Dementia Risk factors for dementia - PowerPoint Presentation

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Dementia

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Risk 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

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Case 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

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DSM-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

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DSM-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

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NIA-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.

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NIA-AA Working Group definition:

All cause dementia

Involves minimum of

2 domains:

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Major neurocognitive disorders

Alzheimer’s disease

Lewy body disease

Frontotemporal dementia

Vascular neurocognitive impairment

Traumatic brain injury HIV Huntington’s disease Other causes

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DSM-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

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Genetics 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

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Genetic 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

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Summary of non-AD major neurocognitive disorders

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Vascular 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)

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Dementia 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

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Frontotemporal 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

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Normal pressure hydrocephalus

“Weird, Wet, & Wobbly”

Weird ⟶ Rapidly progressive cognitive decline

Wet ⟶ Urinary urgency or incontinence

Wobbly ⟶ Gait apraxia

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Delirium

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

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Confusion Assessment Method (CAM)

Acute onset & fluctuating course

Inattention

Disorganized thinking

Altered level of consciousness

Diagnosis of delirium: 1 AND 2 PLUS 3 OR 4

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Recommended 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

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Indications 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)

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Indications 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].

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Driving 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

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