DementiaDementia

Sanjay K Nigam, M.D.Sanjay K Nigam, M.D.

Psychiatry Director,Psychiatry Director,

Greenville Regional HospitalGreenville Regional Hospital

History History

Careful and accurate history Careful and accurate history Distinguishing exceptional symptoms from Distinguishing exceptional symptoms from

complaints due to age-related cognitive decline complaints due to age-related cognitive decline Assess the patient for depression, and inquire about Assess the patient for depression, and inquire about

behavioral and psychotic disturbances behavioral and psychotic disturbances Consider conditions whose symptoms and signs Consider conditions whose symptoms and signs

mimic those of neurodegenerative dementia mimic those of neurodegenerative dementia Obtain and review the patient's medication history for Obtain and review the patient's medication history for

drugs drugs

TestingTesting

Office and LaboratoryOffice and Laboratory Radiologic Radiologic Invasive Invasive Differential DiagnosisDifferential Diagnosis

Rule out conditions or disorders that may mimic a Rule out conditions or disorders that may mimic a neurodegenerative dementia neurodegenerative dementia

History History careful and accurate history careful and accurate history

onset and course of memory and thinking problems onset and course of memory and thinking problems informed collateral source (generally a spouse or adult child) informed collateral source (generally a spouse or adult child) patient's cognitive performance or behavior that negatively affect patient's cognitive performance or behavior that negatively affect

his/her daily life his/her daily life temporal course of symptoms temporal course of symptoms

chronic, stepwise, or progressivechronic, stepwise, or progressive patient's recent and long-term memory patient's recent and long-term memory

everyday activities everyday activities driving, functioning at work, and/or interactions with family and peersdriving, functioning at work, and/or interactions with family and peers

functional loss is not due to physical decline (vision or hearing functional loss is not due to physical decline (vision or hearing loss) loss)

History (cont…)History (cont…) Distinguish exceptional symptoms Distinguish exceptional symptoms

from complaints due to age-related cognitive decline from complaints due to age-related cognitive decline Cognitive changes due to usual aging Cognitive changes due to usual aging

limited attentional resources ("I forgot what I came in here to get") limited attentional resources ("I forgot what I came in here to get") or to diminished speed of information processing ("I couldn't remember his name until later"). or to diminished speed of information processing ("I couldn't remember his name until later"). Such changes usually do not progress nor do they seriously interfere with everyday activities. Such changes usually do not progress nor do they seriously interfere with everyday activities.

Assess the patient for depression, and inquire about behavioral and psychotic disturbances Assess the patient for depression, and inquire about behavioral and psychotic disturbances patients with depressive "pseudodementia“patients with depressive "pseudodementia“

acute onsetacute onset past episodes of depression, anhedoniapast episodes of depression, anhedonia memory deficits that are equal for recent and remote events (vs. greater for recent events in AD),memory deficits that are equal for recent and remote events (vs. greater for recent events in AD), circumscribed (vs. global) cognitive defectscircumscribed (vs. global) cognitive defects

Patients with mild to moderate AD have memory and other cognitive disturbances, but do not Patients with mild to moderate AD have memory and other cognitive disturbances, but do not have the prominent delusions and gross perceptual distortions that are characteristic of have the prominent delusions and gross perceptual distortions that are characteristic of psychotic disorders psychotic disorders

conditions whose symptoms and signs mimic those of neurodegenerative dementia conditions whose symptoms and signs mimic those of neurodegenerative dementia Ask about other medical problems that might complicate the patient's evaluation or management Ask about other medical problems that might complicate the patient's evaluation or management

patient's medication history for drugs patient's medication history for drugs drugs that may cause or exacerbate loss of mental capacity, especiallydrugs that may cause or exacerbate loss of mental capacity, especially

opiates, opiates, sedative-hypnotics, sedative-hypnotics, analgesics, analgesics, anticholinergics, anticholinergics, anticonvulsants, anticonvulsants, corticosteroids, corticosteroids, centrally acting hypertensives,centrally acting hypertensives, psychotropics, psychotropics, alcohol.alcohol.

