DEMENTIA

Presented by-
Sarmila Biswakarma
[Link]. I Year
 NEUROCOGNITIVE DISORDERS

NEUROCOGNITIVE
DISORDERS

Deliriu Major Mild

m NCD NCD
 DEMENTIA

• A disease process marked by progressive cognitive impairment in clear consciousness.

• Involves multiple cognitive domains and cognitive deficits cause significant impairment in social and
occupational functioning.
• The critical clinical points of dementia are the identification of syndrome and clinical workup of its
cause.
• The disorder can be progressive or static, permanent, or reversible.
• The reversible causes of dementia are:
• Neurosurgical conditions (brain tumours, normal pressure hydrocephalus)
• Infectious causes (meningitis, encephalitis)
• Metabolic causes (vitamin B12 deficiency, hypothyroidism)
• Others
• Approximately 15% with dementia have reversible illnesses
• Prevalence
• Age is the leading risk factor.
• Moderate to severe dementia in different population groups is approx. 5% in general populations
older than 65 years.
• 20 – 40 % in older than 85 years of age
• People under the age of 65 can develop dementia (called ‘younger onset dementia’)

• Etiology
• The most common causes of dementia in individuals older than 65 years of age are Alzheimer
disease, vascular dementia and mixed vascular and Alzheimer disease.
• Other illnesses account for approx. 10% includes Lewy body dementia, pick disease,
frontotemporal dementia, Alcoholic dementia, infectious dementia.
 DIAGNOSIS AND CLINICAL FEATURES

• The hallmark feature of dementia is cognitive impairment.

• DSM-5 describes dementia (Major Neurocognitive Disorder) as significant cognitive decline from a previous
level of performance in one or more of the domains of
• complex attention
• executive function
• learning and memory
• language
• perceptual motor ability
• social cognition.
• Noted by individual affected, knowledgeable informant or clinician and demonstrated by standardized
neuropsychological testing / assessment.
• These cognitive deficits interfere with independent functioning in daily activities.
• The cognitive deficits do not occur exclusively in the context of a delirium.
• Not better explained by another mental disorder
• Severity is based on what is impaired and level of impairment
• Mild: instrumental activities of daily life impaired e.g., transportation, using phone, meal
preparation.
• Moderate: basic activities of daily life impaired such as dressing, bathing, feeding.
• Severe: impaired in all activities, fully dependent on others.
 SIGNS AND SYMPTOMS

Cognitive impairment Behavioral and Psychological symptoms

• Memory impairment • Personality changes

• Complex attention • Hallucinations and delusions
• Executive function • Depression, manic and anxiety symptoms
• Language impairment • Apathy, agitation, aggression, wandering and
• Perceptual motor ability circadian rhythm disturbances.
• Social cognition • Catastrophic reaction
• Functional impairment
 COURSE AND PROGNOSIS

• Dementia may be progressive or stable.

• The age of onset is older than 65 years.
• There is gradual deterioration over 5 to 10 years.
• Persons with an early onset or with a family history of dementia, the disease is likely to have a
rapid course.

• Psychosocial determinants
• The severity and course of dementia can be affected by psychological factors.
• The higher a person’s premorbid intelligence and education, the better they can compensate
for intellectual deficits.
 TYPES

Dementia

Cortical
• Early involvement of cortical structures.
• Early and severe presentation of the As: amnesia, apraxia, aphasia, agnosia and
acalculia
• Includes: Alzheimer’s disease, pick’s disease and other frontotemporal dementias

Subcortical
• Early involvement of subcortical structures like basal ganglia, brain stem nuclei and
cerebellum.
• Early presentation of motor symptoms, significant disturbances of executive functioning.
• Prominent behavioral and psychological symptoms like apathy, depression, bradyphrenia
(slowness of thinking).
• Includes: Parkinson’s disease, Huntington's disease, multiple sclerosis.
 ALZHEIMER DI SEASE

