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DementiaClinical Consideration for GP
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http://epilepsy.kku.ac.thSharePoint document libraries I:
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The prevalence of dementia in elderly was 9.8
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The prevalence of dementia in elderly was 9.8
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Dementia: How to Approach
• Reversible ;chronic subdural hematoma,
NPH, metabolic, endocrine , drugs,
CNS infection
• Static / reversible; vascular dementia
• Irreversible; degenerative disease,
Alzheimer’s disease
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D E M E N T I AD : Degenerative (AD), depression, drugs
E : Endocrine
M : Metabolic
E : Epilepsy
N : Neoplasm, nutrition
T : Toxic, trauma
I : Infection, inflammation, infarction
A : Atherosclerosis, alcohol
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Differential diagnosis; 2D 4A
• D epression
• D elirium
• A phasia
• A gnosia
• A nxiety
• A mnesiaSharePoint document libraries I:
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Evaluation
1. Good history and PE, with familywith family
- Neurological and mental status examination
2. CT-brain without contrast initially
3. EEG for rule out epilepsy
4. EKG
5. Blood test
6. Lumbar puncture
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Evaluation : History• Impaired recent memory
• Poor decision making
• Performing routine tasks
• Managing money
• Personality change
• Onset and clinical course
• Education ,Social, Life style
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Evaluation : History
• Risk factor
• Family history
• Medical
– Systemic disease
– Neurological symptom
– Sleep disturbances
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Observation
• Performance
• Dressing
• Concentration and attention
• Patient – relative relationship
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Physical Examination
• Routine neurological examination
• Specific neurological examination
Parieatal lobe
Occipital lobe
Frontal lobe
Visual field
• Mental status examination
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Sensitivity was 88%, specificity was 74%
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Differential diagnosis; 2D 4A
• Depression
• Delirium
• Aphasia
• Agnosia
• Anxiety
• Amnesia
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Dementia and Delirium Quick Reference Table
DeliriumSubcortical DementiaCortical DementiaFeature
Sudden
Hours to days
Fluctuating
Fluctuating
Slurred, incoherent
Anomia, dysgraphia
Encoding deficit
Impaired
Impaired
Apathetic, agitated
Often florid
Tremor, asterixis
Moderate-to-severe slowing
Insidious
Months to years
Progressive
Normal
Hypophonic, dysarthric
Normal or anomic
Retrieval deficit
Slow, delapidated
Preserved
Apathetic
Possible
Tremor, dystonia
Normal or mild slowing
Insidious
Months to years
Progressive
Normal
Normal
Aphasic
Learning deficit
Acalculia, concrete
Impaired
Disinhibited
Possible
None
Diffuse slowing
Onset
Duration
Course
Attention
Speech
Language
Memory
Cognition
Awareness
Demeanor
Psychosis
Motor signs
EEG
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Amnesia
• Impaired recent memory
• Global amnesia
• Preserved remote, immediate memory
• Intact general cognitive function
• Confabulation
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Anxiety
• Personality
• Multiple complaints
• Seek to doctor by themselves
• Loss of concentration
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Aphasia
• Atherosclerosis risks
• Acute /sudden onset
• Typical characteristic of sensory aphasia
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What is it?What is it?
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Object recognitionObject recognition
Object seen by the ‘EYE’
Object seen by the ‘BRAIN’
The answer is ‘ELEPHANT’
Object recognized
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Object recognition
Visual input-Acuity-Colour-Motion
Knowledge and memoryabout object
LanguageCapability
Answer
Attention
Visual Agnosia
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Q: Look at this. What is it?A: I don’t know
Q: Feel this. What is it?A: A key
Q: What do you use to unlock the lock?
A: A key
Memory, knowledgeand naming is intact
Q: Copy it.A: Reasonable
vision
Ability to use tactile information
Q: Look. What is it?A: I don’t know
Inability to use visual information SharePoint document libraries I:
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D E M E N T I AD : Degenerative, depression, drugs
E : Endocrine
M : Metabolic
E : Epilepsy
N : Neoplasm, nutrition
T : Toxic, trauma
I : Infection, inflammation, infarction
A : Atherosclerosis, alcohol
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Blood test
• CBC
• Blood chemistry
• TFT
• VDRL
• ESR
• ANA,RF
• B12
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CBC (,-��2��� hypersegmented neutrophils �- .)
