Dementia

Dementia is a chronic, progressive decline in cognitive ability. It is a diagnosis that has significant morbidity and mortality associated with it for both the patient and the patient's family. It is vital to rule out dementia mimics including: delirium and depression before a diagnosis of dementia can be made. Prevalence is approximately 10% age >65.

Definition
1. Disturbance in consciousness - change in focus/attention/ distractible

2. Disturbance in cognition - change in memory, disorientation, trouble with speech/language

3. Temporal fluctuation - develop over short period of time, fluctuates over hours

4. Evidence of underlying medical d/o

Etiology
I WATCH DEATH
 * I- Infections
 * W-withdrawal
 * A-Acute metabolic d/o (lytes, hepatic failure, renal failure)
 * T-Trauma (head trauma, post-operative)
 * C-CNS pathology (CVA, hemorrhage, tumour, seizure)
 * H-Hypoxia
 * D- Deficiencies of vitamins (B12, Folate, thiamine)
 * E-Endocrinopathies (thyroid, parathyroid, adrenal, glucose
 * A-Acute vascular (shock, HTN encephalopathy, vasculitis)
 * T-Toxins, substance use, MEDICATIONS
 * H- heavy metals (arsenic, lead, mercury)

Investigations
Consider the following based on history, physical
 * Physical: vitals, hydration status, r/o fecal impaction, urinary retention, infected ulcer


 * Blood work: CBC, lytes, Cr, extended lytes - Ca,P,Mg, albumin, TSH, B12, folate, LFTs, glucose, drug levels, tox screen, blood gas, septic w/u - CXR, urinalysis +/- blood cultures, CK, trop


 * Further w/u:ECG, head CT, Lumbar Puncture, EEG


 * ***REVIEW MEDICATION LIST***

Delirium vs Dementia
PLEASE NOTE the below table is a generalization and there are exceptions to the rules.

Depression
See depression page*

Screening: SIGECAPS: sleep disturbance, interest loss, guilt (regrets), energy decreased, concentration difficulties, psychomotor changes, suicidal ideation, low mood

Poor sleep - look for 6 Ps (pain, PND/orthopnea, Pee - BPH, diuretic, partner, pharmaceuticals (diuretic, stimulants, caffeine, cholinesterase inhibitor, physical environment -temperature/noise)

Decreased interest - depression patients operate below their abilities. Dementia - operative above their abilities and withdraw due to social embarrassment

Cognitive symptoms
1. Amnesia: short term memory loss, repeating questions/stories, forgetting details of recent important events, trouble with names, increased use of compensatory strategies (e.g. lists)

2. Aphasia: word finding difficulty, decreased fluency, simplified speech, impaired comprehension, decreased reading/writing, mixing up languages

3. Apraxia: dressing apraxia, difficulty following physical examination, hitting nail with hammer, using appliances

4. Agnosia: difficulty recognizing objects/family/faces

5. Visuospatial: easily disorientated/lost in new environment, trouble driving in non-routine places

6. Calculation: financial difficulties

7. Executive functioning: sequence, organization, abstraction, planning. Trouble with ADLs and iADLs

ADLs and iADLS
ADLS: activities of daily living iADLS: instrumental activities of daily living
 * DEATH: dressing, eating, ambulation, transfers, hygiene
 * SHAFT: shopping, housekeeping/hobbies, accounting, food preperation, telephone/tool use/transportation (driving)/tablets (medications)

** IF lose 1ADL or 2+ iADLS need to R/A driving, finances, medication compliance**

Definition of Dementia
1. Amnesia

2. Apraxia, aphasia, agnosia, executive dysfunction

3. Progressive

4. Impacts on function

Meets criteria #1-4

Types of Dementia:

 * Vascular risk factors: HTN, DM, CAD, CVA, smoking, PVD
 * CJD - creutzfeldt-Jakob disease: rapid, progressive with balance and swallowing change

Screening:
Mini-mental status examination: MMSE

Montreal Cognitive Assessment MOCA

EXIT-25 (frontal lobe dysfunction)

Frontal Assessment Battery

RUDAS

Trails A & B

Treatment

 * Refer to alzheimers society
 * Discuss will, power of attorney, safety (driving, home)
 * Review medications and eliminate any unnecessary medications
 * Alzheimers disease
 * Obtain ECG prior to treatment. Avoid AchEI if LBBB, AV blocks, Sick sinus syndrome, bradycardia< 50
 * Donepezil (aricept)
 * Rivastigmine (exelon)
 * Galantamine (reminyl)
 * Memantine (Ebixa)
 * Vascular: modify vascular risk factors
 * Fronto temporal dementia: SSRI or trazodone. NO AchEI!
 * Lewy Body:
 * rivastigmine (exelon)
 * AVOID NEUROLEPTICS
 * Consider referral for rapid progression, young patients, frontotemporal, lewy body, parkinson's dementia

Resources
Patient Handout: 10 Warning Signs of Dementia (Alzheimers Society)