ronald c. hamdy, md, frcp, facp professor of medicine cecile cox quillen chair of geriatric medicine...

Ronald C. Hamdy, MD, FRCP, FACPRonald C. Hamdy, MD, FRCP, FACP

Professor of MedicineProfessor of Medicine

Cecile Cox Quillen Chair of Geriatric MedicineCecile Cox Quillen Chair of Geriatric Medicine

East Tennessee State UniversityEast Tennessee State University

The Many Faces of DementiaMarch 26, 2013

NO DISCLOSURES NO DISCLOSURES


OBJECTIVES

Recognize the different presentations of various types of dementia: Alzheimer’s disease, Lewy Body Dementia, Normal pressure hydrocephalus, Multi-infarct dementia, Fronto-temporal dementia

Develop a clinical diagnostic approach to identify various dementias.


Dementia

Clinical Syndrome, not disease Different types Decline of acquired cognitive abilities,

leading to impairments in: Attention Language Memory Visuo-spacial skills Executive abilities Personality

Interferes with daily activities.

Mr. DAW, 75 yrs - retired accountant Mr. DAW, 75 yrs - retired accountant brought in by concerned wife and daughterbrought in by concerned wife and daughter

Impaired memory:Shopping lists, phone calls, house chores


Impaired memory:Shopping lists, phone calls, house choresPart-time job at WalMart, forgets to check-in, checks-in wrong

time/dayCannot remember where to go when he gets to shop.




Serious errors tax return forms, second year, refuses to admit it Generous donations, cannot afford, to charitable organizations, Checks bounced twice Gets quite irritable and at times verbally aggressive




Serious errors tax return forms, second year, refuses to admit it Generous donations, cannot afford, to charitable organizations, Checks bounced twice Gets quite irritable and at times verbally aggressive Onset: daughter: 3 years ago when he retired, wife: earlier Gradual deterioration




Serious errors tax return forms, second year, refuses to admit it Generous donations, cannot afford, to charitable organizations, Checks bounced twice Gets quite irritable and at times verbally aggressive Onset: daughter: 3 years ago when he retired, wife: earlier Gradual deterioration

He denies these allegationsHe accuses his wife of stealing his money and being unfaithful to him


1. Deterioration from previous level of cognitive functions?

Yes: Successful accountant


2. Memory impairment:Global or selective?

Shopping lists, phone calls, house chores


2. Memory impairment:Global or selective?

Shopping lists, phone calls, house choresForgets to check-in at work, checks-in at wrong time/dayCannot remember where to go when he gets to work


3. Memory impairment interfering with daily activities?

Forgets to check-in, checks-in at wrong time/dayCannot remember where to go when he gets to work


4. Impaired judgment?


Checks bounced twice Serious errors tax return forms, second year, refuses to admit it Generous donations, cannot afford, to charitable organizations

5. Onset:Insidious or Sudden ?


Daughter: 3 years ago when he retiredWife: earlier ? 5 years

6. Insight ?


No insight – denies allegationsBlames wife and others

7. Impairment of other cognitive domains?

Amnesia: Global


MMSE: 22/30 AnomiaDate, day of week, monthRemembered only 1 of the 3 wordsRefused to write a sentenceRefused to copy geometrical shape


MMSE: 23/30 Anomia, Date, day of week, monthRemembered only 1 of the 3 wordsRefused to write a sentenceRefused to copy geometrical shape


MMSE: 23/30 Anomia, ApraxiaDate, day of week, monthRemembered only 1 of the 3 wordsRefused to write a sentenceRefused to copy geometrical shape


11:10



11:10

Unable to tie shoe lacesWife helps him get dress



11:10

Not aware of current events; “I don’t really care!”Cannot recall any of the TV programs he watchesThought he had about $175 in his wallet, only had $22, accuses his wife

7. Impairment of other cognitive domains?

Amnesia: Global Anomia: Inability to name objects Apraxia: Inability to carry out

voluntary activities, no paralysis


Amnesia Anomia Apraxia



Impaired judgment



Impaired judgment

No insight



No insight


Insidious onset

Impaired judgment


Probable Alzheimer’s Disease

No insight


Insidious onset

Impaired judgment



No insight

Paranoid delusions


Insidious onset

Impaired judgment



No insight

Paranoid delusions


Agnosia Insidious onset

Impaired judgment

Stages of Alzheimer’s Disease

MILD 2 to 4 Years

MILD 2 to 4 Years


MILD 2 to 4 Years

MILD 2 to 4 Years

Protect from others


MILD 2 to 4 Years

MILD 2 to 4 Years

MODERATE2 to 10 Years

Protect from others


MILD 2 to 4 Years

MILD 2 to 4 Years


Protect from others

Protect from self


MILD 2 to 4 Years

MILD 2 to 4 Years

SEVERE 1 TO 3 YearsSEVERE 1 TO 3 Years


Protect from others

Protect from self


MILD 2 to 4 Years

MILD 2 to 4 Years

SEVERE 1 TO 3 YearsSEVERE 1 TO 3 Years


Protect from others

Protect from self

Nursing Care

Mr. LMD, 65 years, CEO – 8 months Wants zolpidem sublingual tablets to prevent jet-lag