• Most common form of dementia accounts for 50%-75% of all cases DSM-5 criteria

• It destroys brain cells and nerves disrupting the transmitters which 1. Evidence of a causative genetic
carry messages in the brain, particularly those responsible for storing mutation from family history
2. Decline in memory and learning
memories and in one other cognitive
• Typically, Alzheimer’s disease begins with lapses of memory, domain.
3. Steadily progressive, gradual
difficulty in finding the right words for everyday objects or mood decline in cognition, without
swings. extended plateaus
• Two types – late onset (after age 65) and early onset (before or at age 4. No mixed etiology
65).
• Insidious onset
• People with Down’s syndrome have significantly high risk for
development of AD.
 Memory
loss
Visuospatia Inability to
l skills learn new
impaired material

Behavioral LTM
changes affected

A
D Abstract
Apraxia thinking
affected

Language
Agnosia
impairment
Judgement
impaired
 VASCULAR DEMENTIA

DSM-5 criteria
• Formerly referred to as multi-infarct dementia. History + imaging/physical findings of
• Accounts for 17 – 30% of all cases of dementia, cerebrovascular (cv) disease
Cognitive decline typical of vascular pathology (≥1):
occurring when small blood clots prevent • Cognitive decline after CV event
oxygen from reaching brain tissue. • Cognitive areas mainly complex attention/ frontal
executive function.
• Causes acute or chronic deterioration of brain Probable (≥1):
functions, finally resulting in dementia. • Neuroimaging evidence of CV disease in brain
• Cognitive impairment may be patchy, with • Neurocognitive symptoms are associated with the
CV events
some areas intact depending on on which area • Clinical/genetic evidence of CV disease
of the brain has been affected. Possible:
• No neuroimaging
• May include severe depression, mood swings • No documented temporal relationship between CV
and periods of confusion events and cognitive changes.
 FRONTOTEMPORAL DEMENTIA (PICK’S DISEASE)

DSM-5 criteria

• The frontal lobe of the brain is particularly Insidious onset and gradual progression.
affected in early stages. Either 1 or 2
1. Behavior variant (≥3):
• Hallmark is a progressive change in • Behavior disinhibition
personality and behavior, with variable degrees • Apathy
• sympathy/empathy
of language and other cognitive impairment.
• Perserveration, stereotypies/ compulsive
• Cause is unknown but the disease constitutes behavior.
approximately 5% of all irreversible Decline in social cognition / executive abilities.
2. Language variant:
dementias. Speech production, word finding difficulty,
• Typically begins before 75 years of age object naming and comprehension

• Features of kluver-Bucy syndrome are much

more common
 DEMENTIA WITH LEWY BODIES

• The abnormal collections of protein, known as Lewy bodies, which occur in the nerve cells
of the brain.
• A progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function.
• Deficits of attention and of frontal executive skills and visuospatial ability may be more prominent early in the course.
DSM -5 criteria
The disorder meets a combination of core and suggestive diagnostic features for either
probable of possible NCD with Lewy Bodies
1. Core diagnostic features
• Fluctuating cognition with variations in attention and alertness.
• Recurrent well formed visual hallucinations
• Parkinsonian symptoms (after cognitive decline)

2. Suggestive diagnostic features

• REM sleep behavior
• Severe neuroleptic sensitivity

Probable : ≥core features or 1 core/1 suggestive

Possible: 1 core feature
 DEMENTIA IN PARKINSON DISEASE

• Parkinsonism is a disease of basal

ganglia, commonly associated DSM-5 criteria
with dementia and depression. • Occurring in the context of Parkinson disease
• cognitive impairment that leads to • Insidious onset and gradual progression
• Probable (both of the following)
dementia typically begins 10 to
• Possible (one of the following)
15 years after motor symptoms • No evidence of mixed etiology
have appeared. • Parkinson disease precedes cognitive symptoms
• Executive dysfunction typically
occurs earlier and is more
common in Parkinson disease
dementia
• The slow movements of persons
with Parkinson disease parallel
the slow thinking (bradyphrenia)
of some affected patients.
 DEMENTIA IN HUNTINGTON DISEASE

