Dementia Diagnosis and Types

Dementia

• Dementia is a disease process characterized by progressive cognitive decline.
• Types of dementia include Alzheimer's, frontotemporal, Lewy body, vascular, traumatic brain injury, and substance/medication-induced dementia.

Incidence

• Worldwide, ~ 50 million people are affected by dementia.
• Alzheimer's is the leading cause, accounting for 60-80% of dementia cases.
• Vascular dementia constitutes 20-30% of cases, with incidence increasing linearly with age.
• Lewy body disease accounts for 10-25% of dementia cases.
• Frontotemporal lobar degeneration (FTD) accounts for 10-15% of dementia cases, but 20-50% in patients younger than 65.

Etiology

• Dementia can be caused by disorders like Alzheimer's, vascular disease, frontotemporal lobar degeneration, Lewy body disease, traumatic brain injury, substance/medication abuse, HIV infection, prion disease, and Parkinson's disease.

Behavioral Disturbances

• Dementia may present with behavioral disturbances, possibly unsafe or disruptive.
• Behavioral disturbances include wandering, restlessness, agitation, aggression, sleep/wake cycle disturbances, apathy, difficulty concentrating, delusions, and hallucinations.

Diagnosis

• Diagnosing dementia requires evidence of cognitive decline from a prior level of functioning in one or more domains which include:
  • Complex attention.
  • Executive function.
  • Learning and memory.
  • Language.
  • Perceptual motor skills.
  • Social cognition.
• Cognitive deficits must be severe enough to interfere with independence in daily activities.

Stages

• Early Stage:
  • Memory loss.
  • Time and spatial disorientation.
  • Poor judgment.
  • Withdrawal or depression.
  • Perceptual disturbances.
• Middle Stage:
  • Recent and remote memory worsens.
  • Increased aphasia.
  • Apraxia.
  • Hyperorality.
  • Disorientation to place and time.
  • Restlessness or pacing.
  • Perseveration.
  • Irritability.
  • Loss of impulse control.
• Late Stage:
  • Incontinence of urine and feces.
  • Loss of motor skills, rigidity.
  • Decreased appetite and dysphagia.
  • Agnosia.
  • Apraxia.
  • Severely impaired communication.
  • Possible inability to recognize family members.
  • Loss of self-care abilities.
  • Severely impaired cognition.

Risk Factors

• Alzheimer's Disease:
  • Age.
  • Family history.
  • Genetics.
• Vascular:
  • Advanced age.
  • History of heart attack, stroke, or mini stroke.
  • Atherosclerosis.
  • High cholesterol.
  • High blood pressure.
  • Diabetes.
  • Smoking.
  • Obesity.
  • Atrial fibrillation.
• Lewy Body Disease:
  • Older than 60 years.
  • Common in men.
  • Family history.
• Frontotemporal Lobar Degeneration:
  • Family history of dementia.

Assessment Findings

• History: Focus should be on cognitive and functional concerns, psychiatric and behavioral changes.
• Physical Exam: May be generally normal, but look for neurological deficits.
• Cognitive Exam:
  • Used to develop differential list and rate severity of symptoms.
  • Mini Mental Status Examination measures cognition, but it is limited in measuring executive functions and memory impairment.

Differential Diagnosis

• Differential diagnoses for dementia include alcoholic dementia, toxic or heavy metal intoxication, medical or infectious diseases, vitamin deficiencies (Thiamine, Vit B12, Folic Acid), neoplasm and paraneoplastic syndrome, trauma like subdural hematoma or hydrocephalus, delirium, and depression.

Diagnostic Studies

• Diagnostic studies are done primarily to rule out other illnesses.
• Studies include complete blood count, complete metabolic panel, urinalysis, liver function studies, thyroid panel, Vit B12 and folate levels, syphilis serology, and CT or MRI.

Pharmacological Management for Mild to Moderate Dementia

• Medications slow the progression of dementia, but do not reverse it.
• Acetylcholinesterase Inhibitors Include:
  • Donepezil (Aricept):
    • Dosage: 5mg once daily, Max: 23 mg once daily
    • Side Effects: Serious arrhythmias, GI bleeds, seizures.
    • Comments: Educate caregivers on GI bleed signs. EKG prior to initiation.
  • Galantamine (Razadyne, Razadyne ER):
    • Dosage: 4mg BID Max: 24mg BID, ER: 8 mg once daily Max: 24mg once daily.
    • Side Effects: Stevens-Johnson syndrome.
    • Comments: Similar to donepezil.

Pharmacological Management for Moderate to Severe Dementia

• NMDA Receptor Antagonists:
  • Memantine (Namenda):
    • Dosage: 5mg BID, Max dose: 20mg BID.
    • Side Effects: Headache, dizziness, mood changes, GI symptoms.
    • Comments: Renal adjustment needed for severe renal disease.
  • Memantine XR (Namenda XR):
    • Dosage: 7 mg once daily, Max dose: 28 mg once daily.
    • Side Effects: Headache, dizziness, mood changes, GI symptoms.
    • Comments: Renal adjustment needed for severe renal disease.
  • Rivastigmine (Exelon):
    • Dosage: 1.5mg BID Max: 12 mg BID, Patch: 4.6 mg Max: 9.5 mg q24hr.
    • Side Effects: Similar to donepezil/galantamine.
    • Comments: Patch great for patients who cant take medicine orally.

