Dementia Diagnosis and

Prognosis
EMILY MORGAN, MD 2020
OHSU INTERNAL MEDICINE AND GERIATRICS
Objectives

Define dementia and mild cognitive impairment

Identify and differentiate the 5 most common types of dementia

Explore key elements of treatment and prognosis in dementia

BILL

Creator:Raul Rodriguez
Copyright:© Fotoluminate LLC
Bill
82 year old man, recently moved to assisted living after his wife died 12 months ago.

His daughter has noticed increasing “forgetfulness” in the past 2-3 years. Bill has good days and
bad days, but his family notices he has been neglecting his appearance recently.

No agitation or delusions, but occasional visual hallucinations. No loss of appetite or weight loss.
He has had 2 falls in the last 3 months. Never smoked, rarely drinks.

Meds: HCTZ, baby aspirin, multivitamin and occasional diphenhydramine for insomnia.
Dementia defined by DSM-V:
Major Neurocognitive Disorder
Deficit in at least one objective assessment of:
◦ Complex attention
◦ Executive ability
◦ Learning and memory
◦ Language
◦ Visuo-constructional-perceptual ability
◦ Social cognition

Deficits must interfere with independence (ADLs/IADLs)

Mild cognitive impairment defined:
Minor Neurocognitive Disorder

Minor cognitive decline from a previous level of

performance in one or more of the stated domains
No interference with function but greater effort and
compensatory strategies may be required to maintain
independence
Why is MCI important?
50% progress to dementia within 7 years
There are interventions that can potential prevent or slow
the rate of conversion to dementia
◦ Controlling vascular risk factors (OSA)
◦ Exercise (Tai chi)
◦ Diet (Mediterranean)
◦ Socialization (avoiding isolation)
Must rule out depression and
delirium when assessing for
dementia!
6 types of dementia
Alzheimer’s

Vascular

Lewy Body

Frontotemporal

Alcohol related

HIV Associated
Dementia

5%
15%
45%
20%

15%

Alzheimers Vascular Mixed LBD FTD

Alzheimer’s Dementia
Impairment in learning and memory plus one:

◦ Complex attention
◦ Executive function
◦ Language
◦ Visuo-constructional-perceptual ability
◦ Social cognition
Vascular Dementia
New cognitive deficit +

Focal neurological signs and symptoms +/-

Brain imaging evidence of cerebrovascular disease

Judged to be temporally related to the dementia

MIXED vascular-Alzheimer’s dementia

Vascular insults are very common in Alzheimer’s disease

20% of patients have evidence of both vascular and Alzheimer’s
pathology
Lewy Body Dementia
New cognitive deficits + 2/3 symptoms:

Parkinsonian findings:
shuffling gait, rigidity, dysphagia >>>tremor

Fluctuation in LOC and cognition

Well formed visual hallucinations

LBD – suggestive findings

REM sleep disorders

Severe antipsychotic sensitivity:

Exaggerated extrapyramidal symptoms
Increased rigidity and bradykinesia
Frontotemporal Dementia

A TALE OF 2 DEMENTIAS
Frontotemporal Dementia: Behavioral variant

Decline in personal or social interpersonal conduct

Impaired reasoning and difficulty with tasks out of proportion to

impairments in memory
Frontotemporal Dementia:
progressive aphasia variant

Deficits in language out of proportion to memory

impairment
◦ Motor speech
◦ Word comprehension or object recognition
◦ Word retrieval or speech errors (substitution)
Alcohol related dementia
Deficiency in thiamine (Vitamin B1)
The toxic effects of alcohol on brain cells
The biological stress of repeated intoxication and withdrawal
Alcohol-related cerebrovascular disease
Head injuries from falls sustained when inebriated
Alcohol related dementia
Learning and memory most effected
Confabulation - making up information not remembered
People with alcohol related dementia many benefit from extended
treatment with oral thiamine and magnesium

