Dementia

General¶

• Mini Mental Status Exam (MMSE)
  • Used to determine dementia/delirium
  • Orientation (time, place) – 10 points
  • Registration (repeating 3 objects) – 3 points
  • Attention and calculation (serial 7s, world backwards) – 1 point each
  • Recall (recall 3 objects)
  • Language (naming objects, 3 step command)
  • Spatial (copy a design, clock)
  • Shorter than MoCA
• Altered Mental Status
  • Reitan Trail Test (timed connect the numbers test)
    • Abnormal indicates AMS
    • Useful for detecting subtle mental status changes
• Normal Aging
  • 1) Memory Loss
    • Can provide details about incidents of forgetfulness
    • Patient is concerned about memory loss
    • Recent conversations and important events memory is intact
  • 2) Word Finding
    • Occasional (expressive aphasia)
    • No receptive aphasia
  • 3) Independence and Functioning
    • Maintains ADLs
    • Able to operate common appliances w/normal social skills
    • Does not get lost in familiar territory (may have to pause to reorient)
      • More important than MoCA for screening
  • Slight decrease in fluid intelligence (Ability to process new information quickly)
  • Normal functioning, No dependence on others for activities of daily living
  • MoCA score ≥26/30

Mild Cognitive Impairment (MCI)¶

• Mild cognitive impairment and mild dementia: a clinical perspective
• Mild decline in ≥1 domain
• Normal functioning in all ADLs with compensation
  • Complex attention, learning and memory, language, executive function
  • Can manage finances
  • Remember names by writing them down
• Types:
  • Amnestic MCI
    • More common (2x), general cognition is intact
    • More likely to degenerate to Alzheimer disease
      • Is Mild Cognitive Impairment a Precursor of Alzheimer's Disease? Short Review
  • Non-amnestic MCI
• MoCA score <26/30 (average 22-23)
• 5-10% progress to dementia per year, 10-20% progress to Alzheimer Disease
• Prevalence of DSM-5 Mild Neurocognitive Disorder in Dementia-Free Older Adults: Results of the Population-Based LIFE-Adult-Study
• Prevention
  • Physical Exercise

Dementia (Major Neurocognitive Disorder)¶

• The initial recognition and diagnosis of dementia
• Persistent deterioration of cognitive function with little or no disturbance of conscious or perception
• Prevention:
  • Controlling vascular RF, dietary modifications, exercise
• Symptoms
  • Significant decline in >1 domain (Memory, Executive, Perception, Language, Behavior), progressive and interfere with daily functioning
    • Worsen in a subacute fashion over a period of months to years
    • Irreversible global impairment
    • Impaired daily functioning, needing help with ADLs
  • MMSE <24 is 87% sensitive and 82% specific for dementia
    • May have normal MMSE/MOCA if highly educated
      • ≥9 years of education: Median MMSE 29
  • Detecting dementia with the mini-mental state examination in highly educated individuals
    • 5-8 years of education: Median 26
  • 1) Memory Loss
    • Cannot remember specific instances of forgetfulness
    • Family>patient concern
    • Notable decline in memory for recent important events
      • Get lost for hours in familiar territory
      • “Sundowning” increased confusion at night
    • Confabulation and unaware of problem
      • “feels like performance was acceptable, questions worded wrong”
  • 2) Word Finding
    • Frequent, with substitutions
    • Some receptive aphasia
  • 3) Independence
    • Dependent for ADLs
    • Unable to operate, loses interest in social activities
    • Can get lost for hours in familiar territory while driving/walking
• W/U: CBC, B12, TSH
  • MRI w/o Contrast > CT w/o contrast for dementia with <3 years since onset
• Treatment
  • Dementia + MVA: Restrict Driving

Pseudodementia (Depression-related cognitive impairment)¶

• Reversible mild-moderate cognitive impairment (<26/30)
  • 8% of all dementia
• Symptoms
  • Acute onset (often after physical illness or loss of loved one)
  • Features of Depression (mood, interest, energy) at onset
    • Poor Concentration (little effort in remembering)
  • Acute onset, then episodic over weeks to months
  • Patient aware of cognitive decline, “I don’t know”
  • More likely to have “physical slowing”
• Treatment
  • SSRIs, ECT, Psychotherapy

Gerstmann Syndrome¶

• Stroke or traumatic brain injury usually
• Dominant parietal injuries
• Agraphia, acalculia, finger agnosia, left-right disorientation