Dementia

  1. In patients with early, non-specific signs of cognitive impairment:

    1. Suspect dementia as a diagnosis.

    2. Use validated tests of cognitive function (eg. MMSE, MoCA) and careful functional inquiry, as well as a careful history (including collateral history from family and caregivers if available) and physical examination, to make an early positive diagnosis.

  2. In patients with obvious cognitive impairment,

    1. Select proper laboratory investigations and neuroimaging techniques to complement the history and physical findings and to distinguish between dementia, delirium, and depression

    2. Consider possible contributing causes, including mental health, alcohol or substance use problems, or delirium

  3. In patients with dementia, distinguish Alzheimer’s disease from other dementias, as treatment and prognosis differ.

  4. In patients with dementia who exhibit worsening function, look for other diagnoses (i.e., don’t assume the dementia is worsening). These diagnoses may include depression, infection, concurrent medical illness, substance use, etc.

  5. When disclosing the diagnosis of dementia,

    1. Do so compassionately

    2. Respect the patient’s right to autonomy, confidentiality, and safety

  6. In patients with dementia, assess competency to involve them in decision making, as appropriate to the situation

  7. In following patients diagnosed with dementia:

    1. Assess function and cognitive impairment on an ongoing basis.

    2. Assist with and plan for appropriate interventions (e.g., deal with medication issues, behavioural disturbance management, safety issues, caregiver issues, comprehensive care plans, advanced care planning, driving safety, placement) in the context of disease progression

    3. Manage comorbidities, including mental health problems based on the goals of care

    4. Review pharmacotherapy (e.g. side effects, drug interaction, polypharmacy)

  8. Assess the needs of and supports for caregivers of patients with dementia.

  9. Report patients with dementia to the appropriate authorities if you suspect they should not be driving.

  10. In patients with early-onset dementia, consider genetic testing

Definition of Major Neurocognitive Disorder (Dementia)

  • Evidence of significant cognitive decline in one or more cognitive domains

    • Learning/memory

    • Language

    • Executive function

    • Complex attention

    • Perceptual-motor

    • Social cognition

  • Impairs function

    • ADLs (dressing, eating/self-feeding, ambulating/transferring, toileting, hygiene/grooming, bath/shower)

    • IADLs (shopping, housework, accounting/finances, food prep, telephone, transportation, taking meds)

  • Not better explained by other disorder

DDx Memory Loss

  • Major Neurocognitive Disorder (previously Dementia)

    • Alzheimer (most common 50%)

      • Gradual onset, normal CNS, initial and most prominent deficit = amnestic (associated with impairment in learning and recall of recently learned information)

    • Mixed Alzheimer and vascular (20%)

    • Vascular (15%)

      • Abrupt, stepwise, cardiovascular risks (HTN, DLP), dysexecutive syndrome, focal neurological features

    • Lewy Body (5%)

      • Core features: Fluctuating cognition, detailed visual hallucinations, REM sleep behaviour disorder, Parkinsonism (bradykinesia, rest tremor, rigidity)

      • Other suggestive: Severe neuroleptic sensitivity (irreversible parkinsonism, impaired consciousness), postural instability, falls, syncope, autonomic dysfunction, hypersomnia, hyposmia, delusions, apathy, anxiety, depression

    • Frontotemporal (1%)

      • Behavioural problems (disinhibition, loss of social awareness), language impairment

    • Parkinson disease with dementia

      • Impaired executive dysfunction and visuospatial function

      • Differentiate from Lewy Body as parkinsonism is present >1y prior to dementia (whereas in DLB dementia occurs before or at the same time as the parkinsonian signs)

    • Other: Progressive supranuclear palsy (vertical supranuclear gaze palsy and postural instability), Huntington disease

  • Mild Neurocognitive Disorder

    • Decline reported by patient, informant or clinician with objective deficits in 1+ domains (typically memory)

    • Preserved independence in function

      • Follow q3-6 months, Alzheimer's 15% per year (2/3 will eventually convert to Alzheimer's)

  • Delirium (sudden onset, decreased concentration, may have visual/tactile hallucinations)

    • Infection

    • Drugs/Toxins (polypharmacy, opioids, cholinergic, benzodiazepine, alcohol)

    • Endocrine (Thyroid, B12)

    • Electrolytes (glucose, sodium)

  • Depression

  • Neurological - Seizures, stroke/TIA

Physical Exam

  • Gait

  • Neurological signs

  • Extra pyramidal symptoms

  • Parkinson (cogwheel rigidity, tremors)

Investigations

  • Labs (low yield <1%)

    • CBC, TSH, electrolytes (Glucose, Cr, Ca), B12, Lipids

      • Neurosyphilis screen only if high clinical suspicion

    • Consider EKG prior to treatment

      • Avoid AchEI if LBBB, 2nd/3rd degree block, sick sinus, HR<50

    • CT head if

      • <60yo

      • Abrupt, rapid decline

      • Focal neurological symptoms (headache, seizure, hemiparesis, babinski reflex)

