DEMENTIA  Relatively uncommon, non-familial illness  Prominent (macroscopic) atrophy of frontal and anterior temporal cortex  Symptoms include executive deficits, Klüver-Bucy syndrome  About 25% of pts have Pick bodies

28 MANAGEMENT

29 BEHAVIORAL PROBLEMS IN DEMENTIA  Present in 80% of cases  Major source of caregiver stress, institutionalization  Common at all stages of the disease  Much more treatable than the underlying dementia  Poorly described in the literature

30 WOOF. MEDS OTHER

31 THREE BASIC PRINCIPLES  Simplicity  Limited goals  The “no-fail” environment

32 “THE CUSTOMER IS ALWAYS RIGHT!”

33 DEPRESSION  20-30% incidence in Alzheimer’s disease, often early in the course of the illness  Most important treatable cause of excess disability  Responds very well to treatment

34 ACUTE BEHAVIOR CHANGE  I atrogenic  I nfection  I llness  I njury  I mpaction  I nconsistency  I s the patient depressed?

35 AGITATION  Present in up to 80% of patients  Up to 34% of patients are combative  Few predictors  Probably a very heterogeneous problem  Cornerstone of treatment is nonpharmacologic

36 EMPIRICALLY EFFECTIVE MEDS FOR AGITATION  Atypical neuroleptics (best when agitation is clearly related to delusions or hallucinations)  Anticonvulsants  Trazodone  Beta-blockers  Buspirone  Benzodiazepines  Others

37 THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes one) WHEN IN DOUBT, GET RID OF MEDICATIONS!

38 DON’T FORGET SAFETY ISSUES!  DRIVING  FIREARMS  POWER TOOLS  SMOKING IN BED  POISONS, MEDICATIONS  FALL RISK

39 WOOF! MEDS OTHER GOOD LUCK!


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