DEMENTIA IN

NEUROSCIENCE

DEPARTEMENT OF NEUROLOGY
CHRISTIAN UNIVERSITY OF INDONESIA
MEDICAL FACULTY

DEFINITION OF
DEMENTIA
DEMENTIA- the disease with acquired
deterioration in cognitive/ intellectual
abilities without impairment of
consciousness
Cognitive deficit represent a decline
from previous level of functioning

DSM IV DIAGNOSTIC
CRITERIA
1. Memory impairment
2. At least one of the following:
Aphasia
Apraxia
Agnosia
Disturbance in executive functioning

3. Disturbance in 1 and 2 interferes with daily function

4. Does not occur exclusively during delirium

TEN WARNING SIGNS OF DEMENTIA

1.

Memory loss that affects job

6.

skills
2.

Difficulty performing familiar

tasks

3.

Problems with language

4.

Disorientation to time and place

5.

Poor or decreased judgment

Problems with abstract

thinking

7.

Misplacing things

8.

Changes in mood or
behavior

9.

Changes in personality

10. Loss of initiative

EPIDEMIOLOGY

Alzheimer's disease is most

common dementia 5075%

Dementia with Lewy bodies

15 to 35 %

Vascular dementia 5 20
%

~ 5 to 8 % at age 65 to 70
~ 15 to 20 % at age 75 to 80
up to 40 to 50 % over age 85

ETIOLOGY
NEURODEGENERATIVE

Alzheimer's Ds; Dementia with Lewy Bodies;

Fronto-temporal dementia; Parkinsons Ds

VASCULAR

Infarction; Hemodynamic insufficiency

NEUROLOGICAL

Multiple Sclerosis; Normal Pressure Hydrocephalus

ENDOCRINE

Hypothyroidism

NUTRITIONAL

Def. of Vit. B12, Thiamine, Niacin

INFECTIOUS

HIV; Prion Ds; Neurosyphilis; Cryptococcus

METABOLIC

Hepatic/ Renal Insufficiency; Wilsons Ds

TRAUMATIC

Subdural Haematoma; Dementia pugilistica

TOXIC AGENTS

Alcohol; Heavy Metals; Anticholinergic Med; CO

CORTICAL VS. SUBCORTICAL

DEMENTIA
Cortical

Subcortical

Symptoms: major changes in

memory, language deficits,
perceptual deficits, praxis
disturbances,lack of
extrapyramidal features

Symptoms: behavioral changes, impaired

affect and mood, motor slowing, executive
dysfunction, less severe changes in
memory, extra pyramidal findings

Affected brain regions: temporal

cortex (medial), parietal cortex,
and frontal lobe cortex

Affected brain regions: thalamus, striatum,

midbrain, striatofrontal projections

Examples: Alzheimers disease,

diffuse Lewy body disease,
vascular dementia, frontotemporal
dementias

Examples: Parkinsons disease, progressive

supranuclear palsy, normal pressure
hydrocephalus, Huntingtons disease,
Creutzfeldt-Jakob disease, chronic
meningitis

MIXED
Both cortical and sub-cortical area
involved.
Example: vascular dementia, Dementia
with Lewy bodies, Corticobasal
degeneration, Neurosyphilis

Reversible DEMENTIA
D=
E=
M=
E=
N=
T=
I=
A=

Delirium
Emotions (depression)& Endocrine Disease
Metabolic Disturbances
Eye & Ear Impairments
Nutritional Disorders
Tumors, Toxicity, Trauma to Head
Infectious Disorders
Alcohol, Arteriosclerosis

Irreversible DEMENTIA
Alzheimers
Lewy Body Dementia
Picks Disease (Frontotemperal Dementia)
Parkinsons
Vascular
Huntingtons Disease
Jacob-Cruzefeldt Disease

How to diagnose
dementia in neurology
Clinical history
Symptoms analysis
Focussed physical examination
Cognitive and neuropsychiatric examination
Laboratory evaluation

CLINICAL SYMPTOMS

FOCUSED HISTORY
Chronology of the problem
- mode of onset abrupt vs gradual
- progression - stepwise vs continous decline
- duration of symptoms
Medical history
Family history
Socio-economic history
Evaluation for toxic agent exposure

PHYSICAL
EXAMINATION
Neurological examination-mobility and balance
assessment
Focal neurological deficits
Extra-pyramidal signs
Vision & hearing screening
Cardiac and pulmonary evaluation

COGNITIVE &
NEUROPSYCHIATRIC
EXAMINATION

Folstein Mini-Mental Status

Examination (MMSE)

