Transcript AD- the extent of the problem • AD represents over 50% of all dementia cases • AD prevalence doubles every 5 years after 60

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AD- the extent of the problem
• AD represents over 50% of all dementia
cases
• AD prevalence doubles every 5 years after
60 years of age
• AD affects 15 million people worldwide
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The diagnosis and
assessment of AD
• "Listen to the patient, they are telling you
the diagnosis."
• "It is possible to make a diagnosis of
Alzheimer's disease, just as we can make a
diagnosis of other major illnesses."
• "The challenge today is to obtain an early,
accurate and specific diagnosis of dementia
using an effective diagnostic process."
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Mini Mental State Examination score
AD prognosis
Optimal case
25 ---------------------| Symptoms
20
|----------------------| Diagnosis
15
|-----------------------| Loss of functional independence
10
|--------------------------------| Behavioral problems
5
Nursing home placement
|-------------------------------------------|
0
Death |------------------------------------------
1
2
3
4
5
Years
6
7
8
9
Feidman and Gracon, 1996
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Definition of the dementia
syndrome
DEMENTIA
• Multiple cognitive deficits
– memory loss
– aphasia
– apraxia
– agnosia
– disturbance in executive function
• These lead to functional decline
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Causes of dementia
Reversible dementias
Irreversible dementias
• Common causes:
– Depression
– Delirium
– Drug toxicity
• Common causes:
– Alzheimer's disease
– Vascular dementia
• Other causes
– Lewy body disease
– Pick's disease (dementia
of the frontal lobe type)
– Parkinson's disease with
dementia
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Differentiating AD from other
dementias
Cognitive impairment
Exclude other causes
(e.g. delirium and
depression, etc)
Dementia
Exclude other
dementias
Alzheimer's disease
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Dementia or delirium
Dementia
Delirium
* Insidious onset with unknown date
* Slow, gradual, progressive decline
* Generally irreversible
* Disorientation late in illness
* Slight day-to-day variation
OR
* Less prominent physiological
changes
* Consciousness clouded
only in late stage
* Normal attention span
* Disturbed sleepwake cycle;
daynight
* Psychomotor changes late in illness
* Abrupt, precise onset, known date
* Acute illness, lasting days or
weeks
* Usually reversible
* Disorientation early in illness
* Variable, hour by hour
* Prominent physiological changes
* Fluctuating levels of consciousness
* Short attention span
* Disturbed sleepwake cycle;
hour-to-hour variation
* Marked early psychomotor
changes
Ham, 1997
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Dementia or depression
Dementia
* Insidious onset
* No psychiatric history
* Conceals disability
* Near-miss answers
* Mood fluctuation day to day
* Stable cognitive loss
* Tries hard to perform but is
unconcerned by losses
* Short-term memory loss
* Memory loss occurs first
* Associated with a decline in
social function
Depression
* Abrupt onset
* History of depression
* Highlights disabilities
* ’Don't know' answers
* Diurnal variation in mood
OR * Fluctuating cognitive loss
* Tries less hard to perform
and gets distressed by losses
* Short- and long-term memory loss
* Depressed mood coincides with
memory loss
* Associated with anxiety
Ham, 1997, modified from Wells CE, 1979
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AD risk and protective factors
Risk factors
Protective factors
* Age
* Family History of AD
(ApoE-4)
* Head trauma
* Low educational level
* Environmental factors
* Down’s syndrome
* Genetic (ApoE-2)
* High educational level
* Long-term antiinflammatory
drug use, e.g.
