HOW TO EXAMINE PATIENTS WITH DEMENTIA

HOW TO EXAMINE PATIENTS WITH DEMENTIA Serge Gauthier, MD, FRCPC McGill Centre for Studies in Aging Douglas Mental Health Research Institute

OUTLINE • Usual clinical presentation of dementia • Diagnostic criteria for the common degenerative dementias • Natural history of AD • Cases

CLINICAL PRESENTATION OF DEMENTIA • Decline in intellectual abilities (memory plus one other domain) • Interfering with social or occupational life

CLINICAL PRESENTATION OF DEMENTIA - MEMORY • Do you need reminders for appointments? • Do you forget birthdays? (Women only!) • Do you look for things at home? • Do you remember recent conversations? • Do you need to read back a page in your book to get back into the story?

CLINICAL PRESENTATION OF DEMENTIA - LANGUAGE • Do you look for words? – do you say “give me the thing there…what do you call it?” • Do you have trouble finishing your cross-word puzzles? • Do you still do ‘Mystery words’?

CLINICAL PRESENTATION OF DEMENTIA - PRAXIS • Do you still fix things in the house? • Do you have trouble using your computer, using the phone? • Do you have difficulties using kitchen appliances? • Do you need help to get the shower running?

CLINICAL PRESENTATION OF DEMENTIA - GNOSIS • Do you have difficulties recognizing people? • Do you have trouble with directions when driving?

CLINICAL PRESENTATION OF DEMENTIA – EXECUTIVE ABILITIES • Do you need help playing a card game? • Do you find it difficult to plan a meal for the family? • Do you need help to pay your bills on time? • Do you need help to take your pills?

CLINICAL PRESENTATION OF DEMENTIA • Decline in intellectual abilities (memory plus one other domain) • Interfering with social or occupational life

CLINICAL PRESENTATION OF DEMENTIA – MOST SENSITIVE ADLs • Using phone and other means of communication • Planning an outing and completing it efficiently • Using medication safely • Using money appropriately

CLINICAL PRESENTATION OF DEMENTIA – MOOD AND BEHAVIOR • Apathy (more quiet, socially withdrawn) • Anxiety & depression (worries about the future, about money) • False beliefs (blames spouse when looking for things) • Irritability (when spouse takes over finances, when making mistakes)

CLINICAL PRESENTATION OF DEMENTIA • There may be little insight and reporting is done by family • Patients are nearly always brought in by someone • There is often need for additional information (other family member, SW or OT going to the house)

ASSESSMENT OF DEMENTIA IN CLINICAL PRACTICE • History with reliable informant is key to diagnosis • Physical & neurological examination • MMSE & MoCA • Recommended blood work: CBC, TSH, lytes, Ca, glycemia. Brain CT or MRI without enhancement optional but done in most cases.

MoCA ►One-page ► 30-point scale ► 10 minutes to administer www.mocatest.org

DIAGNOSTIC CRITERIA FOR PROBABLE AD (90% accuracy) Dementia established clinically, eg deficit in two or more areas or cognition, interfering with daily life, progressing gradually No disturbance of consciousness Onset between 40 and 90 (below 65: early onset) Absence of other brain or systemic disease that could account for the dementia

PROPOSAL FOR MODIFIED NINCDS-AA DIAGNOSTIC CRITERIA – AD DEMENTIA(McKhann et al, A&D 7, 263-9, 2011) • No age specification • Memory decline not mandatory for the two cognitive domains affected • Changes in personality, impaired motivation or initiative as a possible domain • Probable AD: documented cognitive decline or positive biomarker

BIOMARQUERS FOR AD * Amyloid build up - CSF Aß42 (low) - PET amyloid (high) * Evidence of neuronal injury - CSF tau (high) - MRI (atrophy) - PET-FDG (hypometabolism)

DIAGNOSTIC CRITERIA FOR DEMENTIA PROBABLY DUE TO AD USING BIOMARKERS(Modified from McKhann et al, 2011) AßNeuronal injury • Probable AD with++ high likelihood • Probable AD with + or untested untested or + intermediate likelihood • Probable AD dementia untested or conflicting results • Possible AD dementia + + (atypical clinical presentation) * Unlikely AD dementia - -

CRITERIAS FOR VASCULAR DEMENTIA (VaD) • Decline in two or more cognitive abilities interfering with daily life but not caused by the physical effects of stroke • Evidence of stroke by history, physical exam or brain imaging • Temporal relationship between dementia and stroke (within 3 months of a stroke)

CRITERIAS FOR DEMENTIA WITH LEWY BODIES (DLB) • Progressive intellectual decline interfering with daily life • One or two of * fluctuations of cognition * visual hallucinations * spontaneous parkinsonism * Supportive features: REM Behavior Disorder, neuroleptic hypersensitivity

CRITERIAS FOR PARKINSON DISEASE DEMENTIA (PDD) • Idiopathic PD (2 of rigidity, bradykinesia, resting tremor) • Impairment of attention, executive and visuo-spatial abilities • Often with visual hallucinations

PROGRESSION OF SYMPTOMS IN ALZHEIMER’S DISEASE Lovestone & Gauthier 2000

STAGING OF AD: THE GLOBAL DETERIORATION SCALE (Reisberg) • 1, 2: normal or minimal cognitive complaints • 3: early cognitive impairment (MCI) • 4, 5: mild to moderate dementia • 6, 7: severe dementia

CASE 1 • Woman age 82 with progressive memory decline over 2 years • False beliefs of “people stealing things from her” • MMSE 23/30 • Good general health • “Normal for age” head CT scan

CASE 1 • Likely diagnosis? • Any extra tests?

CASE 2 • Man age 82 needing reminders for appointments, forgetting conversations, once could not find his car on the street, over 2 years • MMSE 22/30 • Diabetes type 2; labile HBP • CT with mild WMC (capping) and one lacunar infarct in right external capsule

CASE 3 • Woman age 72 needing reminders for appointments, forgetting conversations for 1 year • Thinks that there are other persons in her house. Sets table for extra people. • MMSE 24/30 • CT mild cortical atrophy

CASE 3 • PET-FDG with occipital hypometabolism • If available: DAT scan

CASE 4 • Man age 40 making mistakes at work (forgets orders from customers) for 1 year • Irritable at home since wife has to supervise finances. • Mother had AD died at age 45. • MMSE 21/30 • CT mild cortical atrophy

CASE 4 • PS1 mutation confirms EOFAD.

CASE 5 • Man age 52 making mistakes at work (pharmacist) for 1 year • Irritable since partner at work has to supervise him. Makes inapropriate jokes in restaurants. • Mother had a dementia, died at age 60. • MMSE 26/30 • CT mild cortical atrophy especially right anterior temporal

CASE 5 • PET-FDG right fronto-temporal hypometabolism • SPECT right fronto-temporal hypometabolism • Genetic testing confirms a progranulin mutation

HOW TO EXAMINE PATIENTS WITH DEMENTIA