Dementia early

EARLY DIAGNOSIS EARLY DIAGNOSIS OF DementiaOF Dementia

ByBy Abeer MahmoudAbeer Mahmoud

Ass.professor of psychiatry , institute of Ass.professor of psychiatry , institute of psychiatry, Ain shams Universitypsychiatry, Ain shams University

Early diagnosis of dementiaEarly diagnosis of dementia

Many evidence suggest that whatever the level Many evidence suggest that whatever the level of disability, the majority of people with of disability, the majority of people with dementia live in their own home. dementia live in their own home.

Other practioners is therefore the first point of Other practioners is therefore the first point of contact with them and their families, as a contact with them and their families, as a result, half of dementia cases remain result, half of dementia cases remain undiagnosed. undiagnosed.

Advantages of early diagnosisAdvantages of early diagnosis

Advantages to patients include:Advantages to patients include:1.1. Confirm the diagnosisConfirm the diagnosis2.2. Excluding treatable causes (however rare)Excluding treatable causes (however rare)3.3. Planning support and avoiding crises. Planning support and avoiding crises.

Advantages to Families:Advantages to Families:1.1. Awareness of prognosis and the disease course, time to Awareness of prognosis and the disease course, time to

organize support and plan for the future. organize support and plan for the future. 2.2. Opportunities to make appropriate legal arrangements and Opportunities to make appropriate legal arrangements and

time to consider genetic counselling. time to consider genetic counselling. 3.3. Better quality of life through enhanced knowledge and Better quality of life through enhanced knowledge and

anticipation of problems. anticipation of problems.

Hazards of early diagnosisHazards of early diagnosis

Early recognition of dementia might lead to Early recognition of dementia might lead to disclosing the diagnosis creating disclosing the diagnosis creating anxietyanxiety and and provoking a provoking a depressive reactiondepressive reaction . .

Relatives could also experience Relatives could also experience shameshame, ,

stigmastigma, , anxiety and isolationanxiety and isolation; they might ; they might alter their relationship with the patientalter their relationship with the patient ..

Diagnostic Approach to DementiaDiagnostic Approach to Dementia

To make the diagnosis, the clinician must To make the diagnosis, the clinician must document evidence of intellectual and document evidence of intellectual and practical functional decline in:practical functional decline in:

1. 1. Cognitive functionCognitive function Decline in short and long term memory and in at least one Decline in short and long term memory and in at least one

other area of cognitive function (attention, abstraction, other area of cognitive function (attention, abstraction, language, praxis, visual-spatial relationships, judgment, and language, praxis, visual-spatial relationships, judgment, and calculations) or personality changes. calculations) or personality changes.

Decline and/or interference with work, social and interpersonal Decline and/or interference with work, social and interpersonal activities, or with the ability to function within society.activities, or with the ability to function within society.

The decline is not part of a delirium, acute confusional state, The decline is not part of a delirium, acute confusional state, and cannot be accounted for by psychiatric illness and cannot be accounted for by psychiatric illness

Early Signs of Possible DementiaEarly Signs of Possible Dementia Memory loss that affects home or job skillsMemory loss that affects home or job skillsMore frequent forgetfulness or unexplainable confusion More frequent forgetfulness or unexplainable confusion

at home or in the workplace may signal that at home or in the workplace may signal that something's wrong.something's wrong.

Difficulty performing familiar tasksDifficulty performing familiar tasksAll of us occasionally get distracted and leave All of us occasionally get distracted and leave

something on the stove too long or don't remember to something on the stove too long or don't remember to serve part of a meal. People with dementia might serve part of a meal. People with dementia might prepare a meal and not only forget to serve it but also prepare a meal and not only forget to serve it but also forget they made it.forget they made it.

Early Signs of Possible Dementia,contEarly Signs of Possible Dementia,cont,,

Problems with languageProblems with languagePeople with dementia may forget simple words or People with dementia may forget simple words or

substitute inappropriate words, making their substitute inappropriate words, making their sentences difficult to understand.sentences difficult to understand.

Disorientation to time and placeDisorientation to time and placeOccasional momentary forgetting of the day of the week Occasional momentary forgetting of the day of the week

is normal. People with dementia can become lost on is normal. People with dementia can become lost on their own street, not knowing where they are, how their own street, not knowing where they are, how they got there, or how to get back home.they got there, or how to get back home.


Poor or decreased judgmentPoor or decreased judgmentPeople with dementia, however, may dress People with dementia, however, may dress

inappropriately in more noticeable ways, inappropriately in more noticeable ways, wearing a bathrobe to the store or several wearing a bathrobe to the store or several blouses on a hot day.blouses on a hot day.

Problems with complex and abstract tasksProblems with complex and abstract tasksPeople with dementia may find recognizing People with dementia may find recognizing

numbers or performing basic calculation to be numbers or performing basic calculation to be impossible.impossible.


Misplacing thingsMisplacing thingsPeople with dementia may put things in People with dementia may put things in

inappropriate places — such as an iron in the inappropriate places — such as an iron in the freezer or a wristwatch in the sugar bowl — freezer or a wristwatch in the sugar bowl — and then not recall how they got there.and then not recall how they got there.

