Dementia Diagnosis, Treatment in Primary Care - Introduction to Geriatrics - Lecture Slides, Slides of Geriatrics

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Dementia Diagnosis and Treatment in

Primary Care

Overview

• Epidemiology
• Age associated Cognitive Changes
• Diagnosis
• Differential Diagnosis
• Etiology
• Workup
• Non-pharmacologic Treatments
• Drug Treatments
• Terminal Care

You agree to give a short talk about dementia at a

local church.

The following questions are asked:

1. Is it true that everybody gets “senile” if they live long enough?
2. My Dad had Alzheimer’s disease. What is my risk of getting it?
3. Sometimes when I talk to my husband, I can’t remember the names of some of those old TV show actors. Am I getting demented?

Epidemiology

• Prevalence:
  • 1% at age 60
  • Doubles every five years
  • 30-50% by age 85
  • Prevalence curve flattens out at about age 90
• 4 th^ leading cause of death in the elderly
• Life expectancy after diagnosis 3-15 years, recent data suggests shorter life expectancy Wolfson, NEJM April, 2001

Vascular Dementias

• Diagnostic criteria murky
• Overlap with AD
• Risk factors
  • Older age
  • Male > female, Black race> white race
  • HTN
  • Cigarettes, AF, DM, hyperlipidemia
• Ischemic stroke survivors: 9X increased dementia risk

Other Causes of Dementia

• Dementia with Lewy Bodies
  • #2 in autopsy studies, males > females
  • Parkinsonism, little benefit from sinemet, fluctuating impairment, visual hallucinations, neuroleptic sensitivity, rapid progression
• Frontotemporal Dementias: e.g. Pick’s disease
  • Personality changes, euphoria, apathy, disinhibition, compulsive behaviors
  • Relatively preserved visuospatial function

“Reversible Dementias”

• More properly called “potentially reversible cognitive impairments”
• Candidates: Drug induced, depression, thyroid, B12, NPH, subdural hematoma
• Truly reversible <1-3%
• Most patients go on to develop dementia
• Depression: 4-7X increase risk of dementia
• B12: 5-15% treatment responsive

Clarfield1994, Larson 1985, Patterson 1999, Freter 1998

Diagnosis of Dementia

• Multiple cognitive deficits manifested by impaired memory plus:
  • Impaired language or
  • Apraxia or
  • Agnosia or
  • Impaired executive function
• Deficits:
  • Significant enough to impair function
  • Interferes with work or social activities
• Not delirium

Age Related Cognitive Changes

• More trouble with difficult tasks when distracted
• Slower information processing
• Some decline in process oriented manipulative

aspects of short term memory

• Primary problem in long term memory is recall,

not recognition

• Most common complaint: word (name) finding

An 81 year old retired insurance salesman lives

alone, but is visited twice a year by his

daughter, who lives out of town. After the last

visit, she remarks to you that he “wasn’t

exactly on the ball”. He called her by her

sister’s name, looked unkempt, and had

difficulty following a conversation. What

might be the diagnosis given the following

information?

Name the Cause of Dementia

• 84 year old woman with AF shows step-wise cognitive decline, now with trouble walking
• 66 year old pilot cannot name a flower, but can still fly with little problem. He seems withdrawn, and has taken to shaving multiple times daily
• 78 year old has been keeping lists for years, and lately can’t name the school where she taught for 20 years. She is starting to get lost in town.
• 60 year old developed confusion, myoclonus, and clumsiness after a corneal transplant
• 68 year old woman s/p partial gastrectomy 10 years ago is confused, withdrawn, and clumsy on her feet

The Workup

• History: onset, personality, meds, family, social supports, functioning
• PE: Focal neuro exam? Vision? Hearing? Acute illness? - Labs: CBC, lytes, Ca, Cr, Bun, Glu, TSH, B - Consider: HIV, RPR, LFTs, heavy metal screen, rarely LP
• Neuroimaging: Highest yield in young, rapid onset, seizures, gait abnormality, focal exam Patterson 1999

• You have just diagnosed Mrs. Green with dementia, and have just conveyed the news to her and her family. What information should you give them up front?
• Your patient is still fairly cognitively intact. Is there anything she should be thinking about now?
• Should they take her care keys away now?
• They are picturing the worst based on a friend’s experience. Can you say anything to reassure them?

Nonpharmacologic Treatment

• Advance directives (for health care and finances) early
• Follow state laws on reporting and driving
• Not all gloom and doom
  • Quality of life may be quite good during much of

course

• Every patient does not develop every problem

associated with dementia

• Some problems get better with time