NSAIDS
* Long-term use of
estrogens (in women)
IPA AD Conference, 1996
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Making a diagnosis of AD
Need for early
diagnosis
Consistent onset, clinical
presentation and disease progression
Practical
assessment
methods
New symptomatic
treatments
Patient and
caregiver support
IPA AD Conference, 1996
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Clinical features of AD
Functional
impairment
* IADL
* ADL
Cognitive decline
Insidious onset
* Memory loss
* Aphasia
* Apraxia
* Agnosia
* Executive
function
difficulties
AD
Behavioral signs
* Mood swings
* Agitation
* Wandering
Age over 60 years
No gait difficulties
IPA AD Conference, 1996
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Clinical features of AD
Mild stage of AD (MMSE 2130)
Cognition
* Recall/learning
* Word finding
* Problem
solving
* Judgement
* Calculation
IMPAIRMENT
Function
* Work
* Money/shopping
* Cooking
* Housekeeping
* Reading
* Writing
* Hobbies
Behavior
* Apathy
* Withdrawal
* Depression
* Irritability
Adapted from Galasko, 1997
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Clinical features of AD
Moderate stage of AD (MMSE 1020)
Cognition
IMPAIRMENT
Function
* Recent memory
(remote memory
unaffected)
* Language (names,
paraphasias)
* Insight
* Orientation
* Visuospatial ability
* IADL loss
* Misplacing
objects
* Getting lost
* Difficulty
dressing
(sequence and
selection)
Behavior
* Delusions
* Depression
* Wandering
* Insomnia
* Agitation
* Social skills
unaffected
Adapted from Galasko, 1997
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Clinical features of AD
Severe stage of AD (MMSE <10)
Cognition
IMPAIRMENT
Function
* Attention
* Basic ADLs
* Difficulty
Dressing
performing
Grooming
familiar activities
Bathing
(apraxis)
Eating
* Language
Continence
(phrases, mutism)
Walking
Motor slowing
Behavior
* Agitation
Verbal
Physical
* Insomnia
Adapted from Galasko, 1997
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Diagnosing AD in primary care
case-finding
"How is your memory?"
Case-finding
Pattie and Gilleard, 1979
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Diagnosing AD in primary care
clinical history, common presentations
* Forgetfulness
* Getting lost in familiar settings
* Difficulties with finance
* Deterioration of work or home
performance
* Inability to recognize, or a lack of interest
in, family members
* Difficulties driving or using the telephone
Clinical History
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Diagnosing AD in primary care
clinical history, questioning
Ask the following questions:
* How did it start? Was it sudden or gradual?
* How long has it been going on?
* Is the situation progressing? If so, how rapidly?
* Is it step-wise or continuous?
* Is it worsening, fluctuating or improving?
* What changes have you noticed?
* Has there been a change in personality?
* Has the patient suffered any delusions or hallucinations?
* Does the patient become agitated or wander?
Clinical History
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Diagnosing AD in primary care
functional assessment
Score Score
Maximum Actual
Functional Activities Questionnaire (FAQ)
1. Dealing with financial matters, paying bills, writing checks
3
2. Keeping records of taxes, business affairs
3
3. Shopping for everyday necessities: groceries, clothes, etc
3
4. Hobbies or playing games
3
5. Making tea, turning the kettle on and off
3
6. Cooking a balanced meal
3
7. Perception of current events
3
8. Level of attention and understanding: books, television
3
9. Memory: remembering appointments and medications
3
10. Getting about: driving or taking public transport
3
Total 30
Functional Assessment
Pfeffer et al 1982
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Diagnosing AD in primary care
cognitive assessments, MMSE
Cognitive area
Mini Mental State Examination: test outline and scoring
Score Score
Maximum Actual
Orientation
*What is the (date, day, month, year, season)?
* Where are you (clinic, town, country)?