Serum electrolyte
Glucose
BUN/creatinine
Liver function tests
Thyroid function tests
Screen for syphilis (VDRL �(� treponent test �(������2��:��-)
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Genetic study : �2��'�, !0�,'�����?���0�����8�".��,,9.1329� Familial AD : presenilin ��� APP mutations � Familial prion disease : prion gene mutations� Familial FTD : tau gene mutations� Huntingtonss disease, SCA. DRPLA : CAG repeats testing� Mitochondrial disorders : mitochondrial DNA mutation� CADASIL : notch 3 mutations
Genetic markers
�!,-��"9!)�:�-����. leptomeningeal metastasis, CNS infection, reaqctiveserum syphilis serology, hydrocephalus, rapidly progressive or unusual dementia, immunosuppression, CNS vasculitis
LP and CSF examination
EEG !���*���8.+� 0��+' . 9�9!{�.1 ��2����(��2!���8� �+'� Creutzfeld >Jakob disease
EEG
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�3,���� 7 recommendation for CT scan CT, MRIMRI, nuclear SPECT, PET scanMEI, nuclear SPECT, PET scan
Neuroimaging� Structure� Functional � Metabolic
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M E D I C A L
M: Metabolic
E: Endocrine
D: Drugs, degenerative (AD)
I : Infection, inflammation
C: Complex partial seizures
A: Atherosclerosis, alcohol
L: Low vitamin
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Neurodegenerative
1.Alzheimer’s disease
2.Progressive supranuclear palsy
3.Parkinson’s disease
4.Other parkinsonism plus syndrome
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Dementia Deficits Table
N
N
N
N
50 – 80
SI
N
SI
I
N
I
I
N
50 –80
SI
N
SI
SI
N
I
I
N
50 – 80
SI
N
SI
I
I
I
SI
SI
<50
SI
SI
I
I
Orientation
Memory
Immediate
Delayed
Recognition
% Retained
Executive function
Language
Naming
Fluency
Visuospatial
PSPHDPDAD
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Surgical condition
1. Chronic subdural hematoma
2.Brain tumor
3.Hydrocephalus : NPH
Ataxic, incontinence, cognitive impairment
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History
•65 year-old
•3 months headache
•Progressive cognitive
impairment
•No history of injury
•Papilledema
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History
• 45 year-old
•Heavy smoking
•Sub-acute progressive
headache
•Cognitive impairment
•Parietal lobe sign
•Increased ICP
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History
•67 year-old
•Chronic progressive
cognitive impairment
•Ataxia
•Urinary incontinence
•LP 30 cc
•VP shuntSharePoint document libraries I:
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Clinical features can be scored using the Hachinski scale
A score of > 7 suggests multi-infarct dementia
A score of < or = to 4 indicates probable primary degenerative dementia
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Abrupt onset
Fluctuating course
History of stroke
Focal neurologic symptoms
Focal neurologic signs
Stepwise deterioration
Nocturnal confusion
Preservation of personality
Depression
Somatic complaints
Emotional incontinence
Hypertension
Evidence of atherosclerosis
ScoreClinical Finding
9
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Sensitivity 85.3%, specificity 72.9%
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Vascular cognitive impairment• Post-stroke dementia
• Vascular dementia
–Cortical (multi-infarct)
–Subcortical (Binswanger’s disease)
–Strategic infarct dementia
–Hypoperfusion
–ICH
• Mixed (AD and Va dementia)
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Strategically localized infarcts
• Angular gyrus
• Basal ganglia
• Thalamic nuclei
• Hippocampus and retrosplenial area
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Risk Factor for Dementia in Thai Elderly
0.009
0.001
0.001
0.024
0.040
0.001
0.001
0.001
141±24
86±13
250±51
27±11
39.6±42
4.9±0.7
41.1±5.1
57.77±11.3
139±25
83±13
251±51
36±51
48.6±63.4
5.1±0.4
40.5±4.7
54.79±10.4
134±22
81±11
230±53
28±19
22.8±16
4.3±0.6
39.2±5.0
53.59±10.9
SBP
DBP
Cholesterol
SGOT
GGT
Albumin
Hct
Weight
P valueNormalCognitive impairment
Dementia
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History
•45 year-old
•Acute cognitive impairment
•CPS to GTC
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AphasiaAphasia
AnxietyAnxiety
Metabolic
EndocrineDrugsInfection
CPSAtherosclerosisLow vitamin
AgnosiaAgnosia
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Question?
• Brain imaging
• Drug
• Benefit
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Question and Comment
Thank you for your interest