Physical Examination Physical Examination

for possible coexisting abnormalities for possible coexisting abnormalities Focus on focal deficits, extrapyramidal signs, and gait disturbances Focus on focal deficits, extrapyramidal signs, and gait disturbances dry skin, periorbital edema, thin hair, and depressed reflexes may dry skin, periorbital edema, thin hair, and depressed reflexes may

indicate hypothyroidism;indicate hypothyroidism; extrapyramidal signs may indicate Parkinson's disease or dementia extrapyramidal signs may indicate Parkinson's disease or dementia

with Lewy bodieswith Lewy bodies focal motor or sensory deficits may indicate vascular dementiafocal motor or sensory deficits may indicate vascular dementia gait disturbances may indicate communicating hydrocephalusgait disturbances may indicate communicating hydrocephalus Coexisting conditions that may exacerbate dementia include profound Coexisting conditions that may exacerbate dementia include profound

hearing or visual loss that isolates the patienthearing or visual loss that isolates the patient In more advanced stages of AD, neurologic examination often reveals In more advanced stages of AD, neurologic examination often reveals

motor dysfunction and reflex abnormalitiesmotor dysfunction and reflex abnormalities

Testing Testing standardized mental status tests standardized mental status tests urinalysis,urinalysis, neuroimaging, neuroimaging, complete blood count, complete blood count, blood chemistry battery blood chemistry battery

electrolytes, glucose, calcium, creatinine, and urea nitrogen, liver and electrolytes, glucose, calcium, creatinine, and urea nitrogen, liver and thyroid function, and serum vitamin B12 level thyroid function, and serum vitamin B12 level

Optional tests not routinely recommended Optional tests not routinely recommended human immunodeficiency virus serology, human immunodeficiency virus serology, syphilis serology, syphilis serology, lumbar puncture, and lumbar puncture, and electroencephalography. electroencephalography.

Selected Clinical Measures in Evaluating Patients Suspected Selected Clinical Measures in Evaluating Patients Suspected of Dementia of Dementia

Mini-Mental State Mini-Mental State Nineteen items measuring orientation, memory, Nineteen items measuring orientation, memory, concentration, language, and praxis; requires some test concentration, language, and praxis; requires some test materials; most widely used screening test materials; most widely used screening test

7 Minute Screen 7 Minute Screen Four tests (orientation, memory, clock drawing, and verbal Four tests (orientation, memory, clock drawing, and verbal fluency); usually completed in 7 to 8 minutes fluency); usually completed in 7 to 8 minutes

Global Deterioration Global Deterioration Scale (GDS) Scale (GDS)

Seven-point ordinal scale; has global descriptors for each Seven-point ordinal scale; has global descriptors for each severity level severity level

Geriatric depression Geriatric depression Scale Scale

Assesses 30 items (either self- or observer-rated) of Assesses 30 items (either self- or observer-rated) of depressive symptomatology in older adults depressive symptomatology in older adults

TestingTesting

RadiologicRadiologic identify CNS tumors, strokes, and hydrocephalus.identify CNS tumors, strokes, and hydrocephalus.

Invasive Invasive Not applicable under normal circumstances Not applicable under normal circumstances Invasive diagnostic procedures (e.g., brain biopsy) in Invasive diagnostic procedures (e.g., brain biopsy) in

patients with suspected dementia offer little advantage over patients with suspected dementia offer little advantage over clinical diagnosis and are unlikely to significantly alter clinical diagnosis and are unlikely to significantly alter clinical management; thus, they should only be considered clinical management; thus, they should only be considered in patients with an unusual clinical course in patients with an unusual clinical course

Differential Diagnosis Differential Diagnosis

Rule out conditions or disorders that may mimic a Rule out conditions or disorders that may mimic a neurodegenerative dementia neurodegenerative dementia normal age-related behaviorsnormal age-related behaviors medication-induced confusion/dementiamedication-induced confusion/dementia focal deficits that point to specific conditions/diseasesfocal deficits that point to specific conditions/diseases basic laboratory studiesbasic laboratory studies

hypothyroidism, B12 or folate deficiency, syphilis, AIDShypothyroidism, B12 or folate deficiency, syphilis, AIDS

