Memory loss and dementia

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Memory loss and dementia

• Chiadi U. Onyike, MD, MHS
• Assistant Professor, Neuropsychiatry
• Johns Hopkins School of Medicine

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Acknowledgments

• Kostas Lyketsos
• Marilyn Albert
• Peter Rabins
• Crystal Evans
• Tanwa Suma
• MACAB
• Johns Hopkins Neuropsychiatry
• Alzheimer Association of Greater Maryland

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What is dementia?

• Is it memory loss?
• Is it old age?
• How is it different from Alzheimer disease?

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What is dementia?

• Loss of mental faculties
• Orientation
• Memory
• Language
• Object recognition
• Executive functions
• Praxis (learned skills)

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Spectrum of Dementia
N 382
Barker WW, et al. Alzheimer Dis Assoc Disord.
200216203-212.
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Dementia in the population

• Afflicts 4 - 5 million in the U.S.
• 18 - 20 M worldwide
• Over 12 M in U.S. (40 M worldwide) by 2050
• 70 live in the community
• Costs 141 billion/year (1997 estimate)
• Cost of care 50,000/patient/year

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Causes of dementia

• Alzheimer disease
• Vascular dementia
• Lewy body disease
• Frontotemporal dementia
• Mixed dementias
• Others
• Trauma, PD, HD, NPH, CJD, others

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Pathology
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Pathology
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Vascular Dementia

• Many causes
• Multiple mini strokes
• Small strategic stroke
• Large stroke
• Leukoaraiosis
• Focal motor and sensory symptoms

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Strategic stroke

• Sudden blindness, tongue numbness, slurring of
  speech
• Transient LOC
• Anterograde verbal and visual amnesias, impaired
  verbal fluency, hypophonia, dysarthria, and word
  agnosia

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Stroke
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Lacunar infarcts
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Subcortical leukoencephalopathy
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Risk factors for AD

• Age
• Family history
• CVD
• Trauma
• Lifestyle - diet, activity

• APOE genotype
• APP
• Presenilin-1
• Presenilin-2
• Trisomy 21

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Antecedents of dementia

• Mild Cognitive Impairment
• Mild cognitive syndromes (or CIND)
• Late-life onset depression
• Apathetic and other behavioral states

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Progression of AD
30
MMSE (points)
Years
Feldman H, Gracon S. In Gauthier S, ed. Clinical
Diagnosis and Management of Alzheimers Disease.
Boston, Mass Butterworth-Heinemann 1996239-252.
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Typical syndromes

• Pathologic emotionality
• Depression
• Apathy
• Catastrophic reactions
• Irritability
• Hallucinations
• Misinterpretations and delusions
• Paranoia

• Disinhibition
• Wandering
• Pacing
• Hoarding
• Sleep disturbance
• Overeating and new habits
• Sexual misdemeanors
• Resistiveness
• Aggression and violence

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DIAGNOSIS
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Evaluation

• History
• Normal neurological exam
• Normal laboratory tests

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Evaluation

• CT/MRI
• SPECT/PET
• MRA
• MRS
• Diffusion Tensor Imaging

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Evaluation

• Neuropsychological testing
• Spinal tap and CSF analysis
• EEG
• Generalized slowing in most dementias
• Biomarkers
• Amyloid and tau staining
• Gene tests

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TREATMENT
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Four Pillars of Dementia Care

• Day-to-day support and/or supervision of IADLs
  and ADLs
• Treat cognitive impairment
• Treat behavioral disturbances
• Provide family and caregiver support

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Maximize functioning

• Maintain general health
• Optimize
• Hearing
• Vision
• Gait
• Use
• Cues
• Prompts
• Mechanical aides
• Modified appliances
• Restrictions

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Medications for AD