MMSE

SCORE RANGE
24-30
18-23
10-17
< 10

Normal
Mild
Moderate
Severe

INVESTIGATIONS
ASSESSMENTS

RATIONALE

Labs: Complete blood count, serum

electrolytes, renal and hepatic function,
glucose, albumin and protein, vitamin B12 and
folate, rapid plasma reagin (syphilis), thyroidstimulating hormone, urinalysis

Rule out correctable or

contributory causes of
dementia

Imaging: Computed tomography without

contrast or magnetic resonance imaging

Rule out infarcts, mass

lesions, tumors, and
hydrocephalus

Neurological examination

Correlate imaging
findings with clinical
examination

Neuropsychological testing

Mini-Mental State
Examination: Screening
test of cognitive
function

DIFFERENTIAL
DIAGNOSIS

DIAGNOSTIC APPROACH
COGNITIVE IMPAIRMENT ?
YES

DETERIORATION FROM A
PREVIOUSLY HIGHER LEVEL ?

NO

MENTAL
RETARDATION

YES

DELIRIUM

NO

APHASIA
AMNESTIC D/O, etc

YES

CONSCIOUSNESS ALTERED?
NO
MULTIPLE COGNITIVE FUNCTIONS
INVOLVED ?
YES

DEMENTIA

The two most common causes of

dementia include :

Alzheimers disease
Vascular dementia
(dementia
due to
strokes).

Alzheimers Disease (AD)

About 70% of all cases of dementia in elderly
Incidence increases with age
Occurs in up to 30% of persons >85 years old
Characterized by:
Progressive loss of cortical neurons
Formation of amyloid plaques (beta-amyloid is
major component) and intraneuronal
neurofibrillary tangles (hyperphosphorylated tau
proteins is major constituent)
constituent

DIAGNOSTIC CRITERIA FOR DEMENTIA OF THE

ALZHEIMER TYPE
(DSM-IV, APA, 1994)
A. Development of multiple cognitive deficits
1. Memory impairment
2. Other cognitive impairment
B. These impairments cause dysfunction in :
social or occupational activities
C. Course shows gradual onset and decline
D. Deficits are not due to:
1 . Other CNS conditions
2. Substance induced conditions
F. Do not occur exclusively during delirium
G. Are not due to other psychiatric disorder

disease
Barry Reisberg, MD and colleagues
New York University Medical Center's Aging and Dementia Research Center
Functional Assessment Staging (FAST) scaleallows professionals and caregivers to chart the decline of people with
Alzheimer's disease.

The FAST scale has 16 stages and sub-stages:

FAST Scale Stage Characteristics
1... normal adult, No functional decline.
2... normal older adult, Personal awareness of some functional decline.
3... early Alzheimer's disease, Noticeable deficits in demanding job situations.
4... mild Alzheimer's, Requires assistance in complicated tasks such as handling
finances, planning parties, etc.
5... moderate Alzheimer's, Requires assistance in choosing proper attire.
6... moderately severe Alzheimer's, Requires assistance dressing, bathing, an
toileting. Experiences urinary and fecal incontinence.
7... severe Alzheimer's, Speech ability declines to about a half-dozen intelligibl
words. Progressive loss of abilities to walk, sit up, smile, and hold head up.

CLINICAL
MANIFESTATION
Begin with memory impairment

language

visuospatial skills
Anosognosia- unaware of difficulties
Cognitive decline-driving,shopping,house-keeping
Language impaired - naming, comprehension then
- fluency
Apraxia - sequence motor task cant perform
Visuospatial deficits
Delusions ,capgras syndrome late stages
End stage-rigid,mute , incontinent & bed-ridden

AD DIAGNOSIS
Neurological exam & neuropsychological testing
Brain imaging: brain atrophy due to extensive
neuronal loss and hippocampal atrophy
Diagnosis confirmed by histology of post-mortem
brain
Plaques & tangles in hippocampus & cerebral
cortex.

Neuritic plaques

Neurofibrilarry tangles

VASCULAR DEMENTIA
Refers to cognitive decline caused by ischemic, hemorrhagic, or
oligemic injury to the brain as a consequence of cerebrovascular
or cardiovascular disease.
Part of a spectrum of vascular disease causing cognitive
impairment, which also includes mild cognitive impairment of
vascular origin & mixed Alzheimer's disease plus cerebrovascular
disease.
Kraepelin first described arteriosclerotic dementia in 1896

DIAGNOSIS
&
CLINICAL
FEATURES
(NINDSAIREN)

OTHER TYPES OF
DEMENTIA
Vascular dementia
Frontotemporal dementia
Lewy Body dementia

