1. Dementia
Nicholas Cascone, PA-C

2. Dementia – general characteristics
Progressive impairment of intellectual function: impaired recall, inability to focus attention, difficulties with perceptual processing
Emotional disorders frequent: depression, anxiety, irritability
Behavior disturbances: impulsiveness, sexual acting-out, aggression, exhibitionism
Causes: Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, Pick’s disease, reversible causes

3. Reversible causes of dementia
Infectious: meningitis, encephalitis
Metabolic: B12/folate deficiency, thyroid disease, uremia
Vascular: hypoperfusion, subarachnoid hemorrhage
Traumatic: subdural/epidural hematoma
Toxic: EtOH, medications
Inflammatory: SLE, MS
Neoplastic: space-occupying lesions, paraneoplastic syndromes
Psychiatric: depression (“pseudodementia”)

4. Dementia – clinical features
Patients present with memory impairment and at least one of:
Language impairment: difficulty with word finding → difficulty following conversations → mutism
Apraxia: difficulty performing previously learned tasks
Agnosia: inability to recognize objects
Loss of executive function: poor abstraction/planning/judgement, mental inflexibility

5. Types of Dementia – Alzheimer’s disease
Pathophysiology: presence of β-amyloid plaques and neurofibrillary tangles made of tau proteins
Presentation: as above, with
Visuospatial loss: becoming lost in familiar surroundings
Personality/behavioral changes: wandering, agitation, inappropriate sexual behavior
Hallucinations in moderate to sever disease
End-stage marked by mutism, inability to sit up, hold up the head, track objects with eyes, difficulty eating/swallowing, bowel/bladder incontinence, recurrent URI/UTI

6. Types of dementia – vascular dementia
Pathophysiology: multiple lacunar infarcts – occlusion of deep penetrating arteries
Characterized by step-wise progression of deficit
Presentation: as above, with
Early loss of executive functioning
Psychomotor slowing
Reduced attention
Personality changes

7. Types of dementia – Dementia with Lewy bodies
Pathophysiology: development of abnormal proteinaceous cytoplasmic inclusions (“Lewy bodies”) throughout the brain
Additionally, loss of dopamine-producing neurons as in Parkinson’s, and loss of acetylcholine-producing neurons as in Alzheimer’s
Presentation:
Combined features of Parkinson’s and Alzheimer’s disease
Prominent complex visual hallucinations an early feature

8. Types of dementia – Pick’s disease
Pathophysiology: abnormal proteinaceous cell inclusions (Pick bodies) in frontotemporal area, absence of neuritic plaques
Presentation: as above, plus
Visuospatial abilities relatively preserved
Early alteration of personality: euphoria, disinhibition, apathy
Compulsive behaviors: peculiar eating habits, hyperorality

9. Dementia – labs and treatment
Labs and imaging only to rule out reversible causes of dementia
MMSE to evaluate cognitive and basic motor skills
Treatment:
Mild to moderate disease: acetylcholinesterase inhibitors (donepezil, rivastigmine)
More advanced disease: NMDA antagonist (memantine)

10. Dementia – treatment Managing behavior problems
Discontinuation of unnecessary medications
Correction of sensory deficits
Accommodate to behaviors that can be tolerated
Avoid precipitants of problematic behavior
Communicate with clear, simple language
Break activities down into simple component tasks
Distract patient from troublesome issues rather than confronting
Pharmacotherapy: low-dose neuroleptics (but studies show increased mortality)