A neurology primer. Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)

A neurology primer

Hospital for Mentally Ill & Epileptics (Frankfurt 1901-1906)

Dementia is an inevitable part of aging Dementia is synonymous with Alzheimer’s

disease Dementia cannot have an acute onset Dementia is an untreatable disorder Dementia cannot be accurately diagnosed

without autopsy

Dementia is a “global” disorder of cognitive function

Dementia is only a memory problem Dementia always impairs insight into

cognitive deficits Dementia is only a cognitive & not a

behavioral disorder

Primary care physicians see large numbers of patients with dementia

Dementia can be accurately diagnosed and managed in a primary care setting

General medical health is closely related to late life cognitive function

Failure to recognize symptoms of dementia Negative attitudes towards treatment and

therapeutic nihilism Limited time Lack of confidence in establishing a

particular diagnosis

Planning for the future Identify patients at high risk of

complications Early treatment may delay progression Refer to community based resources

Decreased speed and efficiency of learning Difficulty inhibiting irrelevant information Troubles with “working memory” No true language dysfunction No more rapid forgetting when controlling

for initial learning

Troubles finding words, coming up with names

Difficulty understanding conversations Getting lost Troubles recognizing people or objects Repeating conversations Difficulty managing medications,

appointments, finances Personality changes, withdrawal, apathy

Troubles managing medications Difficulty providing detail in medical

interview Repetitive questions New onset personality or mood changes Family members expressing concerns over

memory or behavior Episodes of delirium after surgery or

during hospitalization

Acquired disorder of memory and at least one other cognitive domain (language, visuospatial function, executive functions)

Occurs in the setting of a clear sensorium Affects occupational and social functioning

Over 100 illnesses cause dementia Majority of cases are Alzheimer’s disease Non-AD dementias account for ~50%

◦ Vascular dementia ~15%◦ Dementia with lewy bodies ~20%◦ Frontotemporal dementias ~5%◦ Other (NPH, syphillis, HIV, Parkinson’s disease

dementia, vasculitis, etc.)

5 % FTD

5 % Other

55 % Alzheimer’s disease

20 % VascularDementia

15 % DementiaLewy Bodies

DeliriumAcute onsetMarked fluctuationsPoor attention Changes in alertnessMarked circadiandisturbances

DementiaGradualLess fluctuationGenerally attentiveGenerally alertMild circadiandisturbance

Cortical Normal speed of

thought Aphasia Amnesia Visuospatial

dysfunction Normal gait Paratonic rigidity

Subcortical Bradyphrenia No aphasia “Forgetful”, poor recall Visuospatial

dysfunction Impaired gait, posture Movement pathology

Development of cognitive deficits manifested by both

impaired memory aphasia, apraxia, agnosia, disturbed

executive function Significantly impaired social, occupational

function Gradual onset, continuing decline Not due to CNS or other physical conditions

Not due to an Axis I disorder (e.g.,

schizophrenia)

Age Family history CV risk factors (hypertension, diabetes,

elevated homocysteine, cholesterol?) Late onset depression Delirium Fewer years of education Head injury

NSAIDsStatinsAntihypertensivesAntioxidantsExercise

Complete blood count Thyroid function test (TSH) Vitamin B-12 level/folate Complete metabolic panel (BUN/Cr,

glucose, calcium, LAEs, electrolytes) Neuroimaging should be done at least

once◦ Non-contrast CT◦ MRI brain without contrast

Mini Mental Status Exam Clock-drawing tests Blessed-dementia rating scale Mini-cog 7-minute screen

Attention Language Memory Visuospatial/perceptual functions Executive functions Praxis Calculations

Look for extrapyramidal dysfunction Asymmetric findings Pyramidal tract findings and pathologic

reflexes Gait dysfunction Coordination Sensation

Erythrocyte sedimentation rate RPR Lumbar puncture HIV Serial neuroimaging Functional neuroimaging (PET, SPECT) Full neuropsychological testing

Poor short term memory Difficulty learning and retaining new

information Mild word-finding difficulties Naming problems Problems with organization, and complex

planning

Worsening memory problems Remote memory becomes involved More obvious language problems Visuospatial and topographical orientation Getting lost, unable to find way back home Behavioral changes (delusions,

aggression, irritability, anxiety)

Aphasia (unable to comprehend language other than simple commands)

Agnosia (difficulty recognizing objects, people, etc.)

Apraxia (inability to perform skilled movements despite intact motor/sensory skills)

Slow or delay progression Correct exacerbating factors/conditions Treat and prevent concomitant CVD Treat behavioral and psychiatric problems Treat functional problems

Acetylcholinesterase inhibitors◦ Donepezil (Aricept)◦ Rivastigmine (Exelon)◦ Galantamine (Reminyl)

N-methyl-D-aspartate inhibitors◦ Memantine (Namenda)◦ May be used in conjunction with CHEIs

Approved for mild-moderate AD Aricept just approved for severe AD Start as early as possible Continue as long as possible Use maximum dose tolerated Failure to respond to one does not preclude

response to another

Most AD patients decline by 3-4 points on MMSE per year

Treatment generally may delay progression by ~ 6 months

Behavior and function may improve in addition to cognition

ChEI treatment is the standard of care for mild to moderate AD

Improvement, stabilization, or slowed decline represent treatment success◦ Evaluate treatment response in the context of

progressive decline◦ Inform patient and caregiver that stabilization is

desirable◦ Use follow-up visits to reinforce realistic expectations

Aricept has proven benefits on cognitive, functional, and behavioral symptoms

ChEI = cholinesterase inhibitor.

Detect and diagnose early Provide early and persistent treatment Evaluate treatment response in the face of

progressive decline Manage physician, patient, and caregiver

expectations of disease course and treatment response

Dementia is a major public health problem Dementia is under recognized in all settings Dementia is a disorder of cognition,

behavior and function Effective treatments exist that may improve

or help preserve all 3 domains