Chronic jet-lag – Constantly tired Poor quality sleep Often somnolent during day

Chronic jet-lag – Constantly tired Poor quality sleep Often somnolent during day At times difficulties concentrating Needs “power naps”


Chronic jet-lag – Constantly tired Poor quality sleep Often somnolent during day At times difficulties concentrating Needs “power naps” At a recent meeting:

HallucinationsBecame confused

Similar episode few years ago




Similar episode few years ago Frequent nightmares

often wake him up





often wake him up

Cognitive impairment interfering with activities





often wake him up


Fluctuations:alertnessconfusion





often wake him up



Hallucinations:formed





often wake him up




REM Behavioral Disorder





often wake him up Fine tremors hands




REM Behavioral Disorder





often wake him up Fine tremors left hand




REM Behavioral DisorderExtra-pyramidal signs





often wake him up Fine tremors left hand




REM Behavioral DisorderExtra-pyramidal signs

Lewy Body Dementia


Dementia with Lewy BodiesThird Report – DLB Consortium – 2005

Neurology 2005;65(12):1863-72

Central Feature: Dementia

Core Features:Fluctuations, hallucinations, extrapyramidal signs (ONE-Year Rule)

Suggestive Features:• REM sleep behavior disorder (RBD)

• Severe neuroleptic sensitivity

• Dopamine transport (DAT) imaging, various ligands Nigrostriatal dopaminergic system - SPECT/PET

Occipital lobes: 1ry, 2ndry visual cortex # Alzheimer’s disease

• Sympathetic Skin Response & Heart Rate Variability BMJ 2013;3:e001796

Mr. DTF, 65 years WM – English Literature ProfessorInappropriate behavior

Sexual harassment complaint Profane language Impatient Walked out of classroom & meetings Pornographic material Explicit sexual remarks Thrown out of night club Difficulties finding correct word His appointment may be terminated




Change in characterDisinhibitionInappropriate behavior




Change in characterDisinhibitionInappropriate behaviorWord finding difficulties




Fronto-temporal dementia

Change in characterDisinhibitionInappropriate behaviorWord finding difficulties

Fronto-temporal dementia

• Loss of inhibitionsLoss of inhibitions

• Socially inappropriate or withdrawnSocially inappropriate or withdrawn

• Hoarding, overeating and weight gainHoarding, overeating and weight gain

• IrritabilityIrritability

• Memory impairment minimalMemory impairment minimal

• Apraxia less marked than in ADApraxia less marked than in AD

• Word-finding & language difficultiesWord-finding & language difficulties

• Impaired calculation less marked than in ADImpaired calculation less marked than in AD

Mrs. HNP, 59 years - AttorneySeveral falls - Confusion

Several falls trips over objectslooses balance easily no dizzinessno palpitations



Difficulties walkingespecially on carpets, slow

Bouts of urinary incontinence




Bouts of urinary incontinence Difficulties thinking

Mind not as sharp as beforeHas to rely on notes & aides







Urinary incontinence






Muscle tone increased - rigidity



Increased muscle tonerigid gait - ataxia






Muscle tone increased - rigidity


Hydrocephalus


Increased muscle tonerigid gait - ataxia

Mrs. FCG, 78 years – History TeacherCognitive impairment, diabetes, hypertension

Less communicative Unable to hold a conversation Unable to do mental exercises


Less communicative Unable to hold a conversation Unable to do mental exercises



Less communicative Unable to hold a conversation Unable to do mental exercises Swallowing problems Slurred speech Bouts of urinary incontinence Several episodes of poorly controlled hypertension, diabetes: hypoglycemia/acidosis. Left hemiparesis





HypertensionDiabetes mellitusSeveral cerebral infarctsUrinary incontinenceDysphagia