NeuroimagingNeuroimaging subdural hematoma, tumor, and infarctssubdural hematoma, tumor, and infarcts

Mental IllnessMental Illness DepressionDepression

Causes of Dementia in Adults by Etiologic CategoryCauses of Dementia in Adults by Etiologic Category Neurodegenerative DisordersNeurodegenerative Disorders

Alzheimer s diseaseAlzheimer s disease Down syndromeDown syndrome Parkinson's diseaseParkinson's disease Dementia with Lewy bodiesDementia with Lewy bodies Frontotemporal dementias:Frontotemporal dementias:

Pick s diseasePick s disease Frontotemporal lobar degeneration, including frontal-lobe dementia, frontal-lobe Frontotemporal lobar degeneration, including frontal-lobe dementia, frontal-lobe

dementia associated with motor-neuron disease, progressive nonfluent aphasia, dementia associated with motor-neuron disease, progressive nonfluent aphasia, semantic dementiasemantic dementia

TauopathiesTauopathies Frontotemporal dementia with parkinsonism linked to chromosomeFrontotemporal dementia with parkinsonism linked to chromosome Familial progressive subcortical gliosisFamilial progressive subcortical gliosis Familial multiple system tauopathyFamilial multiple system tauopathy Corticobasal degenerationCorticobasal degeneration Progressive supranuclear palsyProgressive supranuclear palsy

Multiple system atrophyMultiple system atrophy Huntington diseaseHuntington disease Mesolimbocortical dementiaMesolimbocortical dementia Amyotrophic lateral sclerosis (ALS)-parkinsonism-dementia complexAmyotrophic lateral sclerosis (ALS)-parkinsonism-dementia complex Argyrophilic brain diseaseArgyrophilic brain disease

Causes of Dementia in Adults by Etiologic CategoryCauses of Dementia in Adults by Etiologic Category Cerebrovascular DisordersCerebrovascular Disorders

Vascular dementias: Vascular dementias: Multi-infarct dementia Multi-infarct dementia Subacute arteriosclerotic encephalopathy (Binswanger s disease)Subacute arteriosclerotic encephalopathy (Binswanger s disease) Amyloid angiopathyAmyloid angiopathy Hereditary cerebral hemorrhage with amyloidosis-Dutch Type Hereditary cerebral hemorrhage with amyloidosis-Dutch Type

(HCWA-D)(HCWA-D) Cerebral autosomal-dominant arteriopathy with subcortical infarcts Cerebral autosomal-dominant arteriopathy with subcortical infarcts

and leukoencephalopathy (CADASIL) and leukoencephalopathy (CADASIL) Hippocampal sclerosisHippocampal sclerosis VasculitisVasculitis Subarachnoid hemorrhageSubarachnoid hemorrhage Neurocognitive disorders associated with cardiac bypass Neurocognitive disorders associated with cardiac bypass

Causes of Dementia in Adults by Etiologic Category Causes of Dementia in Adults by Etiologic Category

Prion-Associated DisordersPrion-Associated Disorders Creutzfeldt-Jakob diseaseCreutzfeldt-Jakob disease Variant Creutzfeldt-Jakob disease (linked to bovine spongiform Variant Creutzfeldt-Jakob disease (linked to bovine spongiform

encephalopathy)encephalopathy) Gerstmann-Sträussler-Scheinker diseaseGerstmann-Sträussler-Scheinker disease Fatal familial insomnia Fatal familial insomnia

