DEMENTIA C L I S K C O N S U LTA N T P H Y S I C I A N I N A C U T E M E D I C I N E A N D G E R I AT R I C M E D I C I N E, B A R N E T H O S P I TA L, R O YA L F R E E N H S F O U N D AT I O N T R U S T A N D H E R T F O R D S H I R E C O M M U N I T Y N H S T R U S T
MENU Epidemiology of dementia Continum of Alzheimers dementia AD Pathological features of AD Clinical features Differential diagnosis Investigations Cognitive testing Management including Resources available and update in the clinical use of established therapies The future perhaps: agents in development Biomarkers Prevention of AD; is this achievable or a pipedream?
Alzheimers dementia Neurodegenerative disorder marked by cognitive and behavioural impairment that significantly interferes with social and occupational functioning. Incurable with long preclinical period and progressive course
PROJECTION: Worlds dementia population is expected to triple by 2050
COSTS
AD PREVALENCE
THE CONTINUM OF AD
Risk factors for AD
AD overview
PATHOLOGICAL FEATURES OF AD
Plaque deposition and AD pathology
Clinical signs and symptoms MILD AD Memory loss Confusion about the location of familiar places Taking longer to accomplish normal daily tasks Trouble handling money and paying bills Compromised judgement often leading to bad decisions Loss of spontaneity and sense of initiative Mood and personality changes; increased anxiety MODERATE AD Increasing memory loss and confusion Shortened attention span Problems recognising friends and family members Difficulty with language; problems with reading, writing, working with numbers Difficulty organising thoughts and thinking logically Inability to learn new things or to cope with new unexpected situations Restlessness, agitation, anxiety, tearfulness, wandering Repetitive statements or movement; occasional muscle twitches, Hallucinations, delusions, suspiciousness or paranoia, irritability Loss of impulse control Perceptual motor problems such as trouble getting out of a chair or setting the table
Clinical signs and symptoms (severe) Cannot recognise family or loved ones Completely independent for all ADLS Vanishing sense of self Weight loss Seizures, skin infections, difficulty swallowing Groaning, moaning, grunting Increased sleeping Lack of bladder and bowel control Death usually from aspiration pneumonia frequently
Other signs and symptoms Language disorders; anosmic, aphasia or anomia Visuospatial and executive functions impairment Less commonly right parietal lobe syndrome, spastic paraparesis.
Distinguishing AD from MCI
Physical examination Complete physical examination Mental status examination Attention and concentration Recent and remote memory Language Praxis (ability to perform skilled motor task without nonverbal prompting) Executive function Visiospatial function
Assessing language
Declining ability to function
RACHEL.
Mood and emotional changes
WHAT TESTS WOULD YOU ORDER FOR RACHEL?
Determining the level of impairment
Cognitive impairment
Differential diagnosis
Differential diagnosis
Workup and what next..
Cognitive testing
AD 8
Biomarker testing
Neuroimaging in AD
Hippocampal volume assessment
MRI IMAGING
MRI
MANAGEMENT: CHOLINESTERASE INHIBITORS
FDA APPROVED DRUGS FOR AD
Cognitive benefit of donepezil
Cognitive benefit of donepezil
Cognitive benefit of donepezil
Rivastigmine
Cognitive effects of rivastigmine
Galantamine
Memantine
Side effects of cholinesterase inhibitors
Caide score for predicting risk of dementia
Antihypertensives and AD
OBSTACLES TO RECOGNISING DEMENTIA
DETECTING COGNITIVE IMPAIRMENT IN PRIMARY CARE
DETECTING COGNITIVE IMPAIRMENT IN PRIMARY CARE
Conclusions