5
5
Memory
*Name three objects. Ask the patient to repeat them
Attention
*Serial sevens. Alternatively ask the patient to spell world
backwards (dlrow)
Cognitive Assessment
Folstein et al 1975
3
5
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Diagnosing AD in primary care
cognitive assessments, MMSE (continued)
Cognitive area
Mini Mental State Examination: test outline and scoring
Score Score
Maximum Actual
Recall
*Ask for the three objects mentioned above to be repeated
3
Language
*Name a pencil and watch
*Repeat, 'No ifs, ands or buts’
*A three stage command
*Read and obey CLOSE YOUR EYES
*Write a sentence
*Copy a double pentagon
Cognitive Assessment
2
1
3
1
1
1
Total 30
Folstein et al 1975
Diagnosing AD in primary care
cognitive assessment
The Clock Draw Test
Time: 5.00
Score: 7 (normal)
Time: .10.30
Score: 3 (demented)
Time: 'no real time'
Score: 2 (demented)
Time: 1/4 past 25
Score: 3 (demented)
Cognitive Assessment
Thalmann et al 1996.
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Diagnosing AD in primary care
physical examination
* Life-threatening conditions, e.g. mass lesions, vascular
lesions and infections
* Blood pressure and pulse
* Vision and hearing assessments
* Cardiac and respiratory function
* Mobility and balance
* Sensory and motor system examination (tone, reflexes,
gait and coordination) and depressive symptoms (sleep
and weight)
Physical examination
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Diagnosing AD in primary care
laboratory tests
All patients
Most patients
* Complete blood count
* Thyroid function
* Vitamin B12 and folate
* Syphilis serology
* BUN and creatinine
* Calcium
* Glucose
* Electrolytes
* Urinalysis
* Liver function tests
* ECG
* Chest X-ray
Laboratory tests
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Diagnosing AD in primary care
neuroimaging, computed (axial)
tomography (CT)
Various CT scan reports in AD
* Normal examination for the patient's age
* Generalized cerebral atrophy
* Small vessel changes, areas of
leucoencephalopathy
* No signs of subdural hematoma (if head
trauma suspected)
* Absence of specific areas of cerebral
infarctions or evidence of stroke
Neuroimaging
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Primary care management of AD
specialist referral
* Inconclusive diagnosis
* Atypical presentation
* Behavioral/psychiatric symptoms
* Second opinion
* Family dispute
* Caregiver support
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The role of the primary care
physician in mild to moderate AD
* Define all contributory factors and other illnesses
* Discuss the diagnosis, and differentiate other
types of dementia
* Withdraw non-essential drugs that may interfere
with cognition
* Treat or manage concomitant illness
(e.g. depression, hearing loss)
Gauthier, Burns and Pettit, 1997
The role of the primary care
physician in mild to moderate AD
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(continued)
* Discuss the use of symptomatic therapies
* Monitor functional ability e.g. driving, safety
* Referral to specialist if appropriate
* Advise on will-making and advance directives
* Refer to local AD association for support
* Managing caregivers
Gauthier, Burns and Pettit, 1997
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The role of the primary care
physician in severe AD
* Help caregivers discover and optimize the
patient's preserved function
* Monitor and treat complications
* Facilitate caregiver support (respite and day
care programs)
* Be aware of caregiver burden and stress
* Plan institutionalization, if needed
* Assist with end-of-life decisions
Gauthier, Burns and Pettit, 1997
Diagnosing AD in primary care
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A systematic approach summary
CASE-FINDING
Symptoms
YES
suggesting
cognitive
impairment
CLINICAL ASSESSMENT
*Clinical history
*Physical examination
*Laboratory tests
*Functional assessment
*Cognitive assessment
Functional decline and cognitive
impairment
DIFFERENTIAL DIAGNOSIS
*Exclude
AD diagnosis
delirium
depression
other causes of dementia
*Evaluate evidence for
AD (neuroimaging)
MANAGEMENT OF AD
*Follow-up
*Patient and caregiver
counseling
*Management and symptomatic
treatment
*Specialist referral if indicated
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Primary care management of AD
follow-up
* Cognitive ability
* Functional ability
* Behavior
* General health
* Routine health checks
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Caregiver support in primary care
* Caring for patients
* Self-help
* Support services
* Medico-legal help
* Caregiver well being