• What are the investigations?

Dementia: Investigations

• History taking

• Clinical examination• Neuropsychological assessment: -Episodic or short term memoryLanguage, particularly word fluencyExecutive functioning

Dementia: investigations

• Laboratory assessment:- Full blood count ESR Thyroid function test Serum electrolytes and calcium Serum glucose Serum BUN/creatinine B12 and folate Liver function test Syphilis serology HIV serology

Dementia: Investigations

• Medical imagingX- Rays, ECGCT or MRI scan of the brain

• How do you want to manage this patient?

Dementia of Alzheimer’s type

• Treat the cognitive deficits

• Treat the neuropsychiatric symptoms

Neurotransmitter system altered in Alzheimer’s disease

• Decreased

• Acetylcholine• Serotonin• Noradrenaline• Dopamine• GABA• Somatostatin• Vasopressin• Substance P• Neuropeptide Y

• Increased

• Monoamineoxidase B

• galanin

Neurotransmitter systems altered in Alzheimer’s disease

• Ach

Major neurotransmitter for memorySeverely affected in Alzheimer’s diseaseAcetylcholinesterase destroys Ach in the

brain to control amount of AchPossible to block this enzyme

Drug therapy in cognitive deficits• Mode of action

• Acetylcholinesterase inhibition

• Precursors loading• Neurotransmitter release

• Muscarinic agonists

• Examples

• Tacrine, donepezil, ENA 713, metrifonate, galanthamine

• Choline, lecithin• Besipiridine

• Milameline, xanomeline

Acetylcholinesterase inhibitors registered in Australia

• Donezepil (Aricept)

• Rivastigmine (Exelon)

• Galatamine (Reminyl)

• S/e – diarrhoea, nausea, vomiting, muscle cramps, insomnia, fatigue, and loss of appetite

precursorsAc CoA + choline

Ach

Ach

NM2

Increase release

Choline + acetate

Cholinesterase inhibitors

M1

Selective M1 agonists

Site of action of cholinergic

agonists

Drug therapy in neuropsychiatric symptoms

• Indications:

Mood, usually depression, rarely maniaPerception with hallucinations and

misindentificationsThought content with delusions and paranoid ideasBehaviour, with aggressions, wandering, sexual

disinhibition

Drug therapy in neuropsychiatric symptoms

• Neuroleptic

Indications – agitation, aggression, delusions and hallucinations

Haloperidol, olanzepine, thioridazine and risperidone

S/e – extrapyramidal, decreased cognitive performance

• Antidepressants

Selective serotonin uptake inhibitors (eg: sertraline)

Atypical antidepressants (trazodone)

Monoamineoxidase inhibitors (moclobemide, selegiline)

Treatment of vascular dementia

• Drug therapyAntiplatelet therapy (e.g aspirin 75 –

325mg)Other antiplatelet agent (e.g ticlopidine)

• SurgicalCarotid endarterectomy

Non drug treatment

• Better information for carers

• Reinforcement of day and time given regularly

• Behaviour modification

• Patient and family support

• Role of GP