Diagnosing & Dealing with Dementia

Transcription

1 Diagnosing & Dealing with Dementia Robert G. Arias, PhD. I have no financial disclosures or conflicts of interest to report. Robert G. Arias, PhD. 1

2 Today We Will Learn About: Diagnosing dementia Characteristics of a few common dementias & mild TBI Decision-making with cognitive changes Diagnosis of Dementia Memory Impairment (learning/recalling) One or more of: laphasia lapraxia lagnosia lexecutive dysfunction Cause functional impairment 2

3 Prevalence of Dementia 10% over age 60 20% over age 80 What s the Difference Between Alzheimer s & Dementia?? 1) Dementia is always Alzheimer s 2) Dementia is different than Alzheimer s 3) Alzheimer s is just one type of dementia 4) I m confused by the question 3

4 Neuropathology of a Few Common Dementias Alzheimer s Disease lneurofibrillary plaques & tangles Lewy Body Disease llewy bodies Vascular Dementia lischemic or hemorrhagic events Frontotemporal Dementia/Pick s Disease lpick s bodies Alzheimer s Disease Believed to account for >50% of dementias Memory Visuo-spatial/constructional skills Word-finding Executive impairment 4

5 Alzheimer s Disease (cont d) EEG: generalized slowing MRI/CT: generalized atrophy PET: generalized hypometabolism Vascular Dementia Believed to account for 20% of dementias Focal neurologic & imaging signs Abrupt onset May have any type of neurocognitive, behavioral, or psychiatric dysfunction (70% with depression) 5

6 Lewy Body Disease Memory, attention, and visuospatial skills Parkinsonism Hallucinations, delusions, and paranoia Insidious onset with fluctuating course MRI/CT: global atrophy Frontotemporal Dementia (FTD) Age at onset: Prevalence: 10-15% Course: Mean of 7 yrs (range 3-17) Most need supervision within 2 yrs of dx Initial presentation tends to be psychiatric 6

7 FTD (Neuropsych Aspects) MMSE - remains intact until late Speech - later onset & ends in mutism Attention - may be severely dysregulated Memory - variable; retrieval-based Visuospatial/construction - intact Sensory/Motor - pout; grasp Executive - disinhibited; severe impairment Emotional - may be euphoric FTD (cont d) MRI/CT: frontotemporal atrophy; may be lateralized PET: reduced anterior blood flow EEG: normal 7

8 AD vs. FTD AD: superficial social functioning remains preserved early on FTD: early social breakdown, personality change, neglect of hygiene and responsibilities. Quiz -- Pt presents as: 65 y/o angry male with acute AMS on 2 yrs of gradual progressive decline in memory. Lives alone & drives Changes in gait Paranoia, Hallucinations, Behavioral Change Severe gen. atrophy/wm (CT/MRI) & slowing (EEG) Chr ETOH, DM2 (A1C=10), HTN urgency, HLD, AKI/CKD3, Hep C, Afib, Hypothyroid, Rx d 15 meds (n/c), 2ppd cigs, COPD, acute hypoxic resp fail 8

9 1) Run & hide in the restroom 2) Give the pt to your partner & tell them you owe them a favor 3) Admit to hospital 4) Deal with the DM2, HTN, AKI 5) Stop the alcohol & deal with WD sx 6) Stablize all other conditions 7) Mobilize any support system the pt has - POA 8) Neuropsych consult Decisional? 9) Placement 10) After medically stable, refer for full neuropsych eval as outpt to determine long-term plan Quiz Pt presents as: 80 y/o pleasant female with 1 yr of mild memory decline. No other problems 1) Neurological referral 2) Bloodwork/scan/MMSE 3) Start memory med & see in a month 4) Neuropsych referral 9

10 Quiz Pt presents as: 80 y/o pleasant female whose family complain of minor MVC s, med errors, asking about dead relatives as though they re alive 1) Bloodwork/scan/MMSE 2) Restrict driving 3) Neurological referral 4) Neuropsych referral Driving 47% of AD patients have had MVC s in past 5 yrs compared to 10% of controls 30% of dementia patients had >1 MVC since onset of symptoms 10

11 Mild Traumatic Brain Injury Dx Based on Subjective Complaints? 1) Yes 2) No MTBI Committee (1993) LOC < 30 min PTA < 24hrs Altered mental state at the time of the accident Focal neurological deficits MTBI Outcomes Do 15% of MTBI pts have lasting sequelae? 1) Yes 2) No 11

12 NO -- Cog & emotional sequelae ALWAYS resolve Typically in 2 wks, but a max of 3 months Reassuring pts of this info improves outcomes Postconcussive Syndrome?? Dx is based on subjective complaints High base rates in general population Occur as often in orthopedic injuries without TBI Twice as often in litigating pts Best predicted by pre-existing psych problems More appropriately categorized as a somatoform disorder 12