Dementia: Difference between revisions

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==Background==
==Background==
===DSM-IV Definition===
*Major impairment in learning and memory plus impairment in handling complex tasks, impairment in reasoning ability, impaired spatial ability and orientation, or impaired language
*Symptoms significantly interfere with work, usual social activities, relationships
*Significant decline from previous level of functioning
*Disturbances are insidious and progressive
*Disturbances are not occurring exclusively during the course of delirium
*Disturbances are not accounted for by major psychiatric diagnosis
*Disturbances are not accounted for by systemic disease or another brain disease


== Clinical Features ==
===Inappropriate Medications in Dementia<ref>Tjia J et Al. Use of Medications of Questionable Benefit in Advanced Dementia. JAMA Intern Med. Published online September 08, 2014. doi:10.1001/jamainternmed.2014.4103</ref>===
*Most common: Cholinesterase inhibitors, memantine hydrochloride, lipid lower agents, antiplatelet (except aspirin)
*Others: hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy, immunomodulators
 
==Clinical Features==
*Loss of mental capacity  
*Loss of mental capacity  
*Slow and steady course  
*Slow and steady course  
*Hallucinations, delusions, repetitive behaviors, and depression are all common  
*Hallucinations, delusions, repetitive behaviors, and depression are all common  
*May coexist w/ [[delirium]]  
*May coexist with [[delirium]]  
*Poor score on [[Mini-Mental Status Exam]]
*Poor score on [[Mini-Mental Status Exam]]


== Differential Diagnosis ==
==Differential Diagnosis==
*Degenerative
===Dementia Acronym===
**Alzheimer's disease
D = drug-induced
**Huntington's disease
 
**Parkinson's disease
E = emotions (depression especially)
*Vascular
 
**Multiple infarcts
M = metabolic and endocrine issues
**Hypoperfusion (MI, profound hypotension)  
 
**Subdural hematoma
E = eyes and ears (sensory problems)
**[[SAH]]
 
*Infectious
N = nutritional issues (B12 and Vit. D)
**[[Meningitis]] (sequelae of bacterial, fungal, or tubercular)  
 
**Neurosyphilis
T = tumors
**Viral [[encephalitis]] (herpes, HIV), Creutzfeldt-Jakob disease
 
*Inflammatory
I = infections
**SLE
**Demyelinating disease
*Neoplastic
**Primary tumors / metastatic disease
**Carcinomatous meningitis
**Paraneoplastic syndromes
*Traumatic
**Traumatic brain injury
**Subdural hematoma
*Toxic
**[[ETOH ]]
**Meds (anticholinergics, polypharmacy)
**Meds considered "never appropriate" in advanced dementia include, but still commonly used<ref>Tjia J et Al. Use of Medications of Questionable Benefit in Advanced Dementia. JAMA Intern Med. Published online September 08, 2014. doi:10.1001/jamainternmed.2014.4103</ref>:
***Most common: Cholinesterase inhibitors, memantine hydrochloride, lipid lower agents, antiplatelet (except aspirin)
***Others: hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy, immunomodulators
*Metabolic
**B12 or folate deficiency
**[[Thyroid Disease]]
**Uremia
*Psychiatric
**Depression (pseudodementia)
*Hydrocephalic
**Normal-pressure hydrocephalus (communicating hydrocephalus)
**Noncommunicating hydrocephalus


==Diagnosis==
A = alcohol
*[[Mini mental status exam]]
*[[Six item screen]]


== Diagnosis ==
S = sleep disorders and rarely seizures
DSM-IV Definition:
*Major impairment in learning and memory plus impairment in handling complex tasks, impairment in reasoning ability, impaired spatial ability and orientation, or impaired language
*Symptoms significantly interfere with work, usual social activities, relationships
*Significant decline from previous level of functioning
*Disturbances are insidious and progressive
*Disturbances are not occurring exclusively during the course of delirium
*Disturbances are not accounted for by major psychiatric diagnosis
*Disturbances are not accounted for by systemic disease or another brain disease


