Presentation on theme: "Differential Diagnosis of Dementia Eric I. Rosenberg, MD, MSPH, FACP Department of Medicine University of Florida."— Presentation transcript:
Differential Diagnosis of Dementia Eric I. Rosenberg, MD, MSPH, FACP Department of Medicine University of Florida
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.
American Psychiatric Association. DSM IV. 1998. “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
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
Harrison's OnLine Internal Med 16th ed. 2005. 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
Am Fam Physician 2001;63:703-13,717-8. Signs and Symptoms Cognitive Psychiatric Personality Problem Behaviors Problems with Activities Daily of Living (ADL’s)
Ann Intern Med 2003;138:411-419. Common Causes of Mild Memory Loss (Early) Alzheimer’s Disease Depression Hearing/Visual Impairment Polypharmacy & Polyprescribers Metabolic Conditions Substance Abuse
“Reversible” Causes of Dementia 1.CNS Conditions 2.Toxins 3.“Medical” Conditions
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
Brain Tumors Usually seizures, focal deficits But if in frontal or temporal lobes, can present with personality changes and memory problems
Chronic Infection HIV risk factors –Cryptococcal meningitis, neurosyphilis –20-30% of AIDS patients develop dementia Headache, cranial neuropathies, radiculopathies, meningismus
Trauma Recent head trauma/fall –Chronic Subdural Hematoma Recurrent head trauma –Dementia Pugilistica
2.) Toxins Alcoholism Other drugs of abuse Heavy metals –Fatigue –Tremors –Neuropathy –Anemia –Abdominal pain
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
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?”
When to Refer Unusually young patient (age<55) Abnormal/focal neurological findings Diagnosis in doubt Rapid progression Not responding to therapy Severe behavior problems
Rx Cause Suggestive Signs or Symptoms Selective Testing “Reversible” Palliate Counsel Control risks Doubt Dx? Agitation Atypical Neuropsych Referral
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.
Bibliography Armon C. Western pacific ALS/PDC and flying foxes. What’s next? Neurology 2003;61:291-292. Bair BD. Diagnostic Dilemmas, Part II: frequently missed diagnosis in geriatric psychiatry. Psychiatr Clin North Am 1998;21(4):941-971. 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 2005. Cummings JL. Alzheimer’s disease. N Engl J Med 2004;351(1):56-67. Karlawish JHT, Clark CM. Diagnostic evaluation of elderly patients with mild memory problems. Ann Intern Med 2003;138:411-419. 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.