Age greatest risk factor Vascular risk factors HTN DM CVD stroke smoking dyslipidemia Genetics apo E genotype late AD PSEN1 PSEN2 APP early AD Recurrent TBI or head trauma Drugs ID: 914175
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Slide1
Dementia
Slide2Risk factors for dementia
Age (greatest risk factor)
Vascular risk factors: HTN, DM, CVD, stroke, smoking, dyslipidemia
Genetics: apo E genotype (late AD), PSEN1, PSEN2, APP (early AD)
Recurrent TBI or head trauma
Drugs:
eg.
long term use of benzodiazepines
Social: low education, social isolation, physical inactivity
Depression (?)
Down’s syndrome
Slide3Case finding and screening for dementia
(CCCDTD5)
Asymptomatic individuals
Routine screening of asymptomatic individuals has no evidence at this point. Cognitive testing to screening asymptomatic adults for the presence of mild cognitive impairment or dementia is not recommended (Grade C, level 1)
BUT
In persons with elevated risk for cognitive disorders or with medical conditions associated with cognitive disorders* it is reasonable to ask the patient (and an informant, if available) about conditions regarding cognition and behaviour (Grade C, level A) If clinically significant memory conditions are elicited then further evaluation using validated assessments of cognition, behaviour, and function is appropriate (Grade B, level 1)
Conditions with elevated risk for cognitive disorders:
History of stroke or TIA
Late-onset depressive disorder or lifetime history of MDD
Untreated sleep apnea
Unstable metabolic or cardiovascular mortality
Recent delirium
First major psychiatric episode at advanced age
Recent head injury
Parkinson’s disease
Slide4DSM-5 Criteria:
Major neurocognitive disorder
Significant cognitive decline in
≥1 cognitive domains
from previous level of functioning, based on both
Concern from patient, informant, or clinician Substantial impairment in performance (preferably on standardized neuropsychological testing or other quantitative assessment) Impairment in independent living (minimum requiring assistance with complex IADLs) Not due exclusively to delirium Not primarily attributable to another psychiatric disorder
Slide5DSM-5:
Cognitive domains
Complex attention
Executive function
Learning and memory
Language Visual construction and perception Social cognition 4 “As” of dementia
Amnesia
Aphasia
Apraxia
Agnosia
Slide6NIA-AA Working Group definition:
All cause dementia
Cognitive or behavioral (neuropsychiatric) symptoms that:
Interfere with function at work or at usual activities; and
Represent decline from previous levels of functioning and performing; and
Not explained by delirium or major psychiatric disorderDiagnosed by (1) history-taking from patient and a knowledgeable informant and (2) an objective cognitive assessment, either a “bedside” mental status examination or neuropsychological testing.
Slide7NIA-AA Working Group definition:
All cause dementia
Involves minimum of
2 domains:
Slide8Major neurocognitive disorders
Alzheimer’s disease
Lewy body disease
Frontotemporal dementia
Vascular neurocognitive impairment
Traumatic brain injury HIV Huntington’s disease Other causes
Slide9DSM-5 Criteria:
Major neurocognitive disorder due to Alzheimer’s disease
Evidence of significant decline in one or more cognitive domains
Cognitive deficits interfere with independence in everyday activities (at minimum, assistance required for complex IADLs
eg.