With treatment:
¼ will completely recover
½ will improve without complete recovery
¼ will remain unchanged
HIV Associated Dementia
Late stage disease: CD4<200 and high viral loads
Characterized by symptoms of cognitive, motor, and behavioral disturbances
Behavioral changes including apathy and social withdrawal
Motor changes include gait impairment, falls, impaired fine motor skills
No quick screening test validated – MoCA likely the best, also Modified HIV
Dementia Scale

https://aidsetc.org/guide/hiv-associated-neurocognitive-disorders
Quick memory Screen
The Mini Cog

◦ 3 item recall

◦ Clock draw
Validated for
diagnosis of
dementia AND for
MCI

Tests 5 brain
domains
Tests 6 brain domains

Helps to assess driving

ability
MoCA < 18
Abnormal trails B
Abnormal clock
MMSE
(proprietary- $1.68/use)
Tests 4 brain domains:
◦ orientation, memory, visual-spatial, verbal fluency

USE ONLY FOR FOLLOWING DEMENTIA OVER TIME

Physical Exam
Neurologic Exam:

◦ Sensory, Reflexes, Strength, Motor Coordination

◦ E/o Parkinsonism?
◦ Gait assessment: Timed Get up and Go (TUG)
Lab studies

TSH
Vitamin B12 (MMA)
Consider HIV and RPR
If none recently: CBC and metabolic panel
Neuroimaging
Non contrast CT scan or MRI
For any patients under age 65
Or patients over age 65 with:
◦ Atypical presentation
◦ Unclear diagnosis
◦ Rapid unexplained deterioration
◦ Unexplained focal neurological symptoms
◦ History of head injury
◦ Urinary incontinence or gait ataxia early in illness
◦ Suspicion of undiagnosed CV disease
BILL

Creator:Raul Rodriguez
Copyright:© Fotoluminate LLC
Bill
SLUMS
Orientation 3/3
Calculation 1/3
Naming 2/3
Object Recall 3/5
Attention 1/2
Clock 0/4
Shapes 2/2
Story Recall 4/8
Total 16/30
Bill
Gait – wide based, mild shuffling, TUG>15 sec
Tone – mild cog wheeling on L side
No tremor, normal facial movements

On further questioning, Bill has a long hx of “insomnia” caused by restless

sleep. He has vivid dreams, often acting them out in his sleep.

Lewy Body Dementia

Now that my patient has a diagnosis, what next?
◦ Staging Dementia for treatment
◦ Behavioral symptoms assessment
◦ Driving assessment
◦ Home safety evaluation
◦ Caregiver burden
◦ Goals of care planning
Staging dementia

Mild
MoCA 20-16 Moderate
MoCA 15-10
Advanced
Decline in End stage
IADLs, mild Decline in
behavioral ADLs, MoCA <10
symptoms Increasing FAST staging
behavioral Needing 24 for hospice
symptoms hour care care
A review of Reviews – what works?
Exercise
Patient+Caregiver QOL interventions
AChE-I
Memantine

Laver K, Dyer S, Whitehead C, Clemson L, Crotty M. Interventions to delay functional decline

in people with dementia: a systematic review of systematic reviews. BMJ Open.
2016;6(4):e010767. Published 2016 Apr 27. doi:10.1136/bmjopen-2015-010767
Cholinesterase Inhibitors
Most studies with statistically significant difference favoring
cholinesterase inhibitors
–Delay in progression of up to 7 months in mild dementia
–Delay of 2-5 months in moderate dementia
–Statistically significant improvement in behavioral symptoms in mild
and moderate dementia
–Effective for all dementia types except FTD

Raina 2008, Rodda 2009

When to stop?
A Systematic Review of Practice Guidelines and Recommendations
for Discontinuation of Cholinesterase Inhibitors in Dementia.
Renn BN, Asghar-Ali AA, Thielke S, et al.
Am J Geriatr Psychiatry. 2017;26(2):134-147.
Risk for Health Events After Deprescribing
Acetylcholinesterase Inhibitors in Nursing Home Residents
With Severe Dementia

Journal of the American Geriatrics Society, First published: 26 November 2019, DOI: (10.1111/jgs.16241)
Memantine
Memantine for Alzheimer's Disease: An Updated Systematic Review
and Meta-analysis. Kishi et al. J Alz Disease, 2017.

