1. Assessment and Diagnosis of Dementia Dr Alison Haddow

2. Dementia Dementia is the word used to describe a collection of symptoms which may be caused by a variety of disease processes

3. Dementia Multiple brain functions are affected: Memory Thinking Orientation Comprehension Calculation Language Ability to learn Judgement

4. What is Dementia? Consciousness is clear Emotional control may be disturbed Social behaviour may change Motivation levels may alter Personality may be affected

5. Risk factors for Alzheimer’s Disease Age Sex Genetic Factors Education Vascular factors (cholesterol, hypertension) Smoking Head injury Thyroid disease Exposure to electromagnetic fields

6. Risk Factors for Dementia – Genetic (1) Family History of : Family History of : –Dementia (about 40%) –Parkinson ’ s Disease –Down Syndrome Concordance Rate for monozygotic / dizygotic twins is 43 / 8 % Concordance Rate for monozygotic / dizygotic twins is 43 / 8 %

7. Genetics Familial Autosomal Dominant AD, single mutated gene causes the disease in each family member carrying the mutation Genes on the chromosome 1, 14 & 21) Associated with the early-onset form of the disease < 5% of cases Gene for Amyloid Precursor protein (APP) is on the long arm of Chromosome 21

8. Genetics Fourth gene associated with Alzheimer’s Disease is Apolipoprotein E gene (ApoE). Chromosome 19 – People : 1 copy of the gene (E4) have 3 times AD than people without E4 – People : 2 copies of the gene (E4) have 8 times AD than people without E4 Common but no routine testing

9. Education Many studies show that more highly educated people less likely to develop dementia, especially AD ?? Effects of education delaying AD ?? Intelligence masks AD

10. Assessment of Dementia ? Medical cause of cog. Impairment? ? Effect of medication ? Neurological condition causing dementia ? Treatable condition

11. Assessment of Dementia Clinical history – Medical Hx (inc. vascular ) – Medication – Family history Detailed history – patient and carer/s – Social Hx; ADL’s Mental State psych symptoms Sleep disorder

12. Assessment of Dementia Cognitive Examination MMSE; MOCA; Frontal tests Neuropsychology

13. Investigations Blood tests – FBC, U&E’s, LFT’s, Ferritin, folate, Vit B12, TFT’s, Calcium, Glucose. (VDRL) ? Vit D Brain imaging – CT, SPECT, CT/SPECT ECG; CXR if indicated *Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementia- not done clinically.

15. Differential Diagnosis Primary Etiology – Alzheimer’s dementia – Lewy body dementia – Frontotemporal dementia (Pick’s)

16. Differential Diagnosis Secondary Etiology – Vascular dementia e.g. cva, tia – Infections e.g. Hiv, syphyllis – Inflammatory e.g. SLE – Alcohol – Traumatic e.g. head injury

17. Differential Diagnosis Neurodegenerative – Multiple Sclerosis – Huntington’s Chorea – CJD (prion) – Wilson’s Disease – other

18. Management of Dementia Non pharmacological Pharmacological

19. Pharmacological Management Cholinesterase inhibitors NMDA (memantine) Medications for disruptive behavior: BPSD Antidepressants for comorbid disorders

20. Cholinesterase Inhibitors Galantamine Donepezil (Aricept) Rivastagmine (Exelon) Patch

21. Kaplan-Meier plot of time to nursing home admission among patients with Alzheimer's disease (A) taking and (B) not taking CEIs. Lopez O L et al. J Neurol Neurosurg Psychiatry 2002;72:310-314 ©2002 by BMJ Publishing Group Ltd

22. When to Prescribe AChEI’s In: – Alzheimer’s disease – Mixed AD & vascular dementia – Lewy Body Dementia – Parkinson’s disease dementia At earliest possible opportunity After a discussion with the person with dementia and their families

23. Vascular Dementias Hypertension Cerebrovascular disease Hyperlipedemia Aspirin/clopidogrel

24. When to review? Post Diagnostic support for one year. Information and advice given Monitor medication –Compliance –Adverse effects

25. Non Pharmacological Cognitive Stimulation Therapy