CMS 200 Dementia

Dementia Overview

• Dementia is a broad term encompassing a spectrum of disorders affecting multiple cognitive functions.
• It's characterized by a decline in cognitive function, memory loss, and difficulties with daily living.
• Risk factors for dementia encompass age, family history, cardiovascular conditions, and modifiable risk factors like hearing loss, smoking, and diabetes.
• Types of dementia include Alzheimer's disease, vascular dementia, Lewy body dementia, and frontotemporal dementia, each with unique characteristics and diagnostic criteria.
• Important to distinguish dementia from delirium, other psychiatric conditions, and normal age-related cognitive changes.
• Diagnosis involves a thorough history, physical exam, cognitive assessment, functional evaluation, and potentially lab tests, neuroimaging, and neuropsychological assessments to rule out underlying conditions, determine subtypes and assess the severity of cognitive decline.
• Early detection is critical for timely intervention and support for patients and caregivers.
• Screening tools like the Mini-Cog, GPCOG, and AD8 are useful for initial evaluation, with varying sensitivities and specificities.

Learning Objectives

• Evaluate the definition, characteristics, prevalence, and risk factors of various dementia subtypes, including associated modifiable and non-modifiable risk factors.
• Differentiate between dementia, delirium, mild cognitive impairment, neurological & psychiatric diseases, and memory loss.
• Synthesize patient information from history, physical exam, functional assessments, cognitive evaluations, and collateral history, incorporating risk factors in the analysis.
• Apply evidence-based principles, interpret lab tests, neuroimaging, and neuropsychological assessments, considering medication effects, interactions and environmental factors when diagnosing cognitive impairment.
• Appraise the effectiveness of methods for early detection and diagnosis of dementia, assessing the importance of screening in older adults. Considering the potential impact of factors like education, occupation, social circles, and cultural background on the presentation of cognitive symptoms.
• Assess the impact of dementia on patients and caregivers, considering ethical considerations, cultural factors, societal expectations, and the importance of support, education, and effective management.
• Formulate strategies for ongoing monitoring, follow-up, and interprofessional collaboration, addressing BPSD (behavioral and psychological symptoms of dementia) and complications.
• Analyze the role of modifiable risk factors, like hypertension, diabetes, smoking, and hyperlipidemia, in preventing dementia and improving patient outcomes. Analyzing the prevalence and incidence of each dementia type to understand its impact on different demographics.

Cognitive Domains

• Perceptual-motor function (visual perception, visuoconstructional reasoning, perceptual-motor coordination).
• Language (object naming, word finding, fluency, grammar, syntax, receptive language).
• Executive function (planning, decision-making, working memory, responding to feedback, inhibition, flexibility).
• Learning & Memory (free recall, cued recall, recognition memory, semantic and autobiographical long-term memory, and implicit learning).
• Social Cognition (recognition of emotions, theory of mind, insight).
• Complex attention (sustained attention, divided attention, selective attention, processing speed).
• Specific cognitive functions can be impaired, depending on the type of dementia, and the specific area of the brain affected.

Dementia Specifics:

• Memory Impairment: Common symptom, but some dementia types don't primarily present with memory loss; some present with prominent language or behavioral issues initially.
• DSM-5: Replaced the term 'dementia' with 'major neurocognitive disorder', emphasizing cognitive decline in multiple domains, excluding delirium.
• Prevalence: Dementia affects millions globally and is projected to rise substantially in the future, with incidence and prevalence increasing with age.
• Epidemiology: Factors of Dementia's risk include age, gender, family history, modifiable risk factors (like hearing loss, smoking, diabetes, and vascular conditions), and potentially ethnicity and socioeconomic factors.

Differential Diagnosis

• Delirium
• Psychiatric disorders (pseudodementia)
• Mild cognitive impairment
• Normal aging

Delirium Overview

• Acute confusional state often triggered by medical conditions, medications, or substance use.
• Characterized by fluctuating cognitive dysfunction, impaired attention, and awareness, often with a rapid onset.
• Crucial to distinguish delirium from other cognitive disorders, especially dementia, via history taking.
• The etiology of delirium is often multifactorial, stemming from a combination of medical problems, and substance use/withdrawal, infections, and side effects of medications.
• Includes physical symptoms that may involve other medical conditions; often requires a holistic evaluation to determine the cause
• It can be treatable and potentially reversible if the underlying cause is identified and addressed promptly.

MCI (Mild Cognitive Impairment)

• Transition phase between normal aging and dementia, characterized by subtle memory or cognitive deficits.
• Individuals with MCI may experience difficulty with day-to-day activities.
• Some cases of MCI progressively develop into dementia, others remain stable or improve.
• Critical to distinguish from normal age-related cognitive decline and other conditions via detailed examinations; often progresses slowly to a more significant decline if not treated
• Early diagnosis is key for potential intervention.

Alzheimer's Disease

• Most common type of dementia, associated with diffuse functional and structural brain abnormalities (pathological hallmarks: amyloid plaques & neurofibrillary tangles) affecting aspects of cognition, including memory and language.
• Risk factors include aging, genetics (APOE ε4 allele), vascular risk factors, and potentially some lifestyle factors
• Characterized by insidious onset and gradual progression of cognitive decline, with memory loss, difficulty with daily activities, language problems, and potential personality changes in later stages.

Vascular Dementia

• Second most common type of dementia, caused by cerebrovascular disease (strokes).
• Risk factors including hyperlipidemia, hypertension, diabetes mellitus, smoking.
• Symptoms fluctuate, depending on the location and extent of the affected brain areas, and may involve abrupt changes or progressive decline.

Lewy Body Dementia

• Dementia type characterized by the presence of Lewy bodies (abnormal protein deposits) in the brain.
• Often accompanied by symptoms that mimic Parkinson's disease (e.g., motor problems) and recurrent visual hallucinations; prominent fluctuations in cognitive function.
• Diagnosis includes clinical evaluation, potentially neuroimaging and other tests, often challenging due to its broad symptom presentation.
• Treatment focuses on symptom management.

Frontotemporal Dementia

• Dementia spectrum involving the frontal and anterior temporal lobes of the brain.
• Characterized by changes in personality, behavior, and language, compared to memory loss being a frequent presentation in Alzheimer's.
• A variety of phenotypes (behavioral variant, semantic variant, and non-fluent variant) presents with unique symptom sets.
• Common to have initial presentations of behavioral problems, language challenges, or personality changes.
• Diagnosis, often supported by neuroimaging and biomarker analysis, may be challenging due to the variability of presentations.

Behavioral & Psychological Symptoms of Dementia (BPSD)

• A wide range of neuropsychiatric disturbances (agitation, aggression, depression, apathy, etc) commonly encountered in dementia patients.
• Often impacts quality of life for both patient and caregiver, creating psychosocial and emotional stressors
• Associated with changes in the brain but also influenced by other factors like psychological and social stressors.

Further Testing (Across types)

• Specific testing criteria exists for each type of dementia to aid in diagnosis, often involving a combination of approaches
• A variety of neuroimaging, blood work, and biomarker analyses are used to aid in diagnosis and differentiate between different types of dementia.