Dementia

Ronald Wilson Reagan (February 6, 1911 –June 5,

2004) was an American politician and actor who
served as the 40th President of the United States of
America from 1981 to 1989.

Ronald Reagan was diagnosed with Alzheimer’s in

1994, though many speculate that symptoms in his
speech were prevalent years before his diagnosis.

He became an advocate for Alzheimer’s –

dedicating the month of November as Alzheimer’s
Awareness Month.

In 2004, he developed pneumonia and passed away

at the age of 93.
What is Dementia ?
 ICD 10 Diagnostic Criteria for Dementia

G1 There is evidence of each of the following

01 A decline in memory, most evident in the learning of new information.

This should be verified from the informant, by neuropsychological tests
and quantified cognitive assessments

02 A decline in other cognitive abilities, as in judgment, thinking,

planning, organizing and in general processing of information. This
should be verified from the informant, by neuropsychological tests and
quantified cognitive assessments. Deterioration from a previously higher
level of performance be established
 ICD 10 Diagnostic Criteria for Dementia

G2
Awareness of environment is preserved sufficiently long to allow the
demonstration of the symptoms in G1
G3 Decline in emotional control or motivation or a change in social behavior
manifested as at least one of the following:
• Emotional lability
• Irritability
• Apathy
• Coarsening of social behavior
G4 For a confident diagnosis, the symptoms in criterion G1 should have been present
for at least 6 months
 mhGAP-IG base course - field test ve
Is Dementia important?
rsion 1.00 – May 2012

 Dementia is one of the major causes of disability in late-life

 Dementia is prevalent worldwide but is often undiagnosed
 Health care provider are often not aware of impact of dementia
on carers and families
Millions

Growth in numbers of people with dementia

Low-and Middle- income countries

High- income countries

6
So what do we do?
 Approximate number of AD patients
in Pakistan?
 Total population = Approx 193 million*
 4.3% of the population is 65 y or older*
 8 million people > 65 yrs age**,***

 2% to 3% of 8 million i.e 160,000 to 240,000 are currently

affected by dementia in Pakistan out of which
 80,000 to 120,000 probably have AD

*2013 CIA World fact book **US census International Database. ***UN Projects
Types of Dementia
AREAS - ASSESSEMENT

History

Mental state examination

Physical examination

Laboratory investigations

Cognitive assessment with instruments

HISTORY TAKING
 HISTORY TAKING
Patient + listen to the carers
 Sx onset & course - insidious,
chronic, progressive
 Duration
 Memory impairment
 Visio spatial problems
 Needs physical help - ADL
 Poor communication,
repetitiveness
 Apathy
 Uncontrolled emotion/behavior
 Emotional reactions
 Mistaken beliefs, paranoia
 Decision making
 Incontinence
 Risks at home/outside
 Burden on family
 Medical co morbidities
 Family Hx
 Drug Hx
History Taking

 pay attention to early signs of

Dementia during history taking.
Ask the family
• Memory lapses
• Retaining new
information
• Handling complex
tasks
• Spatial ability and
orientation
• Reasoning
• Language
• Behavior
 Mental State Exam
 Level of consciousness (arousal)
 Observe; alert, attentive, sleepy,
unresponsive
 Orientation; T,P,P
 Attention & concentration:
 Digit span
 Spell word back words
 Month of year back wards
 Trail making test
 Symbol copying test
 Memory
 Immediate , working
memory – digit span
 Recent memory – list of
unrelated words
 Remote memory – evets
 Visual memory – Rey-
Osterreith complex figure
 Supra-span learning task
 Mental State Exam
 Language:  Praxis
 Fluency  Complex task
 Comprehension
 Calculations
 Content
 Serial 7s
 Repetition
 Naming  Executive Function:
 Reading  Mental flexibility – divide attention
and change sets – trail making B
 Writing
 Ability to inhibit responses – go no go
 Visual spatial perception:  Motor programming – Perseveration –
 Drawing/ copying tasks; 3D cube, Luria, simple rhythmical movement
CDT, overlapping pentagons  Abstract Reasoning:

