Dementia

Dementia (Chronic Brain Failure)

Global impairment of cognitive functions occurring in clear consciousness.
Evidence of significant decline from a previous level of functioning in one or more cognitive domains:
- Memory (learning and recall)
- Executive function (planning, decision-making, judgment)
- Complex Attention
- Language
- Perceptual-motor abilities (visuospatial skills)
- Social cognition (recognizing emotions, behaviors)
Other mental functions can often be affected, including mood, personality, judgment, and social behavior.
Can be progressive or static!
Permanent or reversible (e.g., vitamin B12, folate, hypothyroidism).

Major Neurocognitive Disorder (Dementia)

A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.

B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications) / or praying.

C. The cognitive deficits do not occur exclusively in the context of a delirium.

D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

Specify: Without behavioral disturbance:
- With behavioral disturbance: e.g., psychotic symptoms, mood disturbance, agitation, apathy,
- Specify:
  - Mild: Difficulties with instrumental activities of daily living (e.g., housework, managing money).
  - Moderate: Difficulties with basic activities of daily living (e.g., feeding, dressing).
  - Severe: Fully dependent.

Types of Major or Mild Neurocognitive Disorders According to (DSM-5):

Alzheimer’s Disease
Frontotemporal
Lewy Bodies
Vascular
Traumatic Brain Injury
Substance/Medication-Induced
HIV Infection
Prion Disease
Parkinson’s Disease
Huntington’s Disease
Another Medical Condition
Multiple Etiologies
Unspecified

Possible Etiologies of Cognitive Impairment

Degenerative dementias
- Alzheimer’s disease
- Frontotemporal dementias (e.g., Pick’s disease)
- Parkinson’s disease
- Lewy body dementia
Miscellaneous
- Huntington’s disease
- Wilson’s disease
Psychiatric
- Pseudodementia of depression
- Cognitive decline in late-life schizophrenia
Physiologic
- Normal pressure hydrocephalus
Metabolic
- Vitamin deficiencies (e.g., vitamin B12, folate)
- Endocrinopathies (e.g., hypothyroidism)
- Chronic metabolic disturbances (e.g., uremia)
Tumor
- Primary or metastatic (e.g., meningioma or metastatic breast or lung cancer)
Traumatic
- Dementia pugilistica, posttraumatic dementia
- Subdural hematoma
Infection
- Prion diseases (e.g., Creutzfeldt-Jakob disease, bovine spongiform encephalitis, Gerstmann-Sträussler syndrome)
- Acquired immune deficiency syndrome (AIDS)
- Syphilis
Cardiac, vascular, and anoxia
- Infarction (single or multiple or strategic lacunar)
- Binswanger’s disease (subcortical arteriosclerotic encephalopathy)
- Hemodynamic insufficiency (e.g., hypoperfusion or hypoxia)
Demyelinating diseases
- Multiple sclerosis
Drugs and toxins
- Alcohol, Heavy metals, Carbon monoxide

Dementia of the Alzheimer’s Type

The most common type of dementia
Progressive dementia
The final diagnosis of Alzheimer’s disease requires a neuropathological examination of the brain
Genetic factors esp. in early onset.
Acetylcholine and norepinephrine, both of which are hypothesized to be hypoactive in Alzheimer’s disease

Vascular Dementia

The primary cause of vascular dementia, formerly referred to as multi-infarct dementia, is presumed to be multiple areas of cerebral vascular disease.
Vascular dementia is more likely to show a decremental, stepwise deterioration than is Alzheimer’s disease.

Diagnosis and Clinical Features

The diagnosis of dementia is based on the clinical examination
Memory impairment is typically an early and prominent feature
Early in the course of dementia, memory impairment is mild and usually most marked for recent events; As the course of dementia progresses, memory impairment becomes severe, and only the earliest learned information are intact
Orientation can be progressively affected

Mental Health Symptoms

Personality change, intellectual impairment, forgetfulness, social withdrawal, anger and lability of emotions are common.
Hallucinations … 20 to 30 percent
Delusions … 30 to 40 percent
Physical aggression and other forms of violence are common in demented patients who also have psychotic symptoms.
Depression and anxiety symptoms
Pathological laughter or crying

Physical Findings, and Laboratory Examination

A comprehensive laboratory workup must be performed when evaluating a patient with dementia.
The purposes of the workup are to detect reversible causes of dementia.
The evaluation should follow informed clinical suspicion.

Differential Diagnosis

Delirium
Depression (pseudodementia)
Schizophrenia
Normal Aging

Cognitive Impairment & Dementia

Progressive
- Alzheimer’s disease (AD)
- Dementia with Lewy Bodies (DLB)
- Fronto-temporal dementia (FTD)
- Vascular dementia (VaD)
- Parkinson’s disease dementia (PDD)
- Other degenerative dementias
Non-Progressive
- Traumatic Brain Injury (TBI)
- Anoxia (e.g., sleep apnea)
- Vascular (e.g., single stroke)
Reversible
- Depression & anxiety
- Multiple medical conditions
- Metabolic problems
- Medication side effects
- Infections
- Normal Pressure Hydrocephalus

Delirium Vs Dementia

Features
- Delirium
  - Onset: Acute
  - Course: Fluctuating
  - Duration: Days to weeks
  - Consciousness: Altered
  - Attention: Impaired
  - Psychomotor changes: Increased or decreased
  - Reversibility: Usually
- Dementia
  - Onset: Insidious
  - Course: Progressive
  - Duration: Months to years
  - Consciousness: Clear
  - Attention: Normal, except in severe dementia
  - Psychomotor changes: Often normal
  - Reversibility: Rarely

Prevention of Dementia

Modification of 12 risk factors may prevent or delay 40% of dementias:
- ➢ Early life: Less education
- ➢ Midlife (45–65 years): Hearing loss, hypertension, obesity, traumatic brain injury (TBI), and alcohol (>21 units/week)
- ➢ Late life (>65 years): Smoking, depression, social isolation, physical inactivity, diabetes mellitus, and air pollution

Treatment

The first step in the treatment of dementia is verification of the diagnosis.
Preventive measures are important.
Behavioral modifications.
Supportive and educational psychotherapy.
Any areas of intact functioning should be maximized by helping patients identify activities in which successful functioning is possible.
Compensatory strategies / Occupational therapy.
Cognitive Rehabilitation: maintaining memory and functional abilities, including task-oriented therapies.
Exercise and physical activity.
Speech therapy / Augmentative and alternative communication (AAC) tools.
Caregivers.

Pharmacotherapy

Primary treatments:
- Cholinesterase inhibitors:
  - Donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and tacrine
- NMDA glutamate receptors antagonist: Memantine
Emerging therapies: aducanumab, Anti-amyloid antibodies, ? Efficacy, Expensive!

Antidepressants, anticonvulsants or antipsychotic: may be used to manage severe mood/ psychotic/ agitation symptoms.

Drugs with high anticholinergic activity & Benzodiazepines should be avoided.

Management of Agitation/Aggression in Demented Patients

FIGURE 12
AGITATION MANAGEMENT

Agitation
- Pain, delirium, etc
- Environmental Provocation
- Nocturnal
Memantine; ChE-Is
- Depressive Features
  - SSRI’s, SNRI’s, TCA’s
- Psychotic Features
  - Atypical Antipsychot.
  - Neuroleptics
- Agitation NOS
  - Antipsychotics
  - Mood stabilizers

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