Neurogenetic DisordersNeurogenetic Disorders Spinocerebellar ataxiasSpinocerebellar ataxias Dentatorubral-pallidoluysian atrophyDentatorubral-pallidoluysian atrophy Hallervorden-Spatz diseaseHallervorden-Spatz disease GangliosidosesGangliosidoses Kufs disease (adult neuronal ceroid lipofuscinosis)Kufs disease (adult neuronal ceroid lipofuscinosis) Machado-Joseph disease (Azorean disease)Machado-Joseph disease (Azorean disease) Lafora's diseaseLafora's disease Mitochondrial encephalopathiesMitochondrial encephalopathies Myotonic dystrophyMyotonic dystrophy PorphyriasPorphyrias Hepatolenticular degeneration (Wilson s disease) Hepatolenticular degeneration (Wilson s disease)

Causes of Dementia in Adults by Etiologic Category Causes of Dementia in Adults by Etiologic Category Infectious DisordersInfectious Disorders

Meningitis (e.g., tuberculosis)Meningitis (e.g., tuberculosis) Encephalitis:Encephalitis:

   Herpes simplexHerpes simplex    Human immunodeficiency virusHuman immunodeficiency virus Lye diseaseLye disease Progressive multifocal leukoencephalopathyProgressive multifocal leukoencephalopathy NeurosyphilisNeurosyphilis Whipple s diseaseWhipple s disease

Toxic/Metabolic EncephalopathiesToxic/Metabolic Encephalopathies Systemic Systemic

Thyroid, parathyroid, pituitary, adrenal, liver, pulmonary, pancreas, kidney, or blood disorders Thyroid, parathyroid, pituitary, adrenal, liver, pulmonary, pancreas, kidney, or blood disorders Sarcoidosis Sarcoidosis Sjögren s syndromeSjögren s syndrome Systemic lupus erythematosusSystemic lupus erythematosus HyperlipidemiaHyperlipidemia Nutritional deficiencies (vitamins B1, B12)Nutritional deficiencies (vitamins B1, B12) Fluid and electrolyte abnormalitiesFluid and electrolyte abnormalities HypoglycemiaHypoglycemia Hypoxic/ischemic disordersHypoxic/ischemic disorders

Toxic:Toxic: DrugsDrugs AlcoholAlcohol Industrial agentsIndustrial agents Heavy metals (Pb, Hg, Mn, Ar, Th, Al, Sn, Bi)Heavy metals (Pb, Hg, Mn, Ar, Th, Al, Sn, Bi) Carbon monoxideCarbon monoxide

Diagnostic Criteria Diagnostic Criteria DSM-IV criteria DSM-IV criteria

Development of multiple cognitive deficitsDevelopment of multiple cognitive deficits::1. Memory impairment, and1. Memory impairment, and2. At least one of the following: 2. At least one of the following:   Aphasia   Aphasia   Apraxia   Apraxia   Agnosia   Agnosia

Disturbed executive functioning (planning, organizing, sequencing, Disturbed executive functioning (planning, organizing, sequencing, abstracting). abstracting).

Course is characterized by continued gradual cognitive and functional Course is characterized by continued gradual cognitive and functional decline.decline.

Deficits are sufficient to interfere significantly with social and Deficits are sufficient to interfere significantly with social and occupational functioning and represent a decline from past functioning.occupational functioning and represent a decline from past functioning.

Other causes (medical, neurologic, psychiatric) of dementia are Other causes (medical, neurologic, psychiatric) of dementia are excluded. excluded.

Diagnostic CriteriaDiagnostic Criteria NINCDS-ADRDA Probable Alzheimer's Disease NINCDS-ADRDA Probable Alzheimer's Disease

Dementia established by examination and documented by objective Dementia established by examination and documented by objective testing for:testing for:

Deficits in two or more cognitive areasDeficits in two or more cognitive areas Progressive worsening of memory and other cognitive functionsProgressive worsening of memory and other cognitive functions No disturbance in consciousnessNo disturbance in consciousness Onset between 40 and 90 years of ageOnset between 40 and 90 years of age Absence of systemic disorders or other brain diseases that could account for Absence of systemic disorders or other brain diseases that could account for

the progressive deficits in memory and cognition the progressive deficits in memory and cognition Diagnosis supported by:Diagnosis supported by:

