Assessment and Treatment of Dementia

Assessment and Treatment of Dementia

Juan Francisco Rodriguez, M.D.

Adult and Geriatric Psychiatrist

Outpatient Mental Health Clinic

DSM-IV Criteria

A- memory impairment (impaired ability to learn new information or to recall previously learned information)One (or more) of the following cognitive

disturbances:

aphasia

apraxia

agnosia

disturbance of executive functioning

DSM-IV Criteria (cont)

B- the cognitive deficits with significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

C- the course is characterized by gradual onset and continuing cognitive decline

DSM-IV Criteria (cont)

D- other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, parkinson’s disease, Huntington disease, subdural hematoma, NPH, brain tumor).

Systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B 12 or folic acid deficiency, neurosyphyllis, HIV infection, substance induced conditions

DSM-IV Criteria (cont)

E- the deficits do not occur exclusively during the course of a delirium

F- the disturbance is not better accounted for by another axis 1 disorder

Signs and Symptoms of Dementia

Personality changes

Difficulty coping with changes

Confusion

Repeating themselves (asking the same questions)

Difficulty reading quickly

Forgetfulness

Poor decision making

Assessment of Dementia

Detailed history to identify dementia

Assessment of Mental Status MMSE IADL’SADL’S

Neuropsychological testing

Assessment of Dementia

Blood testsBrain imaging (CT, MRI, PET, SPECT of the headEEGPittsburgh Compound Elevated CSF tau level are associated with AD pathology and can help discriminate AD from other dementiaUCLA Compound

Assessment of Dementia (cont)

Medical condition

Medications

Neurological conditions causing dementia

Treatable conditions

Differential Diagnosis

Primary EtiologyAlzheimer’s dementiaPick’s diseaseFrontotemporal dementiaLewy body dementia

Differential Diagnosis

Secondary EtiologyVascular dementia e.g. cva, tia Infections e.g. Hiv, syphyllis Inflammatory e.g. SLETraumatic e.g. head injury

Differential Diagnosis

NeurodegenerativeHuntington’s ChoreaCJD (prion)Parkinson’s Disease induced dementiaMultiple SclerosisWilson’s Disease

Vascular Dementias

Hypertension

Cerebrovascular disease

Hyperlipedemia

Elevation of homocysteine level

Management Strategies

Carefully plan relocationTemporal and long term

Discuss with family health care by proxy or advanced directives, DNR

Discuss the use of psychotropic medications

Management Strategies

Discuss ethical issues Discuss management of behavioraldisruption and functional deficits

Discuss psychosocial issues Management and discuss quality of the issues and progression of the illnessDiscuss management of Tx plan including medications

Management of Dementia

Non pharmacological

Pharmacological

Pharmacological Management

Cholinesterase inhibitors

NMDA (memantine)

AMOI (eldepryl)

Medications for disruptive behavior

Antidepressants for comorbid disorders

Cholinesterase Inhibitors

Cognex (tacrine)

Rivastagmine (Exelon) Patch

Donepezil (Aricept)

Galantamine

Galantamine (Razadyne ER)

Question

65 yo wf with hx of dementia develops frightening visual hallucinations. Pt was started on low dosage of risperidone, days after the patient develops severe bradykenesia, tremor, rigidity, and gait disturbance. Side effects/adverse reaction suggests which type of dementia?

Question (cont)

a- Alzheimer’s Dementia

b- Frontotemporal Dementia

c- Diffuse Lewy Body Dementia

d- Progressive Supranuclear Palsy

e- Normal Pressure Hydrocephalus

f- Parkinson’s Induced Dementia

Question

Which of the following are not considered as

part of the routine dementia work-up?

a- VDRL

b- Neurological exam

c- Chest xray

d- Vitamin B 12 level

e- CT or MRI of the head

Question

• A 70 yo wm with history of AD was first prescribed Exelon patch x 2 years without good results, he then was changed to galantamine oral bid. Family complains that patient’s cognition continues to deteriorate. Which of the following is the most likely approach in treatment?

Question (cont)

a- Re-start Exelon

b- Continue galantamine

c- Start Razadyine

d- Start Tacrine

e- Start Aricept 5mg po qhs x 30 days then 10mg po qhs

Question

75 yo patient with history of AD with

behavioral disturbance, he scores 15/30 in the

mmse, he has occasional visual hallucinations,

illusions and delusions. Patient has been taking

Aricept 10mg po qhs, he suddenly develops

stomach upset, which his pcp thinks is related

to his cholinesterase inhibitor, what is the next

step in treatment?

Question (cont)

a- Continue Aricept po qhs

b- Change Aricept to po qam

c- D/C Aricept

d- Start rivastagmine

e- Start galantamine

f- Start Namenda