• Characterized by more motor DSM-5

abnormalities and fewer language
abnormalities than in the cortical • Insidious onset and gradual progression.
type of dementia. • Occurring in the context of Huntington disease

• The dementia of Huntington

disease exhibits psychomotor
slowing and difficulty with
complex tasks, but memory,
language and insight remain
relatively intact in the early and
middle stages pf illness. As the
disease progresses, the dementia
becomes complete.
HIV-RELATED DEMENTIA
DSM-5 criteria
• Encephalopathy in HIV infection is associated with dementia
• HIV diagnosis
is called Acquired Immune Deficiency Syndrome (AIDS)
• Associated cognitive
dementia complex, or HIV dementia. symptoms
• Presence of motor abnormalities or personality change (apathy,
emotional lability or behavioral disinhibition)
• TRAUMATIC BRAIN INJURY

DSM-5 criteria

• H/O traumatic bran injury, with associated noncognitive symptoms

Neurocognitive symptoms (≥1):
• Loss of consciousness
• Amnesia following trauma
• Confusion/disorientation
• Neuroimaging evidence of injury/ Neurologic symptoms
• Additional diagnosis types of Dementia in DSM-5 are:
• Neurocognitive disorder due to another medical condition
• Neurocognitive disorder due to multiple etiologies
• Substance/ medication induced neurocognitive disorder
• Unspecified neurocognitive disorder
 TREATMENT

• Firsts step is the verification of the diagnosis- clinical history, physical and neurological examinations.
• Preventive measures, particularly in vascular dementia such as changes in diet, exercise, control of diabetes
and hypertension.
• The general treatment approach is to provide supportive medical care, emotional support for the patients
and their families and pharmacologic treatment.
• Psychotherapeutic Approaches:
• Supportive therapy
• Group therapy
• Psychoeducation
• Behavioral Management:
• Help find ways to deal with the defective functions, such as keeping calendars for orientation problems,
making schedules to help structure activities and taking notes for memory problems.
• Pharmacotherapy
• Clinicians may prescribe sedative-hypnotics for insomnia and
anxiety, antidepressants for depression and antipsychotic drugs for
delusions and hallucinations.

• Drugs such as donepezil, rivastigmine, and galantamine

 PSYCHOLOGICAL TESTS

 Mini mental status examination (MMSE)

• The mini mental state examination provides measures of orientation, registration (immediate
memory), short-term memory (but not long-term memory) as well as language functioning.
• The examination has been validated in a number of populations. Scores of 25-30 out of 30 are
considered normal, 21-24 as mild, 10-20 as moderate and below 10 as severe impairment
 Montreal cognitive Assessment (MoCA)
• Used for screening mild cognitive dysfunction. It assesses different cognitive domains : attention
and concentration, executive function, memory, language, visuoconstructional skills, conceptual
thinking, calculations and orientation.
 Dementia Rating Scale- 2nd Ed. (DRS-2)
• Provide measure of general cognitive ability for individuals suffering from
brain dysfunction and varying levels of severity. The subscales are: Attention,
Initiation/Perseveration, Construction, Conceptualization, Memory and
Attention
 Mini-Cog©
• A three-minute instrument that consists of two components: a three-item recall
test for memory and a clock drawing test.
 REFERENCES

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.).
• Boland R., Verduin M., Ruiz R. (2021). Kaplan & Sadock's Synopsis of Psychiatry (12th ed.).
• Sadock, B. J., Sadock, V. A., Ruiz, P. (2017). Kaplan and Sadock’s comprehensive textbook of
psychiatry (10th ed.).
• Dementia with Lewy Bodies and Parkinson Disease Dementia - Neurologic Disorders. (n.d.).
MSD Manual Professional Edition.
Retrieved January 10, 2023, from [Link]
• Step-by-Step Mini-Cog© Instructions – Mini-Cog©. (n.d.).
[Link]
THANK YOU