medications, finances) Not exclusively in context of delirium Not better explained by another mental disorder Insidious onset and gradual progression of impairment in ≥2 cognitive domains
Either of the following:
**no other neurodegenerative or cerebrovascular disease, or another neurological, mental or systemic disease or condition contributing to cognitive decline
*based on patient/informant concern, or clinician; and substantial impairment in cognitive performance
preferably documented by standardized neuropsychological testing
or another quantified assessment
Slide10Genetics and Alzheimer’s disease
Autosomal dominant
APP, PSEN1, PSEN2
Apolipoprotein E4
May be associated with higher risk & earlier onset
Considered
risk modifier
Not necessary or sufficient
Slide11Genetic testing for AD
Indications for testing or referral:
AD with age of onset <60-65 years
Late-onset and multiple affected close relatives
Close relatives of the above two types of patients
Family member with an identified mutation in APP, PSEN1 or PSEN2 Testing for apo E4 is not recommended for risk assessment due to low sensitivity and specificity
Slide12Summary of non-AD major neurocognitive disorders
Slide13Vascular dementia
Imaging evidence of cerebrovascular disease (
ie
. microangiopathic changes, previous stroke)
Temporal relationship between vascular event and cognitive decline
Often step-wise progression vs. gradual or progressive decline (as seen in Alzheimer’s disease)
Slide14Dementia with Lewy Bodies or with Parkinson’s disease
Fluctuating cognition
early in the course of disease
(rather than late as in Alzheimer’s disease)
Recurrent vivid visual hallucinations (often animals) Associated features of parkinsonism May have concurrent REM sleep disorder Severe sensitivity to neurolepticsMemory and object naming often less affected than in Alzheimer’sIf parkinsonism features for ≥1 year before dementia ⟶ PDIf onset of dementia within one year of parkinsonism features ⟶ LBD
Slide15Frontotemporal dementia
Behavioural
variant
Young onset (50 to 60s)
Personality changes prominent
ie. lack of insight, social awareness, empathy; apathy Language variant (primary progressive aphasia) Semantic-variant Normal fluency but impaired comprehension May demonstrate anomia, semantic paraphasia, surface dyslexia and dysgraphia Non-fluent/agrammatic variant Effortful, non-fluent, halting speechComprehension for short words and sentences preserved but trouble with more complex phrases
May demonstrate anomia and over-simplification of words
Slide16Normal pressure hydrocephalus
“Weird, Wet, & Wobbly”
Weird ⟶ Rapidly progressive cognitive decline
Wet ⟶ Urinary urgency or incontinence
Wobbly ⟶ Gait apraxia
Slide17Delirium
Dementia
Depression
Onset
Acute (hours to days)
Chronic, progressive
Variable; may be abrupt & coincide with life changes
Course
Short, fluctuating, often worse at night
Long, progressive, stable loss over time
Diurnal effects; often worse in the morning
Duration
Typically short (hours to less than 1 month); may persist
Chronic (months to years)
Signs & symptoms present for at least 2 weeks; may persist
Level of consciousness
Lethargic or hyperalert
Fluctuates
Normal until late stage
Normal
Attention
Fluctuating inattention, impaired focus, distractibility
Generally normal; may decline in with progression
Minimal impairment; poor concentration
Orientation Impaired, fluctuating Intact initially Intact Sleep-wake cycle Reversed sleep-wake cycleFragmented sleep at night Early morning wakening
Mood and affect
Anxious, irritable, fluctuating
May be low ± some lability
Stable low mood ± apathy
Cognition
Fluctuating
Decreased executive function; thought paucity; may not be aware
Impaired concentration; aware of deficits; may unwilling to engage in testing
Memory loss
Marked short-term
Short-term, eventually long-term
Short-term
Screening tools
Confusion Assessment Method (CAM)
MOCA, Mini-Cog, MMSE, clock draw test (CDT), RUDAS, Trails A&B
Geriatric Depression Scale, Cornell Depression Scale
Slide18Confusion Assessment Method (CAM)
Acute onset & fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Diagnosis of delirium: 1 AND 2 PLUS 3 OR 4
Slide19Recommended routine lab investigations
(CCCDTD3)
Should do
CBC ⟶ rule out anemia
Calcium ⟶ rule out hypercalcemia
TSH ⟶ rule out hypothyroidism B12 ⟶ rule out B12 deficiency Glucose (FBG) ⟶ rule out hyperglycemia Electrolytes ⟶ rule out hyponatremia Might do Folate (if malnutrition or celiac)
ECG (avoid
AChEi
if left BBB, 2˚ or 3˚ heart block, sick sinus, HR < 50)
Should not do
Homocysteine level
CSF amyloid or tau level
Genetic testing for
apoE
*
*see objective #10 – may consider testing for other genes in select cases with genetic counseling
Slide20Indications for neuroimaging
(CCCDTD3)
CT/MRI recommended if ≥1 of the following are present (Grade B, level 3):
Age < 60 years old
Rapid (
eg. over 1-2 months) unexplained decline in cognition or function Short duration of dementia Recent and significant head trauma Unexplained neurologic symptoms (eg. new onset of severe headache or seizures) History of cancer (especially types that metastasize to the brain) Use of anticoagulants or history of bleeding disorderHistory of urinary and gait disorder early in course of dementia (consider NPH) Any new localizing signs (eg. hemiparesis or Babinski reflex)
Unusual or atypical cognitive symptoms or presentation (
eg.
progressive aphasia)
Gait disturbance(s)
Slide21Indications for neuroimaging
(CCCDTD3)
“There is fair evidence to support the use of structural neuroimaging with CT or MRI to
rule in concomitant cerebrovascular disease
that can affect patient management [grade B, level 2 evidence].
Slide22Driving safety
Absolute contraindications to driving (CMA Driver’s Guide):
Severe dementia
Inability to perform ≥2 IADLs or ≥1 ADL due to cognition
Dementia with LB with hallucinations and visual-spatial impairment
Behavioural variant FTD
Slide23Slide24