1. APPROACH TO DEMENTIA
Guide: DR.PARIDHI SHIVDE
Canditate: DR.SARATH MENON .R
DEPARTMENT OF NEUROLOGY,
MGM MEDICAL COLLEGE ,INDORE.

2. DEMENTIA- “OUT OF ONE’S MIND”
 DEMENTIA- the disease with acquired
deterioration in cognitive/ intellectual abilities
without impairment of consciousness
 Cognitive deficit represent a decline from previous
level of functioning

3. DSM – IV – DIAGNOSTIC CRITERIA
1. Memory impairment
2. At least one of the following:
 Aphasia
 Apraxia
 Agnosia
 Disturbance in executive functioning
3. Disturbance in 1 and 2 interferes with daily function
4. Does not occur exclusively during delirium

4. EPIDEMIOLOGY
 ~ 5 to 8 % at age 65 to 70
 ~ 15 to 20 % at age 75 to 80
 up to 40 to 50 % over age 85
• Alzheimer's disease is most
common dementia  50-75%
• Dementia with Lewy bodies 
15 to 35 %
• Vascular dementia  5 – 20 %

5. ETIOLOGY
NEURO-
DEGENERATIVE
Alzheimer's Ds; Dementia with Lewy Bodies; Fronto-
temporal dementia; Parkinson’s Ds
VASCULAR Infarction; Hemodynamic insufficiency
NEUROLOGICAL Multiple Sclerosis; Normal Pressure Hydrocephalus
ENDOCRINE Hypothyroidism
NUTRITIONAL Def. of Vit. B12, Thiamine, Niacin
INFECTIOUS HIV; Prion Ds; Neurosyphilis; Cryptococcus
METABOLIC Hepatic/ Renal Insufficiency; Wilson’s Ds
TRAUMATIC Subdural Haematoma; Dementia pugilistica
TOXIC AGENTS Alcohol; Heavy Metals; Anticholinergic Med; CO

6. CORTICAL VS. SUBCORTICAL DEMENTIA
Cortical
 Symptoms: major changes in memory, language deficits,
perceptual deficits, praxis disturbances,lack of extrapyramidal
features
 Affected brain regions: temporal cortex (medial), parietal cortex,
and frontal lobe cortex
 Examples: Alzheimer’s disease, diffuse Lewy body disease,
vascular dementia, frontotemporal dementias

7. Subcortical
 Symptoms: behavioral changes, impaired affect and mood,
motor slowing, executive dysfunction, less severe changes in
memory, extra pyramidal findings
 Affected brain regions: thalamus, striatum, midbrain,
striatofrontal projections
 Examples: Parkinson’s disease, progressive supranuclear
palsy, normal pressure hydrocephalus, Huntington’s disease,
Creutzfeldt-Jakob disease, chronic meningitis
CORTICAL VS. SUBCORTICAL DEMENTIA

8. MIXED
 Both cortical and sub-cortical area involved.
 Example: vascular dementia, Dementia with
Lewy bodies, Corticobasal degeneration,
Neurosyphilis

9.  D = Delirium
 E = Emotions (depression)& Endocrine Disease
 M= Metabolic Disturbances
 E = Eye & Ear Impairments
 N = Nutritional Disorders
 T = Tumors, Toxicity, Trauma to Head
 I = Infectious Disorders
 A= Alcohol, Arteriosclerosis
REVERSIBLE DEMENTIA

10.  Alzheimer’s
 Lewy Body Dementia
 Pick’s Disease (Frontotemperal Dementia)
 Parkinson’s
 Vascular
 Huntington’s Disease
 Jacob-Cruzefeldt Disease
IRREVERSIBLE DEMENTIA

11. HOW TO DIAGNOSE A CASE OF DEMENTIA IN
NEUROLOGY OPD
 Clinical history
 Symptoms analysis
 Focussed physical examination
 Cognitive and neuropsychiatric examination
 Laboratory evaluation

