Common Types of Dementia 8F who notes progressive memory loss

Forgetting numbers, missing appointments 5 years ago
Last 1-2 years unable to manage banking and gave up driving because too complex

1. Common Types of Dementia
Alzheimer’s Disease
Vascular Dementia
Frontotemporal Dementia
Lewy Body Dementia
Others…

2. Situation 1
78F who notes progressive memory loss
Forgetting numbers, missing appointments 5 years ago Last
1-2 years unable to manage banking and gave up driving
because too complex
RUDAS 20/30 (Type of cognitive test) Points Lost:
Visuospatial 5/5, Praxis 1/2, Drawing 2/3, Recall 2/8,
Judgment 2/4, Language 8/8
Diagnosis?

3. Alzheimer’s Disease (AD)
Probable AD Dementia:
Insidious onset (months-years)
Initial and most prominent deficits in:
Amnestic (most common)
Non-Amnestic: Language, visuospatial, executive
Should not have:
Another confounding neurologic condition
Prominent features of another dementia
Cerebrovascular disease, DLB, FTD

4. Treatment Strategies
Nonpharmacologic methods
Mental activity
Physical activity
Healthy diet (Mediterranean/MIND)
Socializing
And MUCH more (Details at Deter Dementia)
Medications
Cholinesterase Inhibitors (donepezil, galantamine, rivastigmine)
NMDA Receptor Antagonist (memantine)

5. Situation 2
82M previously cognitively intact has a stroke
Excellent physical recovery but on assessment 2
months later, family notices he’s “not the same”
MMSE 23/30
Points Lost: 0/5 attention, 0/1 Pentagons, 2/3
recall
Screening MMSE by GP prior to stroke: 29/30 (lost
1 on recall)
Diagnosis?

6. Vascular Dementia
No history of gradually progressive cognitive deficits
before or after stroke Would suggest presence of
other neurodegenerative disorder
Cognitive impairment and imaging evidence of CVD
Temporal relation (vascular event and cognitive
deficits) OR Severity/pattern deficits related to
diffuse CVD pathology

7. Treatment Strategies
Treat vascular risk factors
Lifestyle (obesity, diet)
Blood Pressure
Diabetes
Dyslipidemia
Nonpharm strategies as before
Medications may be considered (ChEI, NMDA)
Limited evidence of benefit

8. Situation 3
58M with significant change in behaviour for 3 years
Lost his job due to inappropriate comments
Showed no grief when his mother passed
unexpectedly
Chain-smoking (new) and caught tasting kitchen
plants
Spends all day in front of TV (used to be very active)
MMSE 27/30
Lost points: 2/5 attention

9. Frontotemporal Dementia
Frontal
Behaviour
Executive function
Temporal
Memory, language
Primary progressive aphasia
Semantic dementia

10. FTD - Diagnostic Criteria
Possible bvFTD has 3 of the following:
Early disinhibition
Early apathy
Early loss of sympathy/empathy
Perseveration/compulsivity
Hyperorality
Executive deficit with relative sparing of
memory/visuospatial
Probable = Possible +
Functional decline +
Imaging evidence of frontotemporal changes

11. FTD - Medication Management
Multiple neurotransmitter systems involved:
Cholinergic, serotonergic, dopaminergic, and others
Limited and conflicting evidence of ChEIs
SSRIs or trazodone are standard therapy
May improve some behaviours

12. FTD - Overall Management
Approach should be heavily focused on strategies,
approaches
Focus on ensuring we deter further cognitive decline

13. Mixed Dementia
Usually AD + other pathology (often VaD)1.
Suggest trial of cholinesterase inhibitor2.

14. Situation 4
64F referred for delirium
Sees children playing in a sandbox vividly
Cognition fluctuates
Very rigid on physical examination
Husband has left bedroom because she is violent
while asleep
MMSE 25/30
Lost points: 1/5 attention, 0/1 pentagons

15. Lewy Body Dementia - Diagnostic Criteria
Memory less affected than other cognitive domains
Core features:
Cognitive fluctuations
Visual hallucinations
REM sleep behavior disorder
Parkinsonism (tremor, rigidity, bradykinesia)
Supportive features:
Neuroleptic sensitivity, falls, autonomic dysfunction etc
Biomarkers
SPECT/PET reduced in BG, Sleep study (REM), Low MIBG

16. Lewy Body vs Parkinson’s Disease Dementia
Parkinson’s Disease Dementia
If cognitive changes begin >1 year after onset of parkinsonism
Pathology similar
alpha-synuclein deposits (a.k.a. Lewy bodies)
PDD – substantia nigra deposition
DLB – cortical deposition
Same disease on a spectrum?

17. LBD and PDD - Treatment
Cholinesterase Inhibitors
Recommended by Canadian Guidelines
All have some evidence to support use
Strongest evidence for rivastigmine (Placebo-ctrl RCTs)
Parkinsonism
Use levodopa at low doses and monitor for worsening psychiatric symptoms

18. Other Rare Causes of Dementia
Metabolic
Renal, hepatic, sodium
Thyroid
Infectious
CJD, HIV, Syphilis
Demyelinating disorders
Multiple sclerosis

20. Recap
Alzheimer’s Disease
Vascular Dementia
Frontotemporal Dementia
Lewy Body Dementia
Others…