Memantine showed a significant improvement

Cognitive 95% CI (-0.34, -0.15) p < 0.00001
Behavioral 95% CI (-0.34, -0.07) p = 0.003
Memantine

Studies in vascular, LBD, and FTD trend toward benefit

Dual therapy with AChE-I or monotherapy
Dose: 5mg daily -10 mg bid
eGFR of 30-60, max dose is 10 mg daily
Stop if eGFR below 30
Mild Dementia
Alzheimer’s Vascular Lewy Body FTD
mixed

Trial AChE-I Control vascular risk Trial AChE-I (NO AChE-I)

factors
PT/OT Trial memantine
Trial AChE-I
Driving and safety Driving and
assessment Safety
assessment

Exercise (Tai chi)

Mediterranean diet
Socialization
Mild Dementia
Conversations with patient and family:
What are your wishes?
What’s it going to look like?
Assisted living options
Advance Directive
Plan to stop driving
Moderate Dementia
AlzheimerSs Vascular mixed Lewy Body FTD

Trial AChE-I Control vascular Trial AChE-I Trial memantine

risk factors
Trial memantine Trial memantine
Trial AChE-I
Trial memantine
Moderate Dementia
Conversations with patient and family:
What is our safety plan?
Neuropsychiatric symptoms
Yes and… approach to communication
Memory care options
POLST
Advanced Dementia
Alzheimer’s Vascular Lewy Body FTD
mixed

Consider Consider Consider Trial memantine

stopping AChE-I stopping AChE-I stopping AChE-I

Trial memantine Trial memantine Trial memantine

Advanced Dementia
Conversations with caregiver:
24 hour caregiving
Planning for end stages
◦ Loss of mobility
◦ Loss of verbal interaction
◦ Complete Incontinence
◦ Dysphagia
◦ Weight loss
References
Laver K, Dyer S, Whitehead C, Clemson L, Crotty M. Interventions to delay functional decline in people with
dementia: a systematic review of systematic reviews. BMJ Open. 2016;6(4):e010767. Published 2016 Apr 27.
doi:10.1136/bmjopen-2015-010767
Lockhart IA, Orme ME, Mitchell SA. The efficacy of licensed-indication use of donepezil and memantine
monotherapies for treating behavioural and psychological symptoms of dementia in patients with Alzheimer’s
disease: systematic review and meta-analysis. Dement Geriatr Cogn Dis Extra. 2011;1(1):212–27.
McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev.
2006;2:CD003154.
Raina, P, et al. Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review
for a Clinical Practice Guideline. Ann intern Med. 2008;148: 379-397.
Rodda J, Morgan S, Walker Z. Are cholinesterase inhibitors effective in the management of the behavioral and
psychological symptoms of dementia in Alzheimer’s disease? A systematic review of randomized, placebo-
controlled trials of donepezil, rivastigmine and galantamine. Int Psychogeriatr. 2009;21(5):813–24.
Stinton, et al. Pharmacological Management of Lewy Body Dementia: A Systematic Review and Meta-Analysis.
Am J Psychiatry. 2015 Aug 1; 172(8): 731–742. Published online 2015 Jun 18.
doi: 10.1176/appi.ajp.2015.14121582.
Wang H, Yu J, Tang S, et al. Efficacy and safety of cholinesterase inhibitors and memantine in cognitive
impairment in Parkinson's disease, Parkinson's disease dementia, and dementia with Lewy bodies: systematic
review with meta-analysis and trial sequential analysis. J Neurol Neurosurg Psychiatry 2015;86:135-143.
Questions???