Progressive deficits in language (aphasia), motor skills (apraxia), and Progressive deficits in language (aphasia), motor skills (apraxia), and perception (agnosia)perception (agnosia)

Impaired activities of daily living and altered patterns of behaviorImpaired activities of daily living and altered patterns of behavior Family history of similar disordersFamily history of similar disorders Consistent laboratory or radiologic results (e.g., cerebral atrophy on computed Consistent laboratory or radiologic results (e.g., cerebral atrophy on computed

tomography tomography

NINCDS-ADRDA, National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association

Diagnostic Indicators for the More Common Non-Alzheimer DementiasDiagnostic Indicators for the More Common Non-Alzheimer Dementias

Dementia with Lewy bodies Dementia with Lewy bodies Presence of dementia and at least one of the following three features early in Presence of dementia and at least one of the following three features early in

the disease course: the disease course: visual hallucinations, visual hallucinations, parkinsonism, and parkinsonism, and fluctuating cognitive statusfluctuating cognitive status

Vascular dementia (VaD) Vascular dementia (VaD) Presence of dementia with abrupt onset Presence of dementia with abrupt onset

within 3 months of stroke within 3 months of stroke oror abrupt deterioration or abrupt deterioration or stepwise progression of dementia, and fluctuating course stepwise progression of dementia, and fluctuating course

Frontotemporal dementias Frontotemporal dementias Presence of dementia withPresence of dementia with disinhibition, impulsivity, impaired judgment, and/or disinhibition, impulsivity, impaired judgment, and/or amotivational states resulting in disturbed personality, behavior, and language amotivational states resulting in disturbed personality, behavior, and language

Depression Depression Presence of dementia with noncognitive changes (lack of interest, loss of Presence of dementia with noncognitive changes (lack of interest, loss of

energy, and difficulty in concentrating)energy, and difficulty in concentrating)

TreatmentTreatment Medical Therapy Medical Therapy

focus pharmacotherapy focus pharmacotherapy palliation of cognitive symptoms and palliation of cognitive symptoms and slowing of disease progressionslowing of disease progression

cholinesterase inhibitors donepezil or rivastigmine cholinesterase inhibitors donepezil or rivastigmine Contraindications for this therapy Contraindications for this therapy

cardiac and gastroenteric complications cardiac and gastroenteric complications antioxidant therapy as a treatment strategy for ADantioxidant therapy as a treatment strategy for AD

Evidence for increased oxidative stress and free radical injury in AD motivated a large-scale trial of selegiline (a Evidence for increased oxidative stress and free radical injury in AD motivated a large-scale trial of selegiline (a monamine oxidase inhibitor) and alpha-tocopherol (vitamin E at 1000 IU b.i.d.) for moderately demented AD monamine oxidase inhibitor) and alpha-tocopherol (vitamin E at 1000 IU b.i.d.) for moderately demented AD patients patients

Both compounds used independently (not in combination) delayed progression to clinical milestones (e.g. Both compounds used independently (not in combination) delayed progression to clinical milestones (e.g. institutionalization) by approximately 8 months. institutionalization) by approximately 8 months.

Favorable safety and cost profiles of vitamin E make it acceptable to many patients in the absence of additional Favorable safety and cost profiles of vitamin E make it acceptable to many patients in the absence of additional studies confirming efficacy.studies confirming efficacy.

Neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available Neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available evidence evidence

Prevent new insult Prevent new insult Treat the underlying causes of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, or diabetes) Treat the underlying causes of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, or diabetes)

Treat reversible dementias Treat reversible dementias hypothyroidism, vitamin B12 deficiency, overmedication, depression, and opportunistic infections hypothyroidism, vitamin B12 deficiency, overmedication, depression, and opportunistic infections

accompanying HIV infection accompanying HIV infection no approved therapies for dementia with Lewy bodies or frontotemporal dementias.no approved therapies for dementia with Lewy bodies or frontotemporal dementias. Treat behavioral symptoms Treat behavioral symptoms