== Work-Up ==
{{Dementia DDX}}
*Must rule-out treatable causes of dementia / [[delirium]] (see DDX)
**CBC
**Chemistry
**LFTs
**UA
**CXR
**?Utox
**?CT/LP


== Work-Up ==
==Evaluation==
*Mini-mental status exam
''Major workup consists of ruling out treatable causes of [[dementia]] / [[delirium]]''
**Score less than 24 suggests cognitive impairment
''Evaluate for precipitant of acute decompensation (e.g. infection, dehydration, MI)
**May be influenced by education and age
*[[Mini mental status exam]]
***Score less than 29 if greater than 9 years of schooling suggests cognitive impairment
*[[Six item screen]]
***Score less than 26 if 5-9 years of schooling suggests cognitive impairment
*CBC
***Score less than 22 if less than 4 years of schooling suggests cognitive impairment
**Megaloblastic anemia points to [[vitamin B12 deficiency]]
*CBC
**Normocytic anemia with an elevated RDW may indicated B12 deficiency as well if there are some RBCs with a small MCV and many with a large MCW.
*Chem 10
*Chemistry 10
*UA/Utox
*[[LFTs]]
*ECG, CXR
*[[Urinalysis]]
*[[ECG]]
*[[CXR]]
*ETOH
*ETOH
*CT/MRI
*[[Urine toxicology screen]]
*[[CT head]]
*Consider
*Consider
**LFTs, TSH
**[[LFTs]], TSH
**B12, RPR, ESR, ANA, Folate, Thiamine, HIV
**B12, RPR, ESR, ANA, Folate, Thiamine, HIV
**neuropsych eval
**Neuropsych eval
**Consider LP, urine heavy metals, EEG
**Consider [[LP]], urine heavy metals, EEG


==== Treatment ====
==Management==
*Treat underlying cause (if possible)
*Treat underlying cause (if possible)
*Treat pathology that may be contributing to acute decompensation/presentation (e.g. [[UTI]], [[pneumonia]])


==See Also==
==See Also==
[[Altered Mental Status]]
*[[Altered Mental Status]]
 
*[[Dementia Work-Up]]
[[Category:Neuro]]
[[Category:Neurology]]


==References==
==References==
<references/>
<references/>

Latest revision as of 17:11, 19 August 2019

Background

DSM-IV Definition

  • Major impairment in learning and memory plus impairment in handling complex tasks, impairment in reasoning ability, impaired spatial ability and orientation, or impaired language
  • Symptoms significantly interfere with work, usual social activities, relationships
  • Significant decline from previous level of functioning
  • Disturbances are insidious and progressive
  • Disturbances are not occurring exclusively during the course of delirium
  • Disturbances are not accounted for by major psychiatric diagnosis
  • Disturbances are not accounted for by systemic disease or another brain disease

Inappropriate Medications in Dementia[1]

  • Most common: Cholinesterase inhibitors, memantine hydrochloride, lipid lower agents, antiplatelet (except aspirin)
  • Others: hormone antagonists, leukotriene inhibitors, cytotoxic chemotherapy, immunomodulators

Clinical Features

  • Loss of mental capacity
  • Slow and steady course
  • Hallucinations, delusions, repetitive behaviors, and depression are all common
  • May coexist with delirium
  • Poor score on Mini-Mental Status Exam

Differential Diagnosis

Dementia Acronym

D = drug-induced

E = emotions (depression especially)

M = metabolic and endocrine issues

E = eyes and ears (sensory problems)

N = nutritional issues (B12 and Vit. D)

T = tumors

I = infections

A = alcohol

S = sleep disorders and rarely seizures

Dementia

Evaluation

Major workup consists of ruling out treatable causes of dementia / delirium Evaluate for precipitant of acute decompensation (e.g. infection, dehydration, MI)

Management

  • Treat underlying cause (if possible)
  • Treat pathology that may be contributing to acute decompensation/presentation (e.g. UTI, pneumonia)

See Also

References

  1. ↑ Tjia J et Al. Use of Medications of Questionable Benefit in Advanced Dementia. JAMA Intern Med. Published online September 08, 2014. doi:10.1001/jamainternmed.2014.4103
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