Step-wise deteriorationNeurological signs




Multi-infarct dementia


Step-wise deteriorationNeurological signs

Vascular/Multi Infarct dementiaVascular/Multi Infarct dementia

• Memory impairmentMemory impairment

Not as pronounced as Alzheimer’s diseaseNot as pronounced as Alzheimer’s disease

Often not main complaintOften not main complaint

• Onset, usually abruptOnset, usually abrupt

• Course, usually step-wise deteriorationCourse, usually step-wise deterioration

• Predisposing factorsPredisposing factors

• Neurological signsNeurological signs

68 years old white man, 68 years old white man, former professor of economics; self-referredformer professor of economics; self-referred


Thinks has early Alzheimer’s diseaseThinks has early Alzheimer’s disease

Positive family history of Alzheimer’s diseasePositive family history of Alzheimer’s disease Retired about 2 years agoRetired about 2 years ago Wife died after car accident soon after he retiredWife died after car accident soon after he retired Little contact with 2 children and their familiesLittle contact with 2 children and their families

Lives alone, avoids social contacts, easily boredLives alone, avoids social contacts, easily bored

States that memory is very poor: names,… States that memory is very poor: names,… Does not enjoy watching TV, reading newspapersDoes not enjoy watching TV, reading newspapers Not aware of current eventsNot aware of current events Feels tired, no energy, spends most of the day in pajamasFeels tired, no energy, spends most of the day in pajamas Denies loosing weight, but clothes are loose, looks cachectic. Denies loosing weight, but clothes are loose, looks cachectic.


MMSE: 7/30MMSE: 7/30

Serial 7s, could copy diagram, wrote: “I am tired”Serial 7s, could copy diagram, wrote: “I am tired” Depression Scale: 24/30Depression Scale: 24/30 Physical Examination:Physical Examination:

Bleeding gums, Multiple petechiae, Hematoma on right thigh,

fell on toilet while micturating a week ago.


MMSE: 7/30MMSE: 7/30

Serial 7s, could copy diagram, wrote: “I am tired”Serial 7s, could copy diagram, wrote: “I am tired” Depression Scale: 24/30Depression Scale: 24/30 Bleeding gums, multiple petechiae, large hematoma right Bleeding gums, multiple petechiae, large hematoma right

thigh, s/p fallthigh, s/p fall Laboratory tests:Laboratory tests:

Anemia, Anemia, Hypoalbuminemia, hypoproteinemia, Hypoalbuminemia, hypoproteinemia, Hypocholesterolemia, Hypocholesterolemia, Hypovitaminosis D, Hypovitaminosis D, Hypovitaminosis CHypovitaminosis C


Depression

Anedonia

Malnutrition

Nutritional deficiencies

Easy Fatigue

Isolation

RetirementWife’s death

Pseudo-dementia

67 year-old, white woman, 67 year-old, white woman, pneumonia, lethargy, confusion ? dementia? pneumonia, lethargy, confusion ? dementia?

OA, CCF, UI, insomniaOA, CCF, UI, insomnia

Referred for consult



Medications:

NSAID OA knees

Furosemide

Lisinopril CCF

Tolterodine OAB, wet type

Donepezil ? Alzheimer’s Disease

Zolpidem Insomnia

Albuterol Bronchospasm

Zithromycin Pneumonia



Medications:

NSAID OA knees

Furosemide

Lisinopril CCF



Zolpidem Insomnia



6 months previously:

No medication,

Mentally good

Physically independent

NSAID Fluid retention


Limited CVS reserveCCF

Digoxin

ACE inhibitor

Diuretic

K-supplements



Digoxin

ACE inhibitor

Diuretic

K-supplementsPolyuria/Limited urinary bladder capacity

OAB/UI



Digoxin

ACE inhibitor

Diuretic


OAB/UIAnticholinergics

Confusion



Digoxin

ACE inhibitor

Diuretic


OAB/UI

A Ch E inhib.

Anticholinergics

Confusion

InsomniaWorsening CCF PND, bronchospasm



Digoxin

ACE inhibitor

Diuretic


OAB/UI

A Ch E inhib.

Anticholinergics

Confusion

InsomniaHypnoticsWorsening CCF PND, bronchospasm

Bronchodilators

BronchopneumoniaAntibiotics



Medications:

NSAID OA knees

Furosemide

Lisinopril CCF



Zolpidem Insomnia



6 months previously:

No medication,

Mentally good

Physically independent

Iatrogenic Dementia

Iatrogenic DementiaIatrogenic Dementia

Diagnose accurately the cause of the symptoms/signs before prescribing medication

Avoid prescribing medication to counteract adverse effects of another one

63 years old white woman63 years old white womanSelf referred - ForgetfulnessSelf referred - Forgetfulness


Director of Operations of a large rapidly growing Director of Operations of a large rapidly growing organization, just acquired competing organization.organization, just acquired competing organization.