VASCULAR DEMENTIA

Multi-infarct dementia - Recurrent strokes

- Step wise progression
- HT,DM,CAD
MRI- multiple areas of infarction
Binswangers disease - Diffuse white matter
disease
- Lacunar infarction
Clinical Manifestation:
Confusion, personality changes, psychosis
Pyramidal signs & cerebellar signs +
Gait disorder, urinary incontinence, dysarthria
Emotional lability

Frontotemporal Dementias
Often begins with marked behavioral disturbances, unlike AD
Classic form Picks disease
Patients frequently hot-tempered and socially disinhibited
memory & visuo spatial skills spared
Impaired planning,judgement and language
Echolalia +
Overlap with PSP,CBD, motor neuron disease
Illness progresses for years, like AD
Inevitable decline
MRI- lobar atrophy of frontal and/or temporal
About 50% of patients have family history

LEWY BODY DEMENTIA

Lewy body dementia may present as:
late onset Parkinsons disease followed months or years later
by visual hallucinations, episodes of confusion, memory loss
and then global dementia, or
cognitive or psychiatric symptoms followed by milder
Parkinsonian features later in the course of the disease.

To diagnose Lewy Body disease:

fluctuating cognitive performance with episodes of confusion
hallucinations and/or paranoid delusions
early gait disturbance
any combination of rigidity, bradykinesia, tremor and flexed
posture
temporoparietal dementia with inattention in a patient with
Parkinsons disease

TREATMENT FOR
DEMENTIA
Cholinesterasi Inhibitor
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)

Memantine
Ebixa
Axura

MEDICATION TO AVOID
IN ALL PATIENTS WITH
DEMENTIA
(Dementia and Cognitive Impairment Diagnosis and Treatment
Guideline.
Available
at
https://www.ghc.org/allsites/guidelines/dementia.pdf)

MEDICATION

RATIONALE

Tricyclic antidepresants (TCAs)

Amitriptyline, amoxapine, clomipramine, desipramine, doxepin,
imipramine, nortriptyline, protriptyline, trimipramine

Strong anticholinergic and sedative effects leading to orthostatic hypotension,

confusion and falls

Antispasmodics
Atropine, belladonna alkaloids, dicyclomine, hyosciscyamine,
scopolamine, propantheline

Strong anticholinergic and sedative effects. Associated with orthostatic

hypotension, confusion, and increased fall risk. Uncertain effectiveness.

Antimuscarinics
Darifenacin, fesoterodine, flavoxate, oxybutynin, solifenacin,
tolterodine, trospium

Strong anticholinergic effects. Poorly tolerated by older adults.

Skeletal muscle relaxants

Carisoprodol, cyclobenzaprine, meprobamate, metaxalone,
methocarbamol, orphenadrine, tizanidine

Poorly tolerated by older adults because of strong anticholinergic effects,

sedation, and risk of fracture. Effectiveness at tolerable dosages is questionable.
Within Group Health, see also High-Risk Medications in the Elderly: Skeletal Muscle
Relaxant

Antihistamines
Brompheniramine, chlorpheniramine, clemastine, cyproheptadine,
diphenhydramine, hydroxyzine, loratadine

Greater risk of confusion, dry mouth, constipation, and other anticholinergic

effects and toxicity. Clearance reduced with advanced age, and tolerance develops
when used as a hypnotic.

Antiemetics
Dimenhydrinate, meclizine, promethazine

Strong anticholinergic effects. Poorly tolerated in older adults

H2-receptor antagonists
Ranitidine, cimetidine, famotidine

Adverse effects on central nervous system (CNS).

Antiparkinsonian anticholinergics
Benztropine, trihexyphenidyl

Strong anticholinergic effects. Not recommended for prevention of extrapyramidal

symptoms with antipsychotics

All conventional antipsychotics & clozapine

Haloperidol, chlorpromazine, fluphenazine, loxapine, perphenazine,
pimozide, thioridazine, thiothixene, trifluoperazine

Increased risk of cerebrovascular accident and mortality

Antiarrhythmics
Disopyramide

Potent negative inotrope; may induce heart failure in older adults. Strong
anticholinergic effects

Narcotic analgesics
Meperidine, pentazocine

Increased CNS effects leading to increased confusion and toxicity risk. Safer
alternatives available

Anxiolytics
All benzodiazepines

Older adults have increased sensitivity to benzodiazepines and slower metabolism

of long-acting agents. In general, all benzodiazepines increase risk of cognitive
impairment, delirium, falls, and fractures. Within Group Health, see also Beers
Criteria for Potentially Inappropriate Medications in Older Adults Update Part 3:
Focus on Treatments for Insomnia.

Sleep agents
Zolpidem

Benzodiazepine-receptor agonists have adverse events similar to those of

benzodiazepines in older adults. Minimal improvement in sleep latency and
duration.