Changes in mood or behaviorChanges in mood or behaviorPeople with dementia tend to exhibit more rapid People with dementia tend to exhibit more rapid

mood swings for no apparent reason.mood swings for no apparent reason.


Changes in personalityChanges in personalityPersonality may change as people age. People with Personality may change as people age. People with

dementia often exhibit dramatic, either sudden or dementia often exhibit dramatic, either sudden or over a period of time, personality changes. over a period of time, personality changes.

Loss of initiativeLoss of initiativeAll of us normally tire of housework, business All of us normally tire of housework, business

activities, or social obligations. People with dementia activities, or social obligations. People with dementia may remain uninterested and uninvolved in many or may remain uninterested and uninvolved in many or all of their usual habits.all of their usual habits.

Overlap withOverlap withNormal agingNormal aging Forgets parts of normal experienceForgets parts of normal experience Forgets words or namesForgets words or names Delayed recall of namesDelayed recall of names Able to follow written directionsAble to follow written directions Able to use notes & cues from environmentAble to use notes & cues from environment Able to follow a story in the book or TV.Able to follow a story in the book or TV. Slower calculationsSlower calculations Able to maintain self-careAble to maintain self-care

Overlap withOverlap with

Mild cognitive impairmentMild cognitive impairment Subjective memory complaintSubjective memory complaint Detectable memory deficit abnormal for age.Detectable memory deficit abnormal for age. Normal general cognitive functioning.Normal general cognitive functioning. Normal activities of daily livingNormal activities of daily living 40% of those aged above 65.40% of those aged above 65. 4 fold greater risk of progression to AD4 fold greater risk of progression to AD 80% progress to AD over a 10 year period80% progress to AD over a 10 year period Early detection and follow up (SPECT,MRI)Early detection and follow up (SPECT,MRI) Early intervention may lead to an improved prognosisEarly intervention may lead to an improved prognosis

The interface of depression & The interface of depression & dementiadementia

Depression in patients with dementia (10 – Depression in patients with dementia (10 – 40%).40%).

Cognitive impairment in depressed patients.Cognitive impairment in depressed patients. Symptoms common to both:Symptoms common to both:

• ApathyApathy• AnhedoniaAnhedonia• InsomniaInsomnia• AgitationAgitation• Memory lossMemory loss• Difficulty in concentration Difficulty in concentration

DepressionDepression1.1. Depression is perhaps the most common cause of "reversible" Depression is perhaps the most common cause of "reversible"

dementia in the geriatric population.dementia in the geriatric population.2.2. With abrupt onset and short duration.With abrupt onset and short duration.3.3. Previous psychiatric history may present.Previous psychiatric history may present.4.4. Presence of other depressive symptomsPresence of other depressive symptoms5.5. Elderly depressed patients may present with cognitive Elderly depressed patients may present with cognitive

impairment, i.e., confusion, memory disturbance, attention impairment, i.e., confusion, memory disturbance, attention deficits, all of which can be mistaken for dementia.deficits, all of which can be mistaken for dementia.

6.6. Memory disturbance equal for recent and remote one.Memory disturbance equal for recent and remote one.7.7. Depression may also coexist with dementia and worsen the Depression may also coexist with dementia and worsen the

problem.problem.

DeliriumDelirium Abrupt onsetAbrupt onset Short durationShort duration ReversibleReversible Early disorientation and altered consciousnessEarly disorientation and altered consciousness Fluctuating courseFluctuating course Prominent physiological changesProminent physiological changes Marked psychomotor changes.Marked psychomotor changes.

Alzheimer's diseaseAlzheimer's disease

1.1. Alzheimer's is the most common cause of dementia (50-60%). Alzheimer's is the most common cause of dementia (50-60%). 2.2. Alzheimer's disease (AD) is gradual progressive, neurodegenerative Alzheimer's disease (AD) is gradual progressive, neurodegenerative

disorder disorder 3.3. The clinical symptoms include memory loss, language disorders, visual-The clinical symptoms include memory loss, language disorders, visual-

spatial impairment, and behavioral disturbances. spatial impairment, and behavioral disturbances. 4.4. AD may present with a variety of symptoms, but difficulties with AD may present with a variety of symptoms, but difficulties with

memory are common to all.memory are common to all.5.5. For a diagnosis of probable AD, the criteria are:For a diagnosis of probable AD, the criteria are:a. Dementia established by examination and objective testinga. Dementia established by examination and objective testingb. Deficits in two or more cognitive areasb. Deficits in two or more cognitive areasc. Progressive worsening of memory and other cognitive functionsc. Progressive worsening of memory and other cognitive functionsd. No disturbance in consciousnessd. No disturbance in consciousnesse. Absence of systemic disorders or other brain diseases, which could account e. Absence of systemic disorders or other brain diseases, which could account

for the deficits in memory and cognitionfor the deficits in memory and cognition

Vascular dementiaVascular dementia1.1. Vascular dementia (VaD) may arise as a sequel to any form of Vascular dementia (VaD) may arise as a sequel to any form of

