Dementia - Revision history

Aidan at 16:34, 15 October 2022

2022-10-15T16:34:20Z

← Older revision		Revision as of 16:34, 15 October 2022
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	== ~~Definition~~ ==		== Background ==

			=== Definition ===
	* Acquired cognitive decline that impairs activities of daily living (ADLs)		* Acquired cognitive decline that impairs activities of daily living (ADLs)
	* Without impairment of ADLs, it is referred to as mild cognitive impairment (MCI)		* Without impairment of ADLs, it is referred to as mild cognitive impairment (MCI)
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	* Early-onset is prior to 65 years		* Early-onset is prior to 65 years

	== Etiologies ==		=== Etiologies ===

	* '''[[Alzheimer disease]]''': insidious onset and gradual progression, usually starting with memory and learning but also behavioural and psychological manifestations		* '''[[Alzheimer disease]]''': insidious onset and gradual progression, usually starting with memory and learning but also behavioural and psychological manifestations
	* '''[[Vascular dementia]]'''		* '''[[Vascular dementia]]'''
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	* Less common		* Less common
	** Vitamin deficiencies		** Vitamin deficiencies
	*** Thiamine (B1), ~~cacusing~~ ~~Wenicker's~~ encephalopathy		*** Thiamine (B1), causing [[Wernicke encephalopathy]]
	*** Cobalamin (B12), causing subacute combined degeneration		*** Cobalamin (B12), causing subacute combined degeneration
	*** Niacin (B3), causing pellagra		*** Niacin (B3), causing [[pellagra]]
	** Endocrinopathy		** Endocrinopathy
	*** Hypothyroidism		*** [[Hypothyroidism]]
	*** Adrenal insufficiency and Cushing's syndrome		*** [[Adrenal insufficiency]] and [[Cushing syndrome]]
	*** ~~Hypo-~~ and hyperparathyroidism		*** [[Hypoparathyroidism]] and [[hyperparathyroidism]]
	** Organ failure		** Organ failure
	*** Renal failure		*** Renal failure
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	*** Pulmonary failure		*** Pulmonary failure
	** Chronic infections		** Chronic infections
	*** HIV		*** [[HIV]]
	*** Neurosyphilis		*** [[Neurosyphilis]]
	*** ~~Paovavirus (~~JC virus), causing progressive multifocal leukoencephalopathy (PML)		*** [[JC virus]], causing progressive multifocal leukoencephalopathy (PML)
	*** Tuberculosis, fungal infections, and protozoa		*** [[Tuberculosis]], fungal infections, and protozoa
	*** Whipple's disease		*** [[Whipple disease]]
	** Head trauma and diffuse ~~braine~~ damage		** Head trauma and diffuse brain damage
	*** Dementia pugilistica		*** [[Dementia pugilistica]]
	*** Chronic subdural hematoma		*** [[Chronic subdural hematoma]]
	*** Postanoxia		*** Postanoxia
	*** Postencephalitis		*** Postencephalitis
	*** Normal-pressure hydrocephalus		*** [[Normal pressure hydrocephalus]]
	** Neoplastic		** Neoplastic
	*** Primary or secondary brain tumour		*** Primary or secondary brain tumour
	*** Paraneoplastic limbic encephalitis		*** [[Paraneoplastic limbic encephalitis]]
	** Toxins		** Toxins
	*** Drug, medication, and narcotic overdose		*** Drug, medication, and narcotic overdose
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	*** Organic toxins		*** Organic toxins
	** Psychiatric		** Psychiatric
	*** Depression (pseudodementia)		*** [[Depression]] (pseudodementia)
	*** Schizophrenia		*** [[Schizophrenia]]
	*** Conversion disorder		*** [[Conversion disorder]]
	** Degenerative disorders		** Degenerative disorders
	*** Huntington's disease		*** [[Huntington disease]]
	*** [['''Dementia with Lewy bodies''']]		*** [[Dementia with Lewy bodies\|'''Dementia with Lewy bodies''']]
	*** Progressive supranuclear palsy		*** [[Progressive supranuclear palsy]]
	*** Multisystem atrophy		*** [[Multisystem atrophy]]
	*** Hereditary ataxias		*** [[Hereditary ataxia\|Hereditary ataxias]]
	*** Motor neuron disease, such as amyotrophic lateral sclerosis (ALS)		*** Motor neuron disease, such as [[amyotrophic lateral sclerosis]] (ALS)
	*** '''[[Frontal lobe dementia]]'''		*** '''[[Frontal lobe dementia]]'''
	*** Corticobasal degeneration		*** [[Corticobasal degeneration]]
	*** Multiple sclerosis		*** [[Multiple sclerosis]]
	*** Adult Down syndrome with Alzheimer disease		*** Adult [[Down syndrome]] with Alzheimer disease
	*** ALS Parkinson dementia complex of Guam		*** ALS Parkinson dementia complex of Guam
	*** Prion disease (Creutzfeld-jakob and Gerstmann-Straussler-Scheinker diseases)		*** [[Prion disease]] (Creutzfeld-jakob and Gerstmann-Straussler-Scheinker diseases)
	** Miscellaneous		** Miscellaneous
	*** Sarcoidosis		*** [[Sarcoidosis]]
	*** Vasculitis		*** [[Vasculitis]]
	*** Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)		*** [[Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy]] (CADASIL)
	*** Acute intermittent porphyria		*** [[Acute intermittent porphyria]]
	*** Recurrent non-convulsive seizures		*** Recurrent non-convulsive seizures

