DEMENTIA
Dementia: an acquired deterioration in cognitive abilities that impairs the successful
performance of activities of daily living
-Increasing age is the strongest risk factor
-Most common cognitive ability lost is memory
-Other mental faculties can also be affected such as language, visuospatial ability, calculation, judgement and problem solving
-Other symptoms can include depression, withdrawal, hallucinations, delusions, agitation, insomnia, seizures and disinhibition
Delirium: a mental and behavioral states of reduced comprehension, coherence and capacity to reason that is acute in onset and characterized by a mental status that waxes and wanes
-Common causes: infection, metabolic disorders, endocrine disorders, stroke, drugs (in particular anticholinergics, benzodiazepines, narcotics, corticosteroids, centrally acting antihypertensives, digoxin, muscle relaxants)
-Contributing factors: unfamiliar surroundings, sensory deprivation, restraints, indwelling catheters
-Treatment: treat underlying medical problem, discontinue offending medications, reassure and reorient patient, family support, can also use haloperidol in low doses (0.5 mg to 5 mg per day)
Distinguishing Dementia from Delirium
| Feature | Dementia | Delirium |
| Onset | Insidious | Acute |
| Course | Stable in short term | Fluctuating |
| Consciousness | Clear until late disease | Impaired |
| Orientation | Decrease | Fluctuating |
| Attention | Normal until late disease | Distractible, hypo- or hyperalert |
| Hallucintations/delusions | ±paranoid delusions | ±visual hallucinations, paranoid delusions |
| Thinking | Impoverished, vague, perseverative | Disorganized, incoherent |
| Sleep-wake cycle | Often fragmented | Always disrupted |
| Response to questions | ‘Near misses’ | Incoherent |
Causes of Demetia
-Alzheimer’s disease
-Vascular – multi-infarct, diffuse white matter disease
-Alcoholism
-Vitamin deficiencies – B1 (Wernicke’s), B12, folate, niacin (pellagra)
-Chronic infections – IDS, neurosyphilis, tuberculosis
-Endocrine – hypothyroidism, adrenal insufficiency, Cushing’s syndrome
-Toxic – drugs, medications, heavy metals, organic toxins
-CNS disorders – normal pressure hydrocephalus, anoxic brain injury, chronic subdural hematoma, postencephalitis, primary and metastatic tumors, paraneoplastic syndromes
-Degenerative – Parkinson’s disease, Lewy body dementia, multiple sclerosis, Down’s syndrome
-Psychiatric – depression, schizophrenia
It is important to recognize that many of the causes are reversible such as alcoholism, depression, hydrocephalus, hypothyroidism, vitamin deficiencies, drug intoxication, chronic infection.
Approach to the Patient with Dementia
History
-Focus on the onset, duration and tempo of the progression of dementia
Remember acute onset of symptoms may represent delirium
-Ask about family history, diet, alcohol intake, smoking, hypertension, dyslipidemia, depressive symptoms, drug use, history of stroke and history of chronic infections
-Assess activities of daily living (bathing, grooming, toileting, dressing, eating, transferring), instrumental activities of daily living (finances, cooking, laundering)
Physical Exam
-Focus on neurologic exam (focal neuro deficits, rigidity, tremor, ataxia, gait)
-Focus on cardiovascular exam (apex, arrhythmia, murmurs, carotid bruits)
Mini mental status exam
-When properly administered, it is both sensitive and specific for the diagnosis of dementia
-However it is culturally and educational biased
-Requires intact hearing, vision and motor function to complete
-For patients with limited education, can ask them to do clock-drawing task and 3- item recall
Investigations
-Check FBP, ESR, creatinine, TSH, vitamin B12, folic acid, RBG
-Check rapid test and RPR/VDRL
-CT of the brain without contrast
Treatment
-Treat all reversible causes (example: thyroid supplementation for hypothyroidism)
-Treat symptoms such as agitation, delusions, hallucinations (can use antispychotics)
-Counsel family members
-In US and Europe, donepezil (Aricept) and Namenda are also used for Alzheimer’s dementia
Folstein Mini-Mental Status Exam (MMSE)
| | Maximum Score | Actual Score |
| ORIENTATION | | |
| What is the year, season, date, day, month? | 5 | |
| Where are we: state, county, town, hospital, floor? | 5 | |
| REGISTRATION | | |
| Name 3 objects: one syllable words, 1 second to say each, then ask patient all 3 after you have said them, give 1 point for each correct answer | 3 | |
| ATTENTION AND CALCULATION | | |
| Serial 7’s: 1 point for each correct. Stop after 5 answers. Alternatively spell ‘world’ backwards. | 5 | |
| RECALL | | |
| Ask for 3 objects repeat above. Give 1 point for each correct answer. | 3 | |
| LANGUAGE | | |
| Name a pencil and watch. | 2 | |
| Repeat the following: “No ifs, and or buts.” | 1 | |
| Follow a 3-stage command: “Take this paper in your right hand, fold it in half, and put it on the floor.” | 3 | |
| Read and obey the following: “Close your eyes.” | 1 | |
| Write a sentence. | 1 | |
| Copy design. | 1 | |
| TOTAL SCORE | 30 | |
Case #1
A 75 year old man is brought to the clinic by his son for memory loss. The patient’s son states that over the past year he has noticed that his father’s memory has worsened. He has gotten lost coming home from the market a few times. One night he forgot to turn off the stove after making dinner. He has also had more difficulty sleeping lately. His son states that his father remembers events from his childhood but sometimes does not remember what he ate for lunch. Upon further questioning, he has no focal weakness, numbess or visual changes. He has not had any observed seizures and has no known chronic infections. He does not drink alcohol or smoke cigarettes or take any medications/herbal supplements.