12. CLINICAL SYMPTOMS
 COGNITIVE IMPAIRMENT
 FUNCTIONAL IMPAIRMENT
 NEURO-PSYCHIATRIC
MANIFESTATIONS
 BEHAVIOURAL DISTURBANCES
 MOOD CHANGES
 ANXIETY
 PERSONALITY CHANGES
 PSYCHOSIS
 SLEEP DISTURBANCES

13. FOCUSED HISTORY
 Chronology of the problem- from loved ones
- mode of onset – abrupt vs gradual
- progression - stepwise vs continous decline
- duration of symptoms
 Medical history
 Family history
 Socio-economic history
 Evaluation for toxic agent exposure

14. PHYSICAL EXAMINATION
 Neurological examination-mobility and balance
assessment
 Focal neurological deficits
 Extra-pyramidal signs
 Vision & hearing screening
 Cardiac and pulmonary evaluation

15. COGNITIVE & NEUROPSYCHIATRIC
EXAMINATION
 Folstein Mini-Mental Status Examination (MMSE)

16. MMSE
SCORE RANGE
24-30 Normal
18-23 Mild
10-17 Moderate
< 10 Severe

17. INVESTIGATIONS
ASSESSMENTS RATIONALE
Labs: Complete blood count, serum electrolytes,
renal and hepatic function, glucose, albumin and
protein, vitamin B12 and folate, rapid plasma reagin
(syphilis), thyroid- stimulating hormone, urinalysis
Rule out correctable or
contributory causes of
dementia
Imaging: Computed tomography without contrast or
magnetic resonance imaging
Rule out infarcts, mass
lesions, tumors, and
hydrocephalus
Neurological examination Correlate imaging findings
with clinical examination
Neuropsychological testing Mini-Mental State
Examination: Screening
test of cognitive function

18. DIFFERENTIAL DIAGNOSIS
 DELIRIUM
 MILD COGNITIVE IMPAIRMENT
(MCI)
 AGE-RELATED COGNITIVE
DECLINE
 MENTAL RETARDATION
 SCHIZOPHRENIA
 DEPRESSION
 FACTITIOUS D/O
 ALCOHOL ABUSE

19. DIAGNOSTIC APPROACH
COGNITIVE IMPAIRMENT ?
DETERIORATION FROM A
PREVIOUSLY HIGHER LEVEL ?
CONSCIOUSNESS ALTERED?
MULTIPLE COGNITIVE FUNCTIONS
INVOLVED ?
DEMENTIA
YES
YES
YES
NO
NO
YES
NO
MENTAL
RETARDATION
DELIRIUM
APHASIA
AMNESTIC D/O, etc

20. DEMENTIA –SUB TYPES

21. CASE 1
 70 yr old female present with progressive memory
loss for past 1 yr.She also complaints of difficulty in
naming objects and driving car and house
keeping.for the past 1 month she has difficulty in
dressing ,eating and gets agitated easily and
wanders around at night.
 MMSE – 15/30
 Neurological exam- normal
 Vision & hearing- normal

22. MRI FINDINGS- DIAGNOSIS?

23. ALZHEIMER’S DISEASE (AD)
 About 70% of all cases of dementia in elderly
 Incidence increases with age
 Occurs in up to 30% of persons >85 years old
 Characterized by:
 Progressive loss of cortical neurons
 Formation of amyloid plaques (beta-amyloid is major component)
and intraneuronal neurofibrillary tangles (hyperphosphorylated tau
proteins is major constituent)

24. DIAGNOSTIC CRITERIA FOR DEMENTIA OF THE
ALZHEIMER TYPE
(DSM-IV, APA, 1994)
A. Development of multiple cognitive deficits
1. Memory impairment
2, other cognitive impairment
B. These impairments cause dysfunction in
In social or occupational activities
C. Course shows gradual onset and decline
D. Deficits are not due to:
1. Other cns conditions
2. Substance induced conditions
F. Do not occur exclusively during delirium
G. Are not due to other psychiatric disorder

25. CLINICAL MANIFESTATION
 Begin with memory impairment language
visuospatial skills
 Anosognosia- unaware of difficulties
 Cognitive decline-driving,shopping,house-keeping
 Language impaired- naming,comprehension then
- fluency
 Apraxia- seq. motor task can’t perform
 Visuo spatial deficits
 Delusions ,capgras syndrome – late stages
 End stage-rigid,mute ,incontinent & bed-ridden

26. AD DIAGNOSIS
 Neurological exam & neuropsychological testing
 Brain imaging: brain atrophy due to extensive
neuronal loss and hippocampal atrophy
 Diagnosis confirmed by histology of post-mortem
brain
 ‘Plaques’ & ‘tangles’ in hippocampus & cerebral
cortex.

