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HOW TO EXAMINE PATIENTS WITH DEMENTIA
Serge Gauthier, MD, FRCPC
McGill Centre for Studies in Aging
Douglas Mental Health Research Institute
OUTLINE
• Usual clinical presentation of dementia
• Diagnostic criteria for the common degenerative dementias
• Natural history of AD
• Cases
CLINICAL PRESENTATION OF DEMENTIA
• Decline in intellectual abilities (memory plus one other domain)
• Interfering with social or occupational life
CLINICAL PRESENTATION OF DEMENTIA
• Decline in intellectual abilities (memory plus one other domain)
• Interfering with social or occupational life
CLINICAL PRESENTATION OF DEMENTIA - MEMORY
• Do you need reminders for appointments?
• Do you forget birthdays? (Women only!)
• Do you look for things at home?
• Do you remember recent conversations?
• Do you need to read back a page in your book to get back into the story?
CLINICAL PRESENTATION OF DEMENTIA - LANGUAGE
• Do you look for words? – do you say “give me the thing there…what do you call it?”
• Do you have trouble finishing your cross-word puzzles?
• Do you still do ‘Mystery words’?
CLINICAL PRESENTATION OF DEMENTIA - PRAXIS
• Do you still fix things in the house?
• Do you have trouble using your computer, using the phone?
• Do you have difficulties using kitchen appliances?
• Do you need help to get the shower running?
CLINICAL PRESENTATION OF DEMENTIA - GNOSIS
• Do you have difficulties recognizing people?
• Do you have trouble with directions when driving?
CLINICAL PRESENTATION OF DEMENTIA – EXECUTIVE ABILITIES
• Do you need help playing a card game?
• Do you find it difficult to plan a meal for the family?
• Do you need help to pay your bills on time?
• Do you need help to take your pills?
CLINICAL PRESENTATION OF DEMENTIA
• Decline in intellectual abilities (memory plus one other domain)
• Interfering with social or occupational life
CLINICAL PRESENTATION OF DEMENTIA – MOST SENSITIVE ADLs
• Using phone and other means of communication
• Planning an outing and completing it efficiently
• Using medication safely
• Using money appropriately
CLINICAL PRESENTATION OF DEMENTIA – MOOD AND BEHAVIOR
• Apathy (more quiet, socially withdrawn)
• Anxiety & depression (worries about the future, about money)
• False beliefs (blames spouse when looking for things)
• Irritability (when spouse takes over finances, when making mistakes)
CLINICAL PRESENTATION OF DEMENTIA
• There may be little insight and reporting is done by family
• Patients are nearly always brought in by someone
• There is often need for additional information (other family member, SW or OT going to the house)
ASSESSMENT OF DEMENTIA IN CLINICAL PRACTICE
• History with reliable informant is key to diagnosis
• Physical & neurological examination
• MMSE & MoCA
• Recommended blood work: CBC, TSH, lytes, Ca, glycemia. Brain CT or MRI without enhancement optional but done in most cases.