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	== Clinical Manifestations ==		== Clinical Manifestations ==

			{\| class="wikitable"
	{\|
	! Disease		! Disease
	! Early symptoms		! Early symptoms
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	*** Brain biopsy		*** Brain biopsy

		⚫	=== Cognitive Testing ===
⚫	== Behavioural and Psychological Symptoms of Dementia (BPSD) ==
		⚫	* Clock draw is the most sensitive for executive dysfunction, and also tests visuospatial and language domains
		⚫	* MoCA is the only one with a clock, so MoCA tests executive function (also, abstraction)
		⚫	* Diagnosis is based on clinical history, though, not from cognitive testing

			== Management ==

		⚫	=== Behavioural and Psychological Symptoms of Dementia (BPSD) ===
	* Symptoms include psychosis, aggression, agitation, mania, apathy		* Symptoms include psychosis, aggression, agitation, mania, apathy
	* History most important		* History most important
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	** Risperidone for severe behaviours, but increases risk of death		** Risperidone for severe behaviours, but increases risk of death
	** Document their behaviours over several weeks to document benefit or harm, then reassess every three months if antipsychotics are used		** Document their behaviours over several weeks to document benefit or harm, then reassess every three months if antipsychotics are used

⚫	== Cognitive Testing ==

⚫	* Clock draw is the most sensitive for executive dysfunction, and also tests visuospatial and language domains
⚫	* MoCA is the only one with a clock, so MoCA tests executive function (also, abstraction)
⚫	* Diagnosis is based on clinical history, though, not from cognitive testing

	== Further Reading ==		== Further Reading ==

Aidan: Text replacement - "Creutzfeld-Jakob disease" to "Creutzfeldt-Jakob disease"

2020-11-05T13:54:38Z

Text replacement - "Creutzfeld-Jakob disease" to "Creutzfeldt-Jakob disease"

← Older revision		Revision as of 13:54, 5 November 2020
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	\| Posterior parietal atrophy; hippocampi larger than in AD		\| Posterior parietal atrophy; hippocampi larger than in AD
	\|-		\|-
	\| ~~Creutzfeld~~-Jakob disease		\| Creutzfeldt-Jakob disease
	\| Dementia, mood, anxiety, movement disorder		\| Dementia, mood, anxiety, movement disorder
	\| Variable, frontal/executive, focal cortical, memory		\| Variable, frontal/executive, focal cortical, memory

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-22T01:59:24Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 01:59, 22 July 2020
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	* About 20% have a reversible cause (primarily depression, hydrocephalus, and alcohol abuse)		* About 20% have a reversible cause (primarily depression, hydrocephalus, and alcohol abuse)

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	{\|		{\|

Maintenance script: Imported from text file

2020-07-04T01:17:30Z

Imported from text file

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== Definition ==

* Acquired cognitive decline that impairs activities of daily living (ADLs)
* Without impairment of ADLs, it is referred to as mild cognitive impairment (MCI)
* At least one cognitive domain affected (complex attention, executive function, learning and memory, language, perceptual-motor, social cognition), with poor ADLs and iADLs and no other cause identified
* Early-onset is prior to 65 years

== Etiologies ==

* '''[[Alzheimer disease]]''': insidious onset and gradual progression, usually starting with memory and learning but also behavioural and psychological manifestations
* '''[[Vascular dementia]]'''
** Multi-infarct
** Diffuse white matter disease (Binswanger's)
* Chronic alcohol use
* Parkinson disease
* Drug or medication intoxication
* Less common
** Vitamin deficiencies
*** Thiamine (B1), cacusing Wenicker's encephalopathy
*** Cobalamin (B12), causing subacute combined degeneration
*** Niacin (B3), causing pellagra
** Endocrinopathy
*** Hypothyroidism
*** Adrenal insufficiency and Cushing's syndrome
*** Hypo- and hyperparathyroidism
** Organ failure
*** Renal failure
*** Liver failure
*** Pulmonary failure
** Chronic infections
*** HIV
*** Neurosyphilis
*** Paovavirus (JC virus), causing progressive multifocal leukoencephalopathy (PML)
*** Tuberculosis, fungal infections, and protozoa
*** Whipple's disease
** Head trauma and diffuse braine damage
*** Dementia pugilistica
*** Chronic subdural hematoma
*** Postanoxia
*** Postencephalitis
*** Normal-pressure hydrocephalus
** Neoplastic
*** Primary or secondary brain tumour
*** Paraneoplastic limbic encephalitis
** Toxins
*** Drug, medication, and narcotic overdose
*** Heavy metal intoxication
*** Dialysis dementia (aluminum)
*** Organic toxins
** Psychiatric
*** Depression (pseudodementia)
*** Schizophrenia
*** Conversion disorder
** Degenerative disorders
*** Huntington's disease
*** [['''Dementia with Lewy bodies''']]
*** Progressive supranuclear palsy
*** Multisystem atrophy
*** Hereditary ataxias
*** Motor neuron disease, such as amyotrophic lateral sclerosis (ALS)
*** '''[[Frontal lobe dementia]]'''
*** Corticobasal degeneration
*** Multiple sclerosis
*** Adult Down syndrome with Alzheimer disease
*** ALS Parkinson dementia complex of Guam
*** Prion disease (Creutzfeld-jakob and Gerstmann-Straussler-Scheinker diseases)
** Miscellaneous
*** Sarcoidosis
*** Vasculitis
*** Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
*** Acute intermittent porphyria
*** Recurrent non-convulsive seizures