If moderate to severe mood, behavioral, or other neurologic disturbances are present, use psychotropic (e.g., If moderate to severe mood, behavioral, or other neurologic disturbances are present, use psychotropic (e.g., antipsychotics and antidepressants) and antiepileptic agents for short periods of time, as appropriate antipsychotics and antidepressants) and antiepileptic agents for short periods of time, as appropriate

Lifestyle MeasuresLifestyle Measures safe, supportive, and orderly environmentsafe, supportive, and orderly environment

most contentious issues for families to deal with most contentious issues for families to deal with driving, cooking, independent living, control of financial affairs, self-medication, and participation in driving, cooking, independent living, control of financial affairs, self-medication, and participation in

community affairscommunity affairs Physician and caregiver working togetherPhysician and caregiver working together

Recommend establishment of durable power of attorney Recommend establishment of durable power of attorney for financial and health care decision-makingfor financial and health care decision-making

RecommendRecommend establishment of daily routines establishment of daily routines Constant supervision to monitor the safety of the residential settingConstant supervision to monitor the safety of the residential setting Recommend driving evaluation when necessaryRecommend driving evaluation when necessary

Driving evaluations may be obtained from independent driving evaluation centers, some Driving evaluations may be obtained from independent driving evaluation centers, some occupational therapists, or from the state agency regulating driving privileges.occupational therapists, or from the state agency regulating driving privileges.

Nutrition and hydrationNutrition and hydration increased risk for nutritional imbalance, dehydration, and weight lossincreased risk for nutritional imbalance, dehydration, and weight loss

Encourage maintenance of an active and healthy lifestyle.Encourage maintenance of an active and healthy lifestyle. ExerciseExercise Sleep-restSleep-rest..

consistent daily routine consistent daily routine reducing environmental stimuli in the evening, reducing environmental stimuli in the evening, avoiding caffeine and other stimulants,avoiding caffeine and other stimulants, establishing toileting routines, and establishing toileting routines, and possibly the short-term use of a mild hypnotic to establish a normal sleep-cycle.possibly the short-term use of a mild hypnotic to establish a normal sleep-cycle.

Oral hygieneOral hygiene

Invasive Procedures Invasive Procedures Invasive approaches are not appropriate for most common dementias.Invasive approaches are not appropriate for most common dementias.

Ventricular shunting may be needed to ameliorate normal-pressure hydrocephalus, Ventricular shunting may be needed to ameliorate normal-pressure hydrocephalus, or surgical excision may be indicated for CNS neoplasms.or surgical excision may be indicated for CNS neoplasms.

Complementary Medicine Complementary Medicine Ginkgo biloba.Ginkgo biloba.

Ginkgo biloba is an herb with putative antioxidant and anti-inflammatory properties. Ginkgo biloba is an herb with putative antioxidant and anti-inflammatory properties. Gingko may benefit persons with Alzheimer's disease or mixed dementia including Gingko may benefit persons with Alzheimer's disease or mixed dementia including Alzheimer's disease and vascular dementia Alzheimer's disease and vascular dementia

Many studies of gingko have been inconclusive:Many studies of gingko have been inconclusive: treatment effects are weak and dropout rates have led to selection bias. More treatment effects are weak and dropout rates have led to selection bias. More

rigorous studies are in progress.rigorous studies are in progress. A Dutch study (the Maastrict Ginkgo Trial) employing standard designs and A Dutch study (the Maastrict Ginkgo Trial) employing standard designs and

stringent controls found no cognitive benefit for treatment groups over placebo stringent controls found no cognitive benefit for treatment groups over placebo groupsgroups

Gingko biloba has been reported to have antiplatelet effects, requiring caution for Gingko biloba has been reported to have antiplatelet effects, requiring caution for patients on anticoagulant and aspirin therapies.patients on anticoagulant and aspirin therapies.