1. Is this dementia or delirium?
-dementia
2. What is your differential diagnosis for the etiology?
-Alzheimer’s disease, multi-infarcts, vitamin deficiency, hypothyroidism, normal pressure hydrocephalus, brain tumor, depression, neurosyphilis
On physical exam, he is an elderly man who is awake and alert. He answers questions and follows commands. He scores 23/30 on the MMSE. His cardiovascular and neurologic exams are normal.
3. What investigations would you like to perform?
-FBP, ESR, creatinine, TSH, vitamin B12, folic acid, RBG, rapid test, RPR/VDRL and CT of the brain without contrast
His FBP, ESR, creatinine, TSH, vitamin B12, folic acid and RBG are normal. His rapid test and VDRL are non-reactive. A CT of the brain shows generalized atrophy but no focal intracranial lesions.
4. What is the most likely diagnosis?
-Alzheimer’s dementia
5. How would you like to treat him?
-there are no reversible causes of dementia found, most important thing is to counsel family members about natural history of disease and frequent reorientation of the patient
Six months later his son brings him back to clinic. He states that it has become more and more difficult for his father to sleep at night. He is now experiencing visual hallucinations and occasionally becomes agitated especially at nighttime.
6. What are these symptoms related to?
-as Alzheimer’s dementia progresses, patients can develop symptoms of insomnia, hallucinations, delusions, paranoia, agitation
7. How would you like to treat him?
-start a low dose of an antipsychotic like haloperidol at bedtime
Case #2
An 80 year old female is brought to Bugando for fever and cough productive of yellow-green sputum for 3 days. Respiratory exam reveals crepitatons and bronchial breath sounds in the right lower lung field. A chest x-ray shows a lobar infiltrate in the right lower lobe. She is started on ceftriaxone for treatment of pneumonia. During the third hospital day, the patient becomes confused and has hallucinations about animals in her room. Her mental status waxes and wanes throughout the day. The rest of her physical exam remains unchanged.
1. Is this dementia or delirium?
-delirium
2. What is your differential diagnosis for the etiology?
-the patient has an underlying infection and now may have worsening metabolic abnormalities or hypoxia, the ceftriaxone may also be affecting her, also she is elderly and is in an unfamiliar environment
3. What would you like to do next? What investigations would you order, if any?
-review medications and stop all unnecessary ones that may be contributing to delirium
-check oxygen saturation
-check RBG, creatinine, sodium
4. How would you like to treat this patient?
-treat any metabolic abnormalities
-give oxygen if hypoxic
-move the patient to a bed closest to the window, reorient the patient frequently, counsel family to help with reorientation, remove any catheters and restraints if possible
The patient’s mental status continues to wax and wane. She then becomes more agitated at night and tried to hit a nurse.
5. How would you like to treat her now?
-give a low dose of an antipsychotic such as haloperidol
Case #3
A 70 year old woman is brought to the clinic by her son for memory loss and gait disturbance. Her son states that she has more forgetful about things lately such as remembering where she left an item or what she bought at the market the day before. He has also notices that she is having increasing difficulty managing her finances. He also tells you that he has noticed that she seems unsteady walking around and has fallen a few times. Upon further questioning, he denies that she drinks alcohol, smokes cigarettes, or takes any medications or herbal supplements. She has also had a few episodes of urinary incontinence.
1. Is this delirum or dementia?
-dementia
2. What is your differential diagnosis for the etiology?
-normal pressure hydrocephalus, stroke, Alzheimer’s disease, brain tumor, hypothyroidism, vitamin deficiencies, neurosyphilis
On physical exam, she is awake and alert and able to follow commands. She scores 22/30 on the MMSE. Her cardiovascular exam is normal. She has ataxic gait but otherwise has no other focal neurologic deficits.
3. What investigations would you like to do?
-FBP, ESR, creatinine, TSH, vitamin B12, folic acid, RBG, rapid test, RPR/VDRL and CT of the brain without contrast
Her FBP, ESR, creatinine, TSH, vitamin B12, folic acid and RBG are normal. Her rapid test and VDRL are non-reactive. A CT of the brain shows markedly enlarged ventricles.
4. What is the most likely diagnosis?
-normal pressure hydrocephalus
5. What would you like to do next?
-lumbar puncture, observe the opening pressure, take out a large volume and reassess her gait
You perform a lumbar puncture. The opening pressure is normal. The biochemical analysis and cell counts are normal. You remove 30 ml of CSF. After she rests for a few hours you retest her gait and it is improved.
6. What is the treatment?
-this patient needs a referral for VP shunt
