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Differential Diagnosis of Dementia Eric I. Rosenberg, MD, MSPH, FACP Department of Medicine University of Florida.

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Presentation on theme: "Differential Diagnosis of Dementia Eric I. Rosenberg, MD, MSPH, FACP Department of Medicine University of Florida."— Presentation transcript:

1 Differential Diagnosis of Dementia Eric I. Rosenberg, MD, MSPH, FACP Department of Medicine University of Florida

2 Objectives Describe signs and symptoms concerning for early dementia. Describe common causes of memory loss in the elderly. Help integrate history, physical, and laboratory findings to diagnose “reversible” causes of dementia. Discuss when referral to a neurologist or psychiatrist may be helpful.

3 American Psychiatric Association. DSM IV “An acquired deterioration in cognitive abilities that impairs the successful performance of activities of daily living” Cognitive Losses in two or more: –Memory –Language –Visuospatial (recognize objects) –Executive function (tasks) Progressive

4 Psychiatr Clin North Am 1998;21(4). A Syndrome Made up of multiple causes, multiple disorders Cluster of abnormal results from history, physical, and selected testing Early detection requires continuity of care & attention to cognitive deficits

5 Harrison's OnLine Internal Med 16th ed Dementia is Common > 4 million cases in the U.S. > $100 billion/year 10-15% from “reversible” causes Clinicians fail to detect in 20-70% patients until severe Early detection important –diagnose cause –prolong function/comfort –patient & family can plan future preferences

6 Am Fam Physician 2001;63:703-13, Signs and Symptoms Cognitive Psychiatric Personality Problem Behaviors Problems with Activities Daily of Living (ADL’s)

7 Ann Intern Med 2003;138: Common Causes of Mild Memory Loss (Early) Alzheimer’s Disease Depression Hearing/Visual Impairment Polypharmacy & Polyprescribers Metabolic Conditions Substance Abuse

8 “Reversible” Causes of Dementia 1.CNS Conditions 2.Toxins 3.“Medical” Conditions

9 1.) CNS Conditions Normal-Pressure Hydrocephalus Primary/Metastatic Brain Tumor Chronic infection Trauma

10 Normal Pressure Hydrocephalus Abnormal gait, dementia, urinary incontinence Likely have other concomittant dementias –30-50% show improvement with ventricular shunting –Balance risk of subdural hematoma/infection

11 Brain Tumors Usually seizures, focal deficits But if in frontal or temporal lobes, can present with personality changes and memory problems

12 Chronic Infection HIV risk factors –Cryptococcal meningitis, neurosyphilis –20-30% of AIDS patients develop dementia Headache, cranial neuropathies, radiculopathies, meningismus

13 Trauma Recent head trauma/fall –Chronic Subdural Hematoma Recurrent head trauma –Dementia Pugilistica

14 2.) Toxins Alcoholism Other drugs of abuse Heavy metals –Fatigue –Tremors –Neuropathy –Anemia –Abdominal pain

15 3.) “Medical” Causes

16 Nutritional Deficiencies B-12 Niacin (Pellagra) Thiamine (Wernicke-Korsakoff) Protein, calorie malnutrition

17 Chronic Organ Dysfunction Patients “lost” to medical care Unusual weakness, malaise, physical findings –Hypothyroidism –Cushing’s/Addison’s Disease –Hypo/Hyperparathyroidism –Renal or Liver failure –Pulmonary failure

18 Key Historical Cues Focus on health behaviors & ADL’s –Prescription management –Missed appointments –Non-adherence –Health maintenance Neglected appearance Family concerns –Polite, detailed probing –“How is he managing the bills?” “What about the checkbook? Are there any changes in how that is being organized/balanced?”

19 HistoryClinical Correlation Slow memory lossAlzheimer’s Stroke  irregular progressionMulti-infarct dementia Rapid progression, myoclonusPrion disease SeizuresStroke or neoplasm Gait problemsMulti-infarct, Parkinson’s, NPH HIV risk factorsCNS infection (AIDS) Recurrent head traumaChronic subdural hematoma Remote gastric bypass, alcoholism, malnutritionB-12 deficiency, thiamine Depressive symptomsPseudodementia Factory (battery/chemicals)Heavy metal toxins

20 Physical Exam General appearance Visual, auditory acuity Localizing deficits Gait abnormalities Fasiculations Gaze palsy Cogwheeling

21 Physical FindingClinical Correlation Hemiparesis, focal neuro deficitMulti-infarct dementia, neoplasm Peripheral neuropathy and myelopathy B-12 deficiency, heavy metal intoxication Bradycardia, hair loss, dry skinHypothyroidism Confusion and repetitive movements Seizure disorder Hearing impairment, vision lossPseudodementia due to disorientation Axial rigidity Gaze palsy Cogwheel rigidity, brady kinesia Dystonia Frontotemporal Dementia and/or Parkinson’s Disease and/or Lewy Body Dementia

22 Selective Testing (Old Records) Urinalysis CBC Comprehensive Metabolic Panel TSH B-12, (Folate) RPR (FTA) LP Toxicology HIV EEG Genetic biomarkers/CSF markers

23 Neurology 2001;56(9). Neuroimaging Non-contrasted CT or MRI Others (not routine… yet) –Quantitative CT/MR –PET –SPECT

24 When to Refer Unusually young patient (age<55) Abnormal/focal neurological findings Diagnosis in doubt Rapid progression Not responding to therapy Severe behavior problems

25 Rx Cause Suggestive Signs or Symptoms Selective Testing “Reversible” Palliate Counsel Control risks Doubt Dx? Agitation Atypical Neuropsych Referral

26 Objectives Describe signs and symptoms concerning for early dementia. Describe common causes of memory loss in the elderly. Help integrate history, physical, and laboratory findings to diagnose “reversible” causes of dementia. Recognize when referral to a neurologist or psychiatrist may be helpful.

27 Bibliography Armon C. Western pacific ALS/PDC and flying foxes. What’s next? Neurology 2003;61: Bair BD. Diagnostic Dilemmas, Part II: frequently missed diagnosis in geriatric psychiatry. Psychiatr Clin North Am 1998;21(4): Bird TD, Miller BL. Alzheimer’s disease and other dementias. In: Kasper DL, et al (Eds.) Harrison’s Principles of Internal Medicine, 16 th edition [Online]. Chapter 350. February Cummings JL. Alzheimer’s disease. N Engl J Med 2004;351(1): Karlawish JHT, Clark CM. Diagnostic evaluation of elderly patients with mild memory problems. Ann Intern Med 2003;138: Knopman DS, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Neurology 2001;56(9). Santacruz KS, Swagerty D. Early diagnosis of dementia. Am Fam Physician 2001;63:703-13,717-8.


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