MoCA
►One-page► 30-point scale► 10 minutes to administerwww.mocatest.org
OUTLINE
• Usual clinical presentation of dementia
• Diagnostic criteria for the common degenerative dementias
• Natural history of AD
• Cases
DIAGNOSTIC CRITERIA FOR PROBABLE AD (90% accuracy)
Dementia established clinically, eg deficit in two or more areas or cognition, interfering with daily life, progressing gradually
No disturbance of consciousness Onset between 40 and 90 (below 65: early
onset)Absence of other brain or systemic disease
that could account for the dementia
PROPOSAL FOR MODIFIED NINCDS-AA DIAGNOSTIC CRITERIA – AD DEMENTIA
(McKhann et al, A&D 7, 263-9, 2011)
• No age specification• Memory decline not mandatory for the two
cognitive domains affected• Changes in personality, impaired motivation or
initiative as a possible domain• Probable AD: documented cognitive decline or
positive biomarker
BIOMARQUERS FOR AD
* Amyloid build up
- CSF Aß42 (low)
- PET amyloid (high)
* Evidence of neuronal injury
- CSF tau (high)
- MRI (atrophy)
- PET-FDG (hypometabolism)
DIAGNOSTIC CRITERIA FOR DEMENTIA PROBABLY DUE TO AD USING BIOMARKERS
(Modified from McKhann et al, 2011)
Aß Neuronal injury
• Probable AD with + + high likelihood• Probable AD with + or untested untested or +
intermediate likelihood• Probable AD dementia untested or conflicting results• Possible AD dementia + +
(atypical clinical presentation)
* Unlikely AD dementia - -
CRITERIAS FOR VASCULAR DEMENTIA (VaD)
• Decline in two or more cognitive abilities interfering with daily life but not caused by the physical effects of stroke
• Evidence of stroke by history, physical exam or brain imaging
• Temporal relationship between dementia and stroke (within 3 months of a stroke)
CRITERIAS FOR DEMENTIA WITH LEWY BODIES (DLB)
• Progressive intellectual decline interfering with daily life
• One or two of
* fluctuations of cognition
* visual hallucinations
* spontaneous parkinsonism
* Supportive features: REM Behavior Disorder, neuroleptic hypersensitivity
CRITERIAS FOR PARKINSON DISEASE DEMENTIA (PDD)
• Idiopathic PD (2 of rigidity, bradykinesia, resting tremor)
• Impairment of attention, executive and visuo-spatial abilities
• Often with visual hallucinations
OUTLINE
• Usual clinical presentation of dementia
• Diagnostic criteria for the common degenerative dementias
• Natural history of AD
• Cases
PROGRESSION OF SYMPTOMS IN ALZHEIMER’S DISEASE
Lovestone & Gauthier 2000
STAGING OF AD: THE GLOBAL DETERIORATION SCALE (Reisberg)
• 1, 2: normal or minimal cognitive complaints
• 3: early cognitive impairment (MCI)
• 4, 5: mild to moderate dementia
• 6, 7: severe dementia
OUTLINE
• Usual clinical presentation of dementia
• Diagnostic criteria for the common degenerative dementias
• Natural history of AD
• Cases
CASE 1
• Woman age 82 with progressive memory decline over 2 years
• False beliefs of “people stealing things from her”
• MMSE 23/30
• Good general health
• “Normal for age” head CT scan
CASE 1
• Likely diagnosis?
• Any extra tests?
CASE 2
• Man age 82 needing reminders for appointments, forgetting conversations, once could not find his car on the street, over 2 years
• MMSE 22/30
• Diabetes type 2; labile HBP
• CT with mild WMC (capping) and one lacunar infarct in right external capsule
CASE 2
• Likely diagnosis?
• Any extra tests?
CASE 3
• Woman age 72 needing reminders for appointments, forgetting conversations for 1 year
• Thinks that there are other persons in her house. Sets table for extra people.
• MMSE 24/30
• CT mild cortical atrophy
CASE 3
• Likely diagnosis?
• Any extra tests?
CASE 3
• PET-FDG with occipital hypometabolism
• If available: DAT scan
CASE 4
• Man age 40 making mistakes at work (forgets orders from customers) for 1 year
• Irritable at home since wife has to supervise finances.
• Mother had AD died at age 45.
• MMSE 21/30
• CT mild cortical atrophy
CASE 4
• Likely diagnosis?
• Any extra tests?
CASE 4
• PS1 mutation confirms EOFAD.
CASE 5
• Man age 52 making mistakes at work (pharmacist) for 1 year
• Irritable since partner at work has to supervise him. Makes inapropriate jokes in restaurants.
• Mother had a dementia, died at age 60.• MMSE 26/30• CT mild cortical atrophy especially right
anterior temporal
CASE 5
• Likely diagnosis?
• Any extra tests?
CASE 5
• PET-FDG right fronto-temporal hypometabolism
• SPECT right fronto-temporal hypometabolism
• Genetic testing confirms a progranulin mutation
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