Rapidly climbed the organization ladder. Very Rapidly climbed the organization ladder. Very efficient efficient at her job. at her job.

““Forgets everything” has to be constantly reminded by Forgets everything” has to be constantly reminded by her administrative assistant about engagementsher administrative assistant about engagements

Misplaces files and documentsMisplaces files and documents Performing very well at work; has received several Performing very well at work; has received several

commendations, very recently.commendations, very recently.

Knew exactly how much money she had in her purseKnew exactly how much money she had in her purse Balances her check book and files tax returnsBalances her check book and files tax returns Fully aware of the price of shares of her organization Fully aware of the price of shares of her organization

and several competing onesand several competing ones Fully aware of current events, stock market Fully aware of current events, stock market


Knew exactly how much money she had in her purseKnew exactly how much money she had in her purse Balances own check book and files tax returnsBalances own check book and files tax returns Fully aware of the price of shares of her organization Fully aware of the price of shares of her organization

and several competing onesand several competing ones Fully aware of current events, stock marketFully aware of current events, stock market


Memory Impairment:

Not interfering with daily activities




Memory Impairment: Trivial v/s Global





Memory Impairment: Trivial v/s Global


? Mild Cognitive Impairment? Benign Forgetfulness

Drugs Emotional disorders Metabolic disorders Eyes and ears deficit Neurological disorders Tumors and trauma Infections Atherosclerotic complications

Other Conditions That May Worsen Cognitive Functions

Drugs Emotional disorders Metabolic disorders Eyes and ears deficit Neurological disorders Tumors and trauma Infections Atherosclerotic complications

Other Conditions That May Worsen Cognitive Functions

To develop an appropriate management strategy

To develop an appropriate management strategy

Cognitive Impairment – Previously IntactCognitive Impairment – Previously Intact


Interfering with ADL Interfering with ADL NoNo Not DementiaNot Dementia


Interfering with ADL Interfering with ADL YesYes

YesYes

YesYes

NoNo Not DementiaNot Dementia

Urinary IncontinenceUrinary Incontinence

Ataxia,

rigidity

Ataxia,

rigidity

Hydrocephalus Hydrocephalus


Interfering with ADLInterfering with ADLYesYes

YesYes

YesYes

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity


Global Memory Impairment Global Memory Impairment


Interfering with ADLInterfering with ADLYesYes

YesYes

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity



Medical, iatrogenic Medical, iatrogenic



YesYes

YesYes

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity




Other Cognitive Deficit – 4As Other Cognitive Deficit – 4As



YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity





Insidious Onset Insidious Onset



YesYes

YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity






Alzheimer’s DiseaseAlzheimer’s Disease



NoNo

YesYes

YesYes

YesYes

YesYes

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity



Medical, iatrogenicMedical, iatrogenic



Vascular Dementia Vascular Dementia Alzheimer’s DiseaseAlzheimer’s Disease



YesYes

YesYes YesYes

NoNo

YesYes

YesYes

YesYes

YesYes

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity







Fluctuations Fluctuations Hallucinations Hallucinations

RBD RBD

Lewy Body DementiaLewy Body Dementia



YesYes

YesYes YesYes

NoNo

YesYes

YesYes

YesYes

YesYesNoNo

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity








RBD RBD


Medical Iatrogenic Medical Iatrogenic


Interfering with ADL Interfering with ADL

NoNo

YesYes

YesYes

YesYes YesYes

NoNo

YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity








RBD RBD



Disinhibition Disinhibition


Interfering with ADLInterfering with ADL

NoNo

YesYes

YesYes

YesYes

YesYes YesYes

NoNo

YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity







FluctuationsFluctuations Hallucinations Hallucinations

RBD RBD




Neuro signs Neuro signs

NoNo

FTD FTD


Interfering with ADL Interfering with ADL

NoNo

YesYes

YesYes

YesYes

YesYes YesYes

NoNo

YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo

YesYes

NoNo

NoNo

NoNo



Ataxia,

rigidity

Ataxia,

rigidity







FluctuationsFluctuations Hallucinations Hallucinations

RBD RBD




Neuro signs Neuro signs

YesYes

NeurosyphilisNeurosyphilis

NoNo

FTD FTD

OBJECTIVES

Recognize the different presentations of various types of dementia: Alzheimer’s disease, Lewy Body Dementia, Normal pressure hydrocephalus, Multi-infarct dementia, Fronto-temporal dementia

Develop a clinical diagnostic approach to identify various dementias.


ronald c. hamdy, md, frcp, facp professor of medicine cecile cox quillen chair of geriatric medicine...

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