      • Urinary incontinence, gait disorder (r/o normal pressurehydrocephalus)

      • Previous malignancy, trauma

      • Anticoagulants/Bleeding disorder or history of bleeding disorder

      • If presence of cerebrovascular disease would change management

  • Depression screen

Diagnosis

  • Investigate symptomatic

  • Highly educated

    • Hopkins Verbal Learning test

    • Word List Acquisition test

  • MMSE <24 suggests dementia/delirium (1 in 10 false positive)

  • MoCA <26 (MCI 78%, AD 100%,1 in 4 false positive)

  • Clinical Dementia Rating (Lengthy)

  • Mini-Cog (Brief)

      • Clock drawing task and uncued recall of three unrelated words

Treatment

Lifestyle

  • Refer to Alzheimer society

  • Discuss will, power of attorney, personal directives

  • Safety issues (driving, stove, smoke detector, microwave)

    • Occupational Therapy

  • Hearing and vision screen

  • Social work / Homecare services

  • Healthy diet, smoking cessation

  • Exercise program

  • Eliminate medication (narcotics, anticholinergics, benzodiazepines)

  • Alternative therapy

    • Aromatherapy

    • Multisensory stimulation

    • Music/dance therapy

    • Animal‑assisted therapy

    • Massage/touch therapy

    • Outdoor activities

Pharmacotherapy

  • No pharmacotherapy for mild cognitive disorder

  • Acetylcholinesterase inhibitors may be considered only in mild to moderate Alzheimer's Disease (lower quality evidence in Lewy bodies, vascular, Parkinson), where

    • Healthcare professional has expertise in diagnosing and treating Alzheimer's Disease

    • Adequate support and supervision

    • Adequate adherence and monitoring of adverse effects, which generally requires the availability of a carer

    • Baseline structured cognitive and functional assessment

    • Follow up should be carried out on regular basis at least every 3 months

      • Taper slowly before stopping

      • May restart if decline shortly after stopping

Pharmacotherapy by Dementia Type

  • Alzheimer's

    • AchEI, eg. Donepezil (Aricept) 5mg-10mg PO daily, Rivastigmine, Galantamine

      • Consider in mild to moderate (eg. MMSE 10-26)

      • Titrate q4 weeks

      • Discontinue when risks outweigh benefits (taper, and monitor 1-3 months, if declines can restart)

      • Adverse:

        • GI (nausea, diarrhea, vomiting)

        • Bradycardia, hypotension, dizziness, syncope

        • Insomnia / sleep disturbances

        • QT prolongation and torsades de pointes (EKG prior to treatment as above)

    • NMDA receptor antagonists (Memantine) in severe AD

  • Frontotemporal

    • SSRI (paroxetine) or trazodone

    • No evidence for AchEI

  • Vascular

    • Manage HTN, DM, smoking

    • No evidence for AchEI

  • Lewy Bodies

    • Can consider AchEI (eg. Rivastigmine (Exelon) 1.5-6mg BID)

    • Avoid antipsychotics

      • Risk of NMS

  • Atypical depression

    • Trial of antidepressant, consider Citalopram (max 40mg po daily)

  • Parkinson's/Cerebrovascular disease

    • Can consider AchEI

Behavioral and psychological symptoms of dementia (BPSD)

  • r/o medication side effects or interactions, treatable medical conditions such as sepsis or depression

  • Severe agitation/Violent behaviour

    • Correct underlying

      • Physical (pain, constipation, infection)

      • Environmental (set routines, sound/lights, position, daytime activity)

      • Psychiatric conditions (depression)

      • Review medications

    • Intervention

      • Relaxation, social contact, sensory (eg. music/aromatherapy)

      • Increased services/care

    • Consider newer antipsychotics (less EPS), eg. Risperidone, Olanzapine, Seroquel

      • Caution as increased risk of death, CVA, EPS, falls, somnolence, weight gain, diabetes

Referral

  • Rapid progression

  • Young

  • Frontotemporal, Lewy Body, Parkinson's Dementia

Genetics

  • 25% of the general population above 55yo have a first-degree relative with dementia

    • Lifetime risk of dementia is 20% in those with a family history compared to 10% in general population

    • Most cases not familial

      • Obtain a family history, look for mendelian pattern (eg. autosomal dominant)

    • Alzheimer's

      • Probability of genetic mutation in 2+ first-degree relatives

        • >65yo at onset is <1%

        • <65yo at onset is 15%

        • <60yo at onset is 86%

  • Suspect genetic cause if early onset and mendelian pattern

Driving Assessment

  • Risk of unsafe driving

    • Multiple motor vehicle accidents in past 5 years

    • Self-restricted driving or Family/caregiver concerns

    • Aggressive or impulsive behaviour

    • MMSE 24 or less

  • Evaluating Risk

    • Clinical Dementia Rating scale of 1 or more suggests unsafe driver

      • The Clinical Dementia Rating score equals the memory score unless the patient scores more or less than the memory score in three of the secondary categories.

    • On-road assessment by occupational therapy

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