Non-Pharmacologic Management

• Supportive care.
• Structured, familiar, routine, low-stress environments.
• Frequent meals and fluids for nutritional status and hydration.
• Verbal and nonverbal communication to ensure processing.
• Simple and direct communication.
• Reminiscent therapy.
• Fall precautions.
• Secure environment to minimize getting lost.
• Respite services for caregivers.
• Early discussion of advance directives.
• Facilitate communication between providers.
• Support groups.

Consultation/Referrals

• Neurology for new onset dementia.
• Psychiatry for behavioral disturbances.
• Physical Therapy for exercises and adaptive equipment.
• Occupational Therapy for driving, kitchen, and home safety evaluations.
• Speech therapy for swallowing or dysphagia assessments.
• Hospice under Medicare for end-stage dementia when meeting criteria related to bed-bound status and stage of disease.

Delirium

• Delirium is an acute confusional state, marked by altered loss of consciousness, which inhibits the capability to concentrate, sustain focus, or shift attention.
• Delirium occurs most commonly in hospitalized older adults (> 65), but it can occur at any age.
• Delirium associates with longer hospital stays, increased rates of admission to nursing homes.

Etiology of Delirium:

• Medications such as Anticholinergics and Benzodiazepines.
• Alcohol or drug use or withdrawal.
• Medical conditions such as stroke/heart attack.
• Electrolyte imbalances.
• Severe or terminal illnesses.
• Infections, such as UTI, pneumonia, flu.
• Toxin exposure, such as carbon monoxide or cyanide.
• Poor Nutrition.
• Lack of sleep or severe emotional distress.
• Pain.
• Surgery or other medical procedure that requires being put in a sleep-like state.

Risk Factors for Delirium:

• Advanced age.
• Dementia.
• Low education level.
• High comorbidity.
• Frailty.
• Visual and hearing impairment.
• Depression.
• Alcohol abuse.
• Illicit drug, opioid, or benzodiazepine use.
• Poor nutrition.
• History of delirium.

Post-admission risk facts for Delirium:

• Pain.
• Infection.
• Invasive devices.
• Immobility.
• Metabolic abnormalities.
• Prolonged ileus.
• Blood transfusion.
• Opioids.
• Polypharmacy.
• Sleep deprivation.
• Environmental factors.
• Day night orientation.
• Communication alterations.
• Family visits.
• Deep Sedation.

Presentation:

• Fluctuates between periods of lucidity inattention/high distractibility.
• Motor restlessness.
• Speech that is tough to follow.
• Perceptual disturbance.
• Memory impairment in relation to recent events.
• Disorientation to time or place.
• May exhibit signs of fear, anxiety, or anger.
• Symptoms may be worse in the late afternoon or evening - "sundowning".

Diagnosis

• Detection relies on information from patient or reliable informant, examination of records of pre-admission functional status, and repeated clinical observation.
• Confusion Assessment Method (CAM): Evaluates four key features of delirium.
  • Acute Change in Mental Status with Fluctuating Course.
  • Inattention.
  • Disorganized Thinking.
  • Altered Level of Consciousness.

Differential Dx

• Differential diagnoses include dementia, depression, psychosis, vitamin B1 and B12 deficiency, thyroid disorders, and infections such as HIV and neurosyphilis.

Treatment

• Directed at identifying and treating precipitating causes.
• Care is directed at management of symptoms: agitation, restlessness, and hallucinations).

Pharmacological Treatment

• Antipsychotic medication is used for severe agitation and risk for harm.
  • Haloperidol (Haldol): Dosage: 0.5-1 mg given PO, IV, or IM, max dose 5 mg/day onset of action: 5-20 mins if given IV, longer if given IM or PO. IV use is associated with prolonged QT, higher incidence of extrapyramidal effects in dose > 4.5 mg/day.
• Newer atypical antipsychotic agents with similar efficacy/less side effects: Quetiapine, Risperidone, Ziprasidone, and Olanzapine.

Non-pharmacological prevention/treatment

• Orientation protocols- clocks, calendars, windows, verbal reorienting.
• Cognitive stimulation - daytime visits from family/friends.
• Facilitation of sleep - reduce noise, avoid frequent waking/nighttime procedures.
• Early mobilization, limited use of physical restraints.
• Visual or hearing aids.
• Avoiding/monitoring use of problematic medications (ex. Benzodiazepines, opioids, dihydropyridines, antihistamines).
• Avoiding/treating medical complications (ex. Dehydration, hypoxemia, infections).
• Managing pain - non-opioids if possible.

Explore common dementia types, diagnostic criteria, and associated factors like alcohol abuse and visual hallucinations. Understand the cognitive domains assessed in dementia diagnosis and the distinctions between cognitive deficits.