DEMENTIA

Dr Anil Kakunje DPM, MD

Professor & Head
Department of Psychiatry
Yenepoya Medical College
Mangalore
 India - Demographics

Year No Of Older Persons

1901 12 million
1951 19 million
1990 57 million
2001 77 million (7.7% of the population)
2010 100 million (almost 10% of population)
2025 177 million
 Elderly Health Problems

Persons above the age of 65 usually

have 2 to 3 physical illness (vision,
hearing, heart diseases, diabetes,
hypertension, arthritis...)

plus a mental illness

DEMENTIA
• Latin dementia madness,
De ...without
Mentia.....mind

• equivalent to - out of one's mind

What is dementia
Dementia is not a specific disease. It's an
overall term that describes a wide range
of symptoms associated with a decline in
memory or other thinking skills severe enough
to reduce a person's ability to perform everyday
activities.

• DSM-5 classifies dementia as a neurocognitive

disorder.
What is dementia
• Dementia is characterised by a decline of
information processing abilities accompanied by
changes in personality and behaviour

• Dementia is an umbrella term for progressive

disorder of cognition
Prevalence

• Starting at age 65, the risk of developing the disease

doubles every 5 years.
• The Alzheimer's & Dementia: The Journal of the Alzheimer's Association 2015 11, 332-
CLASSIFICATIONS
• REVERSIBLE DEMENTIA – IRREVERSIBLE

• PRIMARY DEMENTIA – SECONDARY

• CORTICAL DEMENTIA- SUBCORTICAL

• EARLY ONSET – LATE ONSET

 Treatable Dementias
Thyroid disease
B12 deficiency
Thiamine deficiency (Wernicke
encephalopathy)
Pellegra
Normal- pressure hydrocephalus
Sub-dural haematoma
Benign brain tumors
Chronic meningitis
Abscess
Cyst
 Classification of dementias
• Primary degenerative dementias
▫ Dementia pure: neurodegenerative disorders primarily
involving cerebral cortex
 Alzheimer’s disease
 Focal degenerations
▫ Dementia plus: neurodegenerative disorders involving
additional brain areas such as basal ganglia or other
subcortical structures
 Dementia with Lewy bodies
 Parkinson’s disease
 FTD-Parkinsonism-17; FTD with motor neuron disease
 Corticobasal degeneration
 Huntington diseae
 Familial multiple system taupathy
 Progressive subcortical gliosis
 Classification of dementias - II
Secondary forms of dementia
▫ Disorders damaging the brain tissue directly
 Vascular-ischaemic causes
 Infections
 Inborn metabolic disorders
 Traumatic brain injury
 Post-radiation dementia
 Some brain tumors
 Parasitic cysts or brain abscess
▫ Disorders changing intracranial contents and distorting
brain structures
 Normal pressure or obstructive hydrocephalus
 Subdural or intraparenchymal haematoma
 Primary or metastatic brain tumors
• Cortical dementias : Alzheimer’s dementia,
Creutzfeldt-Jakob disease

• Sub-cortical : result from dysfunction in the

parts of the brain that are beneath the cortex.
Huntington's disease, and AIDS dementia
complex, Parkinson’s dementia
Percentages of various dementias
Early vs Late
(Kate Jefferies Aug 2009)
Dementia-Risk factors
(10/66 Research group)

NON MODIFIABLE MODIFIABLE

• Age • Vascular Disease
• Female • Hypertension
• Family history • Diabetes
• Genes-ApoE4 • Dyslipidemia
• Head trauma • Nutritional def
• Mutat on chr 1,14,21 • Smoking
• Down’s syndrome • Alcohol
• Obesity
 Dementia - Protective factors
Christine A.F , Journal of Alzheimer’s disease, 2012

• Statins • Active mental faculties

• Antioxidants- Vit E
• Anti-inflamm meds
• Diet-omega 3 fats,
carotene
• Vitamins
• Exercise
• Estrogen use?
• ApoE2 allele
 Stages of Alzheimer’s Disease 1
Mild
Primary early symptom is forgetfulness
names/words
addresses
shopping items

