1 ad- the extent of the problem ad represents over 50% of all dementia cases ad prevalence doubles...
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AD- the extent of the problem
• AD represents over 50% of all dementia cases
• AD prevalence doubles every 5 years after 60 years of age
• AD affects 15 million people worldwide
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The diagnosis and assessment of AD
• "Listen to the patient, they are telling you the diagnosis."
• "It is possible to make a diagnosis of Alzheimer's disease, just as we can make a diagnosis of other major illnesses."
• "The challenge today is to obtain an early, accurate and specific diagnosis of dementia using an effective diagnostic process."
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AD prognosisOptimal case
Min
i Men
tal S
tate
Exa
min
atio
n s
core
1 2 3 4 5 6 7 8 9
25 ---------------------| Symptoms
20 |----------------------| Diagnosis
15 |-----------------------| Loss of functional independence
10 |--------------------------------| Behavioral problems
5 |-------------------------------------------|
0 Death |------------------------------------------
Nursing home placement
Feidman and Gracon, 1996Years
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Definition of the dementiasyndrome
• Multiple cognitive deficits – memory loss – aphasia – apraxia – agnosia – disturbance in executive function
• These lead to functional decline
DEMENTIA
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Causes of dementia
• Common causes: – Depression– Delirium– Drug toxicity
• Common causes: – Alzheimer's disease– Vascular dementia
• Other causes– Lewy body disease– Pick's disease (dementia
of the frontal lobe type) – Parkinson's disease with
dementia
Reversible dementias Irreversible dementias
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Differentiating AD from other dementias
Cognitive impairment
Dementia
Alzheimer's disease
Exclude other causes (e.g. delirium and depression, etc)
Exclude other dementias
Differentiating AD from other dementias
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Dementia * Insidious onset with unknown date* Slow, gradual, progressive decline* Generally irreversible* Disorientation late in illness* Slight day-to-day variation* Less prominent physiological changes* Consciousness clouded only in late stage* Normal attention span* Disturbed sleep wake cycle; day night
* Psychomotor changes late in illness
Delirium * Abrupt, precise onset, known date * Acute illness, lasting days or weeks * Usually reversible * Disorientation early in illness * Variable, hour by hour * Prominent physiological changes * Fluctuating levels of consciousness * Short attention span * Disturbed sleep wake cycle; hour-to-hour variation * Marked early psychomotor changes
OR
Dementia or delirium
Ham, 1997
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Dementia * Insidious onset * No psychiatric history * Conceals disability * Near-miss answers * Mood fluctuation day to day * Stable cognitive loss * Tries hard to perform but is unconcerned by losses * Short-term memory loss * Memory loss occurs first * Associated with a decline in social function
Depression * Abrupt onset * History of depression * Highlights disabilities * ’Don't know' answers * Diurnal variation in mood * Fluctuating cognitive loss * Tries less hard to perform and gets distressed by losses * Short- and long-term memory loss * Depressed mood coincides with memory loss * Associated with anxiety
OR
Dementia or depression
Ham, 1997, modified from Wells CE, 1979
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Risk factors* Age* Family History of AD (ApoE-4) * Head trauma* Low educational level* Environmental factors* Down’s syndrome
Protective factors * Genetic (ApoE-2)* High educational level* Long-term anti- inflammatory drug use, e.g. NSAIDS* Long-term use of estrogens (in women)
AD risk and protective factors
IPA AD Conference, 1996
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Need for earlydiagnosis
Consistent onset, clinicalpresentation and disease progression
Practicalassessmentmethods
New symptomatictreatments
Patient and caregiver support
Making a diagnosis of AD
IPA AD Conference, 1996
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IPA AD Conference, 1996
Functionalimpairment * IADL * ADL
Insidious onset Cognitive decline* Memory loss * Aphasia * Apraxia * Agnosia * Executive function difficultiesBehavioral signs
* Mood swings * Agitation* Wandering
Age over 60 years
No gait difficulties
AD
Clinical features of AD
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Cognition * Recall/learning* Word finding* Problem solving* Judgement* Calculation
Function* Work* Money/shopping* Cooking* Housekeeping* Reading* Writing* Hobbies
Behavior* Apathy* Withdrawal* Depression* Irritability
IMPAIRMENT
Adapted from Galasko, 1997
Clinical features of ADMild stage of AD (MMSE 21 30)
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Cognition * Recent memory (remote memory unaffected) * Language (names, paraphasias)* Insight* Orientation* Visuospatial ability
Function* IADL loss* Misplacing objects* Getting lost* Difficulty dressing (sequence and selection)
Behavior * Delusions* Depression* Wandering* Insomnia* Agitation* Social skills unaffected
IMPAIRMENT
Clinical features of ADModerate stage of AD (MMSE 10 20)
Adapted from Galasko, 1997
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Cognition * Attention* Difficulty performing familiar activities (apraxis)* Language (phrases, mutism)
Function* Basic ADLs Dressing Grooming Bathing Eating Continence Walking Motor slowing
Behavior* Agitation Verbal Physical* Insomnia
Clinical features of ADSevere stage of AD (MMSE <10)
Adapted from Galasko, 1997
IMPAIRMENT
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"How is your memory?"
