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Dementia

Hammad Mohsin, MD and Swagato Bhattacharyya, D.O. Reviewed 06/2022
 


BASICS

DESCRIPTION

Dementia refers to cognitive decline from previous level of performance in various cognitive domains (attention, executive function perceptual-motor, social cognition, language, and ...

DIAGNOSIS

Clinical diagnosis 

HISTORY

Requires a family member or someone who knows the patient well to describe changes in the patient’s cognition and behavior. 
  • Probable diagnosis AD (2):

    • Age between 40 and 90 years (u...

PHYSICAL EXAM

CLINICAL ASSESSMENT  
  • Physical exam to assess for neurological deficits, motor and gait abnormalities, tremors, etc.

  • No disturbances of consciousness

  • Can start with brief initial screening ...

DIFFERENTIAL DIAGNOSIS

  • Major depression

  • Medication side effect

  • Chronic alcohol use

  • Delirium

  • Subdural hematoma

  • Normal pressure hydrocephalus

  • Brain tumor

  • Thyroid disease

  • Parkinson disease

  • Vitamin B12 deficiency

  • T...

Initial Tests (lab, imaging)

  • Used to rule out causes

    • CBC, CMP

    • Thyroid-stimulating hormone

    • Vitamin B12 level

  • Select patients based on clinical suspicion

    • HIV, rapid plasma reagin (RPR)

    • Erythrocyte sedimentati...

Follow-Up Tests & Special Considerations

  • Genetic testing for dementia not recommended, such as testing for APOE4 for Alzheimer, unless there are multiple family members diagnosed with AD at a youn...

Diagnostic Procedures / Other

PET scan not routinely recommended; has been approved to differentiate between Alzheimer disease and frontotemporal dementia 

GENERAL MEASURES

  • Daily schedules and written directions

  • Emphasis on nutrition, personal hygiene, accident-proofing the home, safety issues, sleep hygiene, and supervision

  • Socialization (adult daycare)

  • Se...

MEDICATION

  • Cognitive dysfunction

  • Medications for AD  (4)[A] show a small improvement in some cognitive measures, but it remains unclear if the improvement is clinically significant and associated with ...

First Line

Non-pharmacologic management: environmental modifications, caregiver training, music therapy, exercise, pet therapy 

Second Line

  • Cholinesterase inhibitors, memantine, atypical antipsychotics, antidepressants, mood stabilizers, methylphenidate, benzodiazepines, melatonin

  • Antidepressants not clearly superior to placebo...

ISSUES FOR REFERRAL

Neuropsychiatric evaluation helpful in early stages or mild cognitive impairment 

ADDITIONAL THERAPIES

Behavioral modification 
  • Socialization, such as adult daycare, to prevent isolation and depression

  • Sleep hygiene program as alternative to pharmaceuticals for sleep disturbance

  • Sched...

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Psychiatry admission may be required because of safety concerns (self-harm/harm to others), self-neglect, aggressive behaviors, or other behavioral iss...

Patient Monitoring

  • Progression of cognitive impairment by use of standardized tool (e.g., MMSE, ADAS-Cog)

  • Development of behavioral problems: sleep, depression, psychosis, aggression

  • Adverse events of p...

PATIENT EDUCATION

  • Advance care planning—​​​​​​Discuss safety, management of finances, medical decision making, possible skilled facility placement; legal guardianship, if necessary.

  • Advance directives,...

PROGNOSIS

  • AD: usually steady progression leading to profound cognitive impairment:

    • Average survival of AD is about 10 years.

  • VaD: incrementally worsening dementia, but cognitive improvement is unlikely

  • S...

COMPLICATIONS

  • Wandering

  • Sundowner syndrome is common in older people (who are sedated) and also in people who have dementia (can have adverse reaction to even small dose of psychoactive substances).

  • Fal...

REFERENCES

1
McGuinness B, Craig D, Bullock R, et al. Statins for the prevention of dementia. Cochrane Database Syst Rev. 2009;(2):CD003160.
2
Blass DM, Rabins PV. In the clinic. Dementia. Ann Intern Med...

ADDITIONAL READING

Lyketsos  CG, Colenda  CC, Beck  C, et al; for Task Force of American Association for Geriatric Psychiatry. Position statement of the American Association for G...

SEE ALSO

  • Algorithm: Dementia

CODES

ICD10

  • F03 Unspecified dementia

  • G30.9 Alzheimer’s disease, unspecified

  • F01.50 Vascular dementia without behavioral disturbance

  • G31.83 Dementia with Lewy bodies

SNOMED

  • 52448006 Dementia (disorder)

  • 429998...

CLINICAL PEARLS

  • Medications for AD show a small, statistically significant improvement in some cognitive measures, but it remains unclear if the improvement is clinically significant.

  • Do not forget the...

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