Main deficit is in recent memory

Intellectual deficits confirmed by neuropsychological testing

Some awareness of their symptoms, so the person may

become anxious, depressed and may be in denial

No distinguishing features on physical examination

Stages of Alzheimer’s Disease 2
Moderate
Significant memory loss – close family members / well

known routes/places

Personality and behavioural changes

Self-neglect

Disorientation in time and space

Inability to undertake simple tasks i.e. dressing

Reduced range of thinking (intellectual deficits)

Language problems start

Disinhibition
Stages of Alzheimer’s Disease 3
Severe
Dysphasia with disordered and fragmented speech

Aggression, restlessness and wandering

Hallucinations and delusions

Incontinence

Immobility, rigidity and recurrent falls

General physical deterioration

NEURO ANATOMY IN DEMENTIA
NEUROTRANSMITTERS in dementia
Complex Interaction of Factors

Psychological

Biological /
Social /
Physiologic
al Environme
ntal
Psychiatric manifestations
• Psychiatric manifestations in clinical
populations of patients suffering
from dementia is high:

• 15% to 30% for hallucinations,

• 15% to 30% for delusions,
• 10% to 20% for major depression
• 40% to 50% for depressed mood

(Paquette, CJP 1993)

Psychiatric manifestations

• BPSD – Behavioural & psychological

symptoms of dementia
• Behavioural symptoms, sleep
problems, anxiety, aggression,
personality changes, inappropriate
sexual behaviour
• Atipcal presentations are common

(Paquette, CJP 1993)

Laboratory tests
Routine Optional
Blood glucose
CBC Serum calcium
Thyroid function tests EEG
AST, ALT Drug levels
Urinalysis Heavy metals in urine
BUN CSF analysis
Uric acid PET/SPECT
Sedimentation rate
Syphilis serology
CT, MRI
Chest X-ray
HIV testing
Vitamin B12 level
ECG
 DIFFERENTIAL DIAGNOSIS
DEMENTIA DELIRIUM DEPRESSION
ONSET GRADUAL ACUTE VARIES - WEEKS
PMA NORMAL INCREASED HYPO/AGITATED
ORIENTATION PRESERVED CONFUSED NORMAL
MOOD APATHY FLUCTUATING LOW
SLEEP DISTURBED SUN DOWNING EARLY MORNING
AWAKENING
PSYCHOTIC LATE IMMEDIATE LATE
SYMPTOMS
AGE ELDERLY ANY ANY
THINKING COGNITIVE POOR ATTENTION POOR
DECLINE CONCENTRATION
SCREENING TOOL MMSE CAM GDRS
COURSE CHRONIC REVERSIBLE USUALLY
MILD COGNITIVE IMPAIRMENT
▫ Somewhere between memory changes of
normal aging and dementia
▫ Can affect memory, or other domains or
both
• Mild cognitive impairment causes cognitive
changes that are serious enough to be
noticed by the individuals experiencing them
or to other people, but the changes are not
severe enough to interfere with daily life or
independent function.
DEMENTIA AND INDIAN MOVIES
DEMENTIA AND INDIAN MOVIES
CASE VIGNETTE
• This 65 year old man presented with a 9 months
history of increasing forgetfulness. He would get
lost on local journeys . Over the same period his
personality had changed and he became
extremely emotional at times. The symptoms
were progressive and by the time of admission
he was unable even to tie up his shoe laces. On
neurological examination he was withdrawn,
irritable, and tremulous. MMSE score was
13/30.
The Evidence
1. Is it possible to promote earlier diagnosis of
dementia, and how might this be achieved?
▫ Screening tools in primary care (5 minutes or
less) - the General Practitioner Assessment of
Cognition (GPCOG), the Memory Impairment
Screen (MIS), the Mini Cog, Brief version of the
Community Screening Instrument for Dementia
(brief CSI-D)

▫ Memory Clinics
Prevention-Summary
• Modifiable risk factors- Vascular, DM, BP,
Obesity/BMI – all disorders
• Healthy Active lifestyle- Exercise, diet,
socialization, mental activity, spirituality
• Early screening & treatment
• Specially...screen persons at risk for disorders
• Public education & awareness
• Improve access to treatment, reduce barriers
Summary
• Dementia is a group of symptoms. Alzheimer’s
the commonest Dementia
• Prevalence reaching alarming proportions
• Managing the risk factors, spreading awareness,
early detection holds the key
• Differentiating from other illnesses important
• We need to remember those who cannot
remember!