ComplicationsComplications

Monitor patients for side effects of drug regimens and Monitor patients for side effects of drug regimens and for interactions with other medications for interactions with other medications Because neuroactive compounds commonly used by the Because neuroactive compounds commonly used by the

elderly can exacerbate dementia symptomselderly can exacerbate dementia symptoms dose reduction or discontinuation of benzodiazepines, dose reduction or discontinuation of benzodiazepines,

antidepressants, and minor and major tranquilizersantidepressants, and minor and major tranquilizers Neuroleptics can induce orthostatic hypotension, which can lead to Neuroleptics can induce orthostatic hypotension, which can lead to

falls, fractures, stroke, or even heart attack in the elderlyfalls, fractures, stroke, or even heart attack in the elderly If such adverse effects are suspected, discontinue or reduce the If such adverse effects are suspected, discontinue or reduce the

medication and routinely monitor the patient throughout treatment.medication and routinely monitor the patient throughout treatment.

Special Circumstances Special Circumstances

If dementia appears to be rapidly progressing (onset If dementia appears to be rapidly progressing (onset and progression measured in weeks and months as and progression measured in weeks and months as opposed to years), opposed to years), consider the possibility of Creutzfeldt-Jakob disease (CJD), consider the possibility of Creutzfeldt-Jakob disease (CJD),

a potentially transmissible dementia.CJD is a prion disease,a potentially transmissible dementia.CJD is a prion disease, a member of a rare family of diseases that includes scrapie in sheep a member of a rare family of diseases that includes scrapie in sheep

and bovine spongiform encephalopathy (BSE) in cows (popularly and bovine spongiform encephalopathy (BSE) in cows (popularly known as "mad cow disease").known as "mad cow disease").

When to Consult or ReferWhen to Consult or Refer Refer patients suspected of having a potentially treatable Refer patients suspected of having a potentially treatable

neurologic conditionneurologic condition e.g., normal-pressure hydrocephalus, mass lesion) to a neurologist or e.g., normal-pressure hydrocephalus, mass lesion) to a neurologist or

neurosurgeon for evaluation.neurosurgeon for evaluation.

Consider referring patients with dementia to a dementia Consider referring patients with dementia to a dementia specialist if theyspecialist if they Are <55 years of age; Are <55 years of age; Have rapidly progressing dementia (e.g., possible Creutzfeldt-Jakob Have rapidly progressing dementia (e.g., possible Creutzfeldt-Jakob

disease); disease); Have psychosis early in the course of dementia; Have psychosis early in the course of dementia; Have prominent focal deficits (e.g., progressive aphasia); or Have prominent focal deficits (e.g., progressive aphasia); or Reveal neurologic abnormalities (e.g., extrapyramidal dysfunction).Reveal neurologic abnormalities (e.g., extrapyramidal dysfunction). Refer patients who have refractory psychological symptoms (e.g., Refer patients who have refractory psychological symptoms (e.g.,

depression) to a psychiatrist. depression) to a psychiatrist. Refer patients and their family/caregivers who need additional Refer patients and their family/caregivers who need additional

reassurance or assistance to community resources and/or geriatric case reassurance or assistance to community resources and/or geriatric case managers if appropriate. managers if appropriate.

Prognosis Prognosis Recall that Alzheimer's disease is a treatable disorder.Recall that Alzheimer's disease is a treatable disorder.

Drugs can ameliorateDrugs can ameliorate the cognitive and behavioral symptoms of Alzheimer's disease (AD) and the cognitive and behavioral symptoms of Alzheimer's disease (AD) and aid in maintaining activities of daily living, but progression is inevitable (as in the aid in maintaining activities of daily living, but progression is inevitable (as in the

other most common neurodegenerative dementias).other most common neurodegenerative dementias). cholinesterase inhibitors cholinesterase inhibitors

Symptomatic progression of the disease may be delayed up to 12 months in Symptomatic progression of the disease may be delayed up to 12 months in patients with AD patients with AD

The total duration of the illness averages between 7 and 10 years. The total duration of the illness averages between 7 and 10 years. For those patients who have endstage disease, For those patients who have endstage disease,

death results from aspiration, pneumonia, pulmonary embolus, sepsis, or death results from aspiration, pneumonia, pulmonary embolus, sepsis, or exhaustion resulting from lack of food and waterexhaustion resulting from lack of food and water

.Although not well studied, it is widely accepted that strokes affecting .Although not well studied, it is widely accepted that strokes affecting critical volumes and locations can cause irreversible dementia.critical volumes and locations can cause irreversible dementia.