cerebrovascular disease. cerebrovascular disease. 2.2. VaD is responsible for approximately 20 percent of dementia cases.VaD is responsible for approximately 20 percent of dementia cases.3.3. As a co-morbid As a co-morbid conditioncondition, VaD may worsen the dementia of Alzheimer's , VaD may worsen the dementia of Alzheimer's

disease.disease.4.4. Diagnosis of probable vascular dementia is supported from the following Diagnosis of probable vascular dementia is supported from the following

criteria:criteria:a. sudden onset of dysfunction in one or more cognitive domainsa. sudden onset of dysfunction in one or more cognitive domainsb. Stepwise deteriorating courseb. Stepwise deteriorating coursec. presence of focal signs on neurological examination .c. presence of focal signs on neurological examination .d. History of previous strokesd. History of previous strokese. Evidence of stroke risk factors and of systemic vascular disease.e. Evidence of stroke risk factors and of systemic vascular disease.f. Evidence of relevant CVD by brain imaging, f. Evidence of relevant CVD by brain imaging,

Treatable and comorbid conditionsTreatable and comorbid conditions

1. 13% of all dementias are potentially reversible. 2. Treatable causes of dementia occur in 21% of those under 65

and 5% of those over 65%.3. The clinician must identify the coexisting medical conditions

which may worsen the dementia. "co-morbidity."4. Undetected or untreated comorbid conditions may exacerbate

an already existing cognitive impairment.5. The most common comorbid conditions affecting demented

patients are: Parkinson's disease, depression, infections (particularly urinary tract, congestive heart failure, and chronic obstructive pulmonary disease.

Comprehensive patient evaluation includesComprehensive patient evaluation includes::

1.1. A complete medical history and physical A complete medical history and physical examinationexamination

2.2. Neurological and mental status assessmentsNeurological and mental status assessments3.3. Neuropsychological assessmentNeuropsychological assessment4.4. Investigations: blood and urine, electrocardiogram, Investigations: blood and urine, electrocardiogram,

electroencephalogram (EEG), lumbar puncture, electroencephalogram (EEG), lumbar puncture, imaging exam (CT or MRI).imaging exam (CT or MRI).

Investigations

Lab WorkLab Worka. a. CBC, electrolytes and calcium, renal function, VDRL , Thyroid CBC, electrolytes and calcium, renal function, VDRL , Thyroid

function studies, B12 level, level of oxygenation.function studies, B12 level, level of oxygenation.b. Consider HIV testing, drug screening, toxin screen, collagen-vascular b. Consider HIV testing, drug screening, toxin screen, collagen-vascular

studies, general biochemical screensstudies, general biochemical screens

Imaging Studya. Duration of cognitive complaints less than 6 monthsb. Symptom onset before the age of 60c. Focal signs, focal symptoms, or papilledemad. Diagnosis of a seizure by history, or usual gait abnormalities (e.g..

ataxia or apraxic gait)

Medication-induced dementiaMedication-induced dementia

Medication-induced dementia is the most Medication-induced dementia is the most frequent cause of "reversible" dementia.frequent cause of "reversible" dementia.

Alterations in pharmacokinetics and Alterations in pharmacokinetics and pharmacodynamics, together with the pharmacodynamics, together with the presence of concomitant illnesses (especially presence of concomitant illnesses (especially renal, hepatic, and cardiac) and the number of renal, hepatic, and cardiac) and the number of prescribed medications taken, all make older prescribed medications taken, all make older people more vulnerable to this.people more vulnerable to this.

Metabolic/endocrine/nutritional/Metabolic/endocrine/nutritional/systemic disorderssystemic disorders

Metabolic/endocrine/nutritional/systemic Metabolic/endocrine/nutritional/systemic disorders (e.g., hypothyroidism, B12 disorders (e.g., hypothyroidism, B12 deficiency, and systemic infections) are deficiency, and systemic infections) are additional causes of "reversible" dementias.additional causes of "reversible" dementias.

Diagnose with routine laboratory tests. Diagnose with routine laboratory tests.

Other ConditionsOther Conditions

HIVHIV dementia. dementia.The most common of the structural brain The most common of the structural brain

lesions, presenting with dementia.lesions, presenting with dementia. Normal pressure hydrocephalus (dementia, gait Normal pressure hydrocephalus (dementia, gait

disturbance, and incontinence).disturbance, and incontinence). Brain tumors, and subdural hematomaBrain tumors, and subdural hematoma..

Behavioral Symptoms Associated with Behavioral Symptoms Associated with DementiaDementia

Behavioral problems may appear slowly and Behavioral problems may appear slowly and change as dementia progresses. The most change as dementia progresses. The most common problematic behaviors are:common problematic behaviors are: agitation; aggression , agitation; aggression , suspiciousness/paranoia; delusions; suspiciousness/paranoia; delusions; hallucinations; insomnia; and wanderinghallucinations; insomnia; and wandering

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Dementia early

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