 Mood & thought content

 Differences elicited by History
NORMAL AGING
Independent in all activities of daily living(ADL)
Patient claims of memory loss but can recalls
incidents of forgetfulness
Patient more concerned about memory loss
Recent memory of events and conversations intact
Occasional difficulty in finding words (expressive
aphasia)
No history of getting lost in familiar territory, may
pause briefly to reorient
Able to operate common appliances
Normal interpersonal and social skills
- http://www.ama-assn.org/resources/doc/public-health/aging_vs_dementia.pdf
DEMENTIA
Dependent on others for ADL
May report memory loss if asked, unable to recall
instances of forgetfulness
Close family members more concerned about
memory loss
Notable decline in memory of recent events and
conversations
Frequently experiences difficulty in finding words
with or without difficulty of understanding
(expressive and receptive aphasia)
History of getting lost in familiar territory while
walking or driving
Unable to operate common appliances
Loss of interpersonal and social skills, lack of interest
in social activities or inappropriate behavior
Pay Attention!!
 Instruments for Assessment

 Cognitive assessment
 At least one standard screening instrument
 1-MMSE
 2-GPCOG
 3-Mini-Cog
 4-Abbreviated Mental Test Score

 Supplemented with additional tests of memory

MMSE
 Recognizing Dementia

 Lack of awareness about dementia is quite common in both

the general population as well as the physician workforce.
 There is a lack of focus on geriatric medical education in
medical schools.
 Detection of differences between normal aging and dementia
then becomes rather difficult for the non-discerning eye.

- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569732/
 Diagnostic Imaging

 Neuro-imaging should be performed in the diagnostic work up to

exclude other potentially treatable causes of dementia, to look for
vascular lesions and to differentiate different types of dementia.
 MRI is preferable over CT brain. For Rapidly progressing
dementias MRI should include DWI and ADC sequences
 Functional imaging is recommended only in cases where diagnosis
is in doubt after clinical and structural imaging and in special
circumstances.
(EFNS guidelines 2012)
 Recommendations:
 The patient should be counselled about the progressive nature
of disease and unavailability of disease modifying agents
 The decision to initiate a trial of therapy with a cholinesterase
inhibitor or memantine should be made by the treating
physician based on individualized assessment.
 The choice of pharmacologic agents should be based on
tolerability, adverse effect profile, ease of use, and cost of
medication.
Recommendations
 Non-pharmacological treatment/Dietary
supplements

 There was no additive effect from selegiline plus vitamin E, neither agent
improved cognitive function (ADAS–Cog) compared with baseline values,
and those on drug did not decline less than those on placebo on these types
of measures

 Similarly there are no clinical trials to support a recommendation of

dietary and supplemental omega-3 polyunsaturated fatty acid for the sole
purpose of preventing cognitive impairment or dementia

- Sano M, et al. New Eng J Med 1997; 336: 1216–1222

- Lim WS, et al. Cochrane Database Syst Rev 2006;(1):CD005379).
Patient Safety Issues

 Patient safety should be assessed and any gap should be addressed

on follow up visits for all dementia patients.

 Common safety issues that can lead to significant morbidity and

even mortality are presence of sharp object within easy reach,
slippery floor, loose throw rugs, poor lighting etc.

 Driving is contraindicated for demented patients if they have poor

reasoning and safety awareness as well as impaired ADLs and
instrumental activities of daily living (IADL).
Patient Safety Issues

 Home help which may be needed 24/7.

 Fall risk assessment, Berg balance test should be done and

appropriate walking aids advised to minimize the risk of falls.

 Arm bands with identification and contact information.

 Watches/ cell phones/ devices with GPS monitoring

Pharmacological Interventions
Thank you