Dementia

DEMENTIA

NOOR HAFIZAH BT HASSAN 2007287236

REFERENCES:

1. Kaplan & Sadock’s Synopsis of PsychiatryBehavioral Sciences/Clinical Psychiatry10th edition

2. Clinical Practice Guidelines For Management of DementiaMinistry of Health Malaysia

INTRODUCTION

• Definition: progressive impairment in cognitive function with normal consciousness

• Essential features: intellectual impairment– Memory– Thinking– Attention– Comprehension

• Other mental function may affected mood / judgement / social behaviour

DSM IV DIAGNOSIS

EPIDEMIOLOGY

• 5 % of population > 65 years old are demented.• Prevalence ↑ with increasing age.• Dementia shortens life expectancy by 5-9.3 years.• M:F equally affected• Alzheimer’s disease: 50-60 %• Vascular dementia: 15-30 %

AETIOLOGY

DEMENTIA OF ALZHEIMER’S TYPE

• Insidious onset• Gradual progression• Definitive diagnosis: neuropathological examination– Senile plaques– Neurofibrillary tangles

• Pathophysiology:– Genetic: 40% has family history– Neuropathology: amyloid deposition– Neurotransmitter: ↓ Ach and norepinephrine

SENILE PLAQUES

NUEROFIBRILLARY TANGLES

Diffuse cerebral atrophy with enlargement of the ventricle seen on CT scan and MRI

DIFFERENTIATING FEATURES

ALZHEIMER’S DISEASE

VASCULAR DEMENTIA

ETIOLOGY• Genetic• Neuropathology• Neurotransmitter

• Hypertension• Other cardiovascular risk

AGE OF ONSET Usually > 65 y/o Less common in those > 75 y/o

ONSET OF SYMPTOMS Insidious Abrupt

COURSE OF ILLNESS Steady progression in function decline Worsening dementia

PATTERN OF COGNITIVE DEFICIT Global

Patchy: depending on the area of the brain

affected

RADIOLOGICAL FINDINGS

Diffuse cerebral atrophy with

ventricle enlargement

Multifocal infarcts

ASSESSMENT OF DEMENTIA

HISTORY:- Patient’s history:

o memory: past and recent

- Caregiver’s history:o pre-morbid personalityo attitudeo social functioningo interesto self-care

PHYSICAL EXAMINATION:

- To exclude treatable and reversible causes of dementia

MENTAL & COGNITIVE STATE EXAM:

-Mini mental state exam (MMSE)- Clock drawing test

CLOCK DRAWING TEST1. In the space below,

please draw the face of a clock and put the numbers in the correct position

2. Now, draw in the hands at ten minutes after eleven

SUMMARY OF MANAGEMENT

Non pharmacologicalintervention

Pharmacological treatment

General principles

1. Set treatment goals 2. Involve patient and family members in

decision making3. Treat the main distressing problem first4. Set a frame time: monitor cognitive &

non cognitive symptoms5. Assess success/failure of the

intervention

SUMMARY OF MANAGEMENT

Non pharmacologicalintervention

Pharmacological treatment

General principles

GENERAL PSYCHOSOCIAL:• educate the pt and family• optimize function & QOL• address family issue: financial, emotional• related ethical issue

SPECIFIC PSYCHOTHERAPY:• behaviour-oriented• emotion-oriented• cognition oriented• stimulation oriented

SUMMARY OF MANAGEMENT

Non pharmacologicalintervention

Pharmacological treatment

General principles

1. COGNITIVE IMPROVEMENT:- Cholinesterase inhibitor: Donepezil / Rivastigmine / Galantamine- NMDA antagonist: Memantine

2. BEHAVIOURAL & PSYCHOLOGICAL SYMPTOMS:- psychosis & agitation- depression- sleep disturbance

CHOLINESTERASE INHIBITOR

Donepezil (Aricept) 5-10 mg OD- For all stages of Alzheimer’s disease

Rivastigmine (Exelon) 6-12 mg BD- For mild to moderate Alzheimer’s disease

Galantamine (Reminyl) 16-24 mg BD- For mild to moderate Alzheimer’s disease

NMDA INHIBITOR

• Memantine (Ebixa) 5-20 mg BD

• M.O.A: inhibit glutamate activity

• Effective in moderate to severe dementia, including vascular dementia and HIV dementia

THANK YOU