== Epidemiology ==

* About 20% have a reversible cause (primarily depression, hydrocephalus, and alcohol abuse)

== Clinical Presentation ==

{|
! Disease
! Early symptoms
! Mental status
! Neuropsych
! Neuro
! Imaging
|-
| Alzheimer dementia
| Memory loww
| Episodic memory loss
| Initially normal
| Initially normal
| Entorhinal cortex and hippocampal atrophy
|-
| Frontal-temporal dementia
| Apathy, poo judgement/insight, speech and language, hyperorality
| Frontal/executive, language; spares drawing
| Apathy, disinhibition, hyperorality, euphoria, depression
| May have vertical gaze palsy, axial rigidity, dystonia, alien hand, or MND
| Frontal, insular, and/or temporal atrophy; spares posterior parietal lobe
|-
| Lewy body dementia
| Visual hallucinations, REM sleep disorder, delirium, Capgras (imposter) syndrome, parkinsonism
| Drawing and frontal/executive; spares memory; delirium-prone
| Visual hallucinations, depression, sleep disorder, delusions
| Parkinsonism
| Posterior parietal atrophy; hippocampi larger than in AD
|-
| Creutzfeld-Jakob disease
| Dementia, mood, anxiety, movement disorder
| Variable, frontal/executive, focal cortical, memory
| Depression, anxiety
| Myoclonus, rigidity, parkinsonism
| Cortical ribboning and basal ganglia or thalamus hyperintensity on MRI
|-
| Vascular dementia
| Often but not always sudden and stepwise; variable early symptoms; apathy, falls, focal weaknesses
| Frontal/executive, cognitive slowing; can spare memory
| Apathy, delusions, anxiety
| Usually motor slowing, spasticity; can be normal
| Cortical and subcortical infarcts, confluent white matter disease
|}

=== Physical Examination ===

* Mental status examination, including affect
* Full neurological examination
** Cranial nerves, including eye movements
** Motor exam, with axial and appendicular rigidity and rule out stroke and UMN signs (as would be seen in ALS)
** Sensory examination, first light touch before cortical sensory function
** Comment on signs of Parkinsonism
** Cerebellar examination

== Investigations ==

* The goal is to rule out reversible causes
* Laboratory
** TSH to rule out hypothyroidism
** Vitamin B12 to rule out B12 deficiency
** CBC for anemia and occult infection
** Electrolytes
* Imaging
** CT or MRI brain to rule out strokes, NPH, and tumour(s)
*** Age <60
*** Rapid, unexplained decline (1-2 months)
*** Short duration of dementia (<2 years)
*** Recent head trauma
*** New neurological symptoms
*** History of cancer
*** ...
*** ...
* Optional
** Laboratory
*** Lumbar puncture
*** Liver and renal function
*** Urine toxicology
*** HIV
*** Apolipoprotein E
*** Syphilis screen
*** Parathyroid function
*** Adrenal function
*** Urine for heavy metals
*** ESR
** Imaging
*** Chest x-ray
*** Angiogram
*** PET or SPECT
** Other
*** EEG
*** Psychometric testing
*** Brain biopsy

== Behavioural and Psychological Symptoms of Dementia (BPSD) ==

* Symptoms include psychosis, aggression, agitation, mania, apathy
* History most important
** Triggers for behaviour
** Reversible causes
** Risks of harm to self or others
* Non-pharmacologic interventions
** Make the environment nice
** Caregiver education
* Try not to use drugs, but can try...
** Risperidone for severe behaviours, but increases risk of death
** Document their behaviours over several weeks to document benefit or harm, then reassess every three months if antipsychotics are used

== Cognitive Testing ==

* Clock draw is the most sensitive for executive dysfunction, and also tests visuospatial and language domains
* MoCA is the only one with a clock, so MoCA tests executive function (also, abstraction)
* Diagnosis is based on clinical history, though, not from cognitive testing

== Further Reading ==

* [http://dx.doi.org/10.5770/cgj.15.49 Canadian Dementia Guidelines CCCDTD4 2012]

[[Category:Geriatrics]]
[[Category:Neurology]]