Case-finding Pattie and Gilleard, 1979
Diagnosing AD in primary carecase-finding
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Clinical History
* Forgetfulness * Getting lost in familiar settings * Difficulties with finance * Deterioration of work or home performance * Inability to recognize, or a lack of interest in, family members * Difficulties driving or using the telephone
Diagnosing AD in primary careclinical history, common presentations
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Clinical History
Ask the following questions: * How did it start? Was it sudden or gradual? * How long has it been going on? * Is the situation progressing? If so, how rapidly? * Is it step-wise or continuous? * Is it worsening, fluctuating or improving? * What changes have you noticed? * Has there been a change in personality? * Has the patient suffered any delusions or hallucinations? * Does the patient become agitated or wander?
Diagnosing AD in primary careclinical history, questioning
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Functional Assessment
Functional Activities Questionnaire (FAQ)1. Dealing with financial matters, paying bills, writing checks2. Keeping records of taxes, business affairs3. Shopping for everyday necessities: groceries, clothes, etc4. Hobbies or playing games5. Making tea, turning the kettle on and off6. Cooking a balanced meal7. Perception of current events8. Level of attention and understanding: books, television9. Memory: remembering appointments and medications10. Getting about: driving or taking public transport
Pfeffer et al 1982
ScoreMaximum
3333333333
Total 30
ScoreActual
Diagnosing AD in primary carefunctional assessment
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Cognitive Assessment
Cognitive areaMini Mental State Examination: test outline and scoring
Orientation *What is the (date, day, month, year, season)? * Where are you (clinic, town, country)?
Memory *Name three objects. Ask the patient to repeat them
Attention*Serial sevens. Alternatively ask the patient to spell world backwards (dlrow)
Folstein et al 1975
ScoreMaximum
55
3
5
ScoreActual
Diagnosing AD in primary carecognitive assessments, MMSE
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Cognitive Assessment
Cognitive areaMini Mental State Examination: test outline and scoring
Recall *Ask for the three objects mentioned above to be repeated
Language*Name a pencil and watch*Repeat, 'No ifs, ands or buts’*A three stage command*Read and obey CLOSE YOUR EYES*Write a sentence*Copy a double pentagon
ScoreMaximum
3
213111
Total 30
ScoreActual
Folstein et al 1975
Diagnosing AD in primary carecognitive assessments, MMSE (continued)
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The Clock Draw Test
Cognitive Assessment
Time: 5.00 Score: 7 (normal)
Time: 'no real time' Score: 2 (demented)
Thalmann et al 1996.
Time: .10.30 Score: 3 (demented)
Time: 1/4 past 25 Score: 3 (demented)
Diagnosing AD in primary carecognitive assessment
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Physical examination
* Life-threatening conditions, e.g. mass lesions, vascular lesions and infections * Blood pressure and pulse * Vision and hearing assessments * Cardiac and respiratory function * Mobility and balance * Sensory and motor system examination (tone, reflexes, gait and coordination) and depressive symptoms (sleep and weight)
Diagnosing AD in primary carephysical examination
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Laboratory tests
All patients* Complete blood count* Thyroid function* Vitamin B12 and folate* Syphilis serology * BUN and creatinine * Calcium * Glucose * Electrolytes * Urinalysis * Liver function tests
Most patients * ECG* Chest X-ray
Diagnosing AD in primary carelaboratory tests
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Neuroimaging
Various CT scan reports in AD * Normal examination for the patient's age * Generalized cerebral atrophy * Small vessel changes, areas of leucoencephalopathy* No signs of subdural hematoma (if head trauma suspected) * Absence of specific areas of cerebral infarctions or evidence of stroke
Diagnosing AD in primary careneuroimaging, computed (axial)
tomography (CT)
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* Inconclusive diagnosis * Atypical presentation * Behavioral/psychiatric symptoms * Second opinion * Family dispute * Caregiver support
Primary care management of ADspecialist referral
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* Define all contributory factors and other illnesses * Discuss the diagnosis, and differentiate other types of dementia * Withdraw non-essential drugs that may interfere with cognition * Treat or manage concomitant illness (e.g. depression, hearing loss)
The role of the primary care physician in mild to moderate AD
Gauthier, Burns and Pettit, 1997
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* Discuss the use of symptomatic therapies * Monitor functional ability e.g. driving, safety * Referral to specialist if appropriate * Advise on will-making and advance directives * Refer to local AD association for support * Managing caregivers
The role of the primary care physician in mild to moderate AD
(continued)
Gauthier, Burns and Pettit, 1997
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The role of the primary care physician in severe AD
* Help caregivers discover and optimize the patient's preserved function * Monitor and treat complications * Facilitate caregiver support (respite and day care programs) * Be aware of caregiver burden and stress * Plan institutionalization, if needed * Assist with end-of-life decisions
The role of the primary care physician in severe AD
Gauthier, Burns and Pettit, 1997
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CASE-FINDINGSymptomssuggestingcognitive
impairment
MANAGEMENT OF AD *Follow-up *Patient and caregiver counseling *Management and symptomatic treatment *Specialist referral if indicated
CLINICAL ASSESSMENT *Clinical history
*Physical examination *Laboratory tests
*Functional assessment *Cognitive assessment
Functional decline and cognitive impairment
DIFFERENTIAL DIAGNOSIS *Exclude delirium depression other causes of dementia *Evaluate evidence for AD (neuroimaging)
YES
AD diagnosis
Diagnosing AD in primary careA systematic approach summary
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* Cognitive ability* Functional ability * Behavior * General health * Routine health checks
Primary care management of ADfollow-up