Pure vascular dementia has been over-reported in clinical studies.Pure vascular dementia has been over-reported in clinical studies. Patients with presumptive vascular dementia are frequently found to have Patients with presumptive vascular dementia are frequently found to have

Alzheimer's disease on histological examination Alzheimer's disease on histological examination Vascular dementia and mixed dementia (vascular and AD) have the same Vascular dementia and mixed dementia (vascular and AD) have the same

prognosis as AD aloneprognosis as AD alone

Patient EducationPatient Education Disclose diagnosis of dementia to the patient and familyDisclose diagnosis of dementia to the patient and family

to allow for discussion of advance planning, treatment options, prognosis, and support to allow for discussion of advance planning, treatment options, prognosis, and support groups.groups.

Advise patients and caregivers that dementia may be less disablingAdvise patients and caregivers that dementia may be less disabling if the patient's activities are structured and surroundings are safe and familiar.if the patient's activities are structured and surroundings are safe and familiar.

Educate caregivers regarding the signs and symptoms associated with dementia.Educate caregivers regarding the signs and symptoms associated with dementia. Advise patient, family, and caregivers that treatment of the most common Advise patient, family, and caregivers that treatment of the most common

dementias (AD, DLB, VaD) is symptomaticdementias (AD, DLB, VaD) is symptomatic e.g. memory and thinking may improve a littlee.g. memory and thinking may improve a little they should not expect reversal of the symptoms of dementia from therapies available they should not expect reversal of the symptoms of dementia from therapies available

today.today. Self-care InstructionsSelf-care Instructions

Advise patient and caregivers to learn the signs and symptoms of adverse drug reactions Advise patient and caregivers to learn the signs and symptoms of adverse drug reactions [and [and

to contact a physician promptly if an adverse reaction is suspectedto contact a physician promptly if an adverse reaction is suspected

Follow-upFollow-up

Re-evaluate a patient suspected of dementia at Re-evaluate a patient suspected of dementia at 6- to 12-month intervals6- to 12-month intervals

Assess disease progression, Assess disease progression, Confirm the diagnosis, and Confirm the diagnosis, and Establish a prognosis Establish a prognosis

Prevention and ScreeningPrevention and Screening Recall that insufficient evidence exists regarding the recommendation for Recall that insufficient evidence exists regarding the recommendation for

or against routine screening for dementia with standardized tests in or against routine screening for dementia with standardized tests in asymptomatic individuals.asymptomatic individuals.

Treat the underlying causes/risk factors of vascular dementia (VaD) (e.g., Treat the underlying causes/risk factors of vascular dementia (VaD) (e.g., hypertension, atherosclerosis, and diabetes) to prevent stroke or additional hypertension, atherosclerosis, and diabetes) to prevent stroke or additional insult following stroke.insult following stroke.

Consider timely correction of metabolic disturbances (e.g., vitamin B12 Consider timely correction of metabolic disturbances (e.g., vitamin B12 deficiency, hypothyroidism, alcoholism) associated with dementia to deficiency, hypothyroidism, alcoholism) associated with dementia to reduce the incidence of subsequent dementia.reduce the incidence of subsequent dementia.

Be aware that neither estrogen therapy nor prednisone is recommended for Be aware that neither estrogen therapy nor prednisone is recommended for the treatment of AD, based on available evidencethe treatment of AD, based on available evidence

Be aware that nonsteroidal anti-inflammatory drugs (NSAIDS) are not Be aware that nonsteroidal anti-inflammatory drugs (NSAIDS) are not recommended for the prevention of AD, based on available evidencerecommended for the prevention of AD, based on available evidence

Be aware that genetic screening in patients suspected of having AD is of Be aware that genetic screening in patients suspected of having AD is of no diagnostic value at this time. no diagnostic value at this time.