27. CASE 2
 76 yr old male presented in neuro opd with c/o
progressive memory loss,emotional lability,gait
disturbance for past 5 months
 h/o of 3 episodes of cerebrovascular accidents +
recent attack 7 months back
 h/o HTN,DM,CAD+
 O/E- incresed tone in all limbs,power 3+ in RT.UL
&LL. 4+ in LT side, B/L extensor plantar

28. VASCULAR DEMENTIA
 Refers to cognitive decline caused by ischemic, hemorrhagic, or
oligemic injury to the brain as a consequence of cerebrovascular or
cardiovascular disease.
 Part of a spectrum of vascular disease causing cognitive impairment,
which also includes mild cognitive impairment of vascular origin & mixed
Alzheimer's disease plus cerebrovascular disease.
 Kraepelin first described “arteriosclerotic dementia” in 1896

29. DIAGNOSIS
&
CLINICAL
FEATURES
(NINDS-
AIREN)

30. VASCULAR DEMENTIA
 Multi-infarct dementia- recurrent strokes
- step wise progression
- HTN,DM,CAD
MRI- multiple areas of infarction
 Binswanger’s d/s– Diffuse white matter disease
- lacunar infarction
C/F:confusion,personality changes,psychosis
pyramidal signs & cerebellar signs +
gait disorder,urinary incontinence,dysarthria
emotional lability

32. CASE 3
 55 YR old woman presented with 2yr history of
progressive alteration in social behavior. The pt had
h/o social disinhibation,abusive
language,euphoria.there is complaints of excessive
food intake and weight gain for past 1 yr and pt was
taken to psychiatrist once.
 o/e- vitals stable..neurological exam –WNL
 MMSE-18/30

33. MRI

34. FRONTOTEMPORAL DEMENTIAS
 Often begins with marked behavioral
disturbances, unlike AD
 Classic form – Pick’s disease
 Patients frequently hot-tempered and socially
disinhibited
 memory & visuo spatial skills spared
 Impaired planning,judgement and language
 Echolalia +
 Overlap with PSP,CBD, motor neuron disease
 Illness progresses for years, like AD
 Inevitable decline
 MRI- lobar atrophy of frontal and/or temporal
 About 50% of patients have family history

35. CASE 4
 82 yr old male came to opd with c/o progressive
decline in memory for the past 6-8 months.He also
complaints of having decreased sleep and
occasional nightmares.He occasional sees his
deceased wife at times.
 o/e- vitals stable ,rigidity of limbs+
- gait- slow stepping gait,bradykinesia+
MMSE- 21/30
WHAT IS THE DIAGNOSIS?

36. DIFFUSE LEWY BODY DISEASE
 Patients have clinical parkinsonism with early and
prominent dementia
 Lewy bodies found in brain stem, limbic system, and
cortex
 Visual hallucinations and cognitive fluctuations
common, capgras syndrome & REM sleep disorder
 Longstanding PD without cognitive decline develop
dementia
 Better memory but severe visuospatial deficit
 Patients sensitive to adverse effects of neuroleptics
 May be second most common cause of dementia
after AD

38. PARKINSON’S DISEASE
 About 50% of patients have dementia by 85 years old
 Affects executive function disproportionately
 Dementia occur in later stage, or as a result of co
morbidities- AD,DLB or side effects of drug
 Associated depression & anxiety
 Frontal lobe dysfnct- complex tasks,planning,
-memorizing
 Language & mathematical skills spared
 Predictors- late onset,akinetic-rigid,severe depression
- advanced stage

39. CASE 5
 65 YR old male presented to neuro opd with c/o
gait disturbance for past 1 yr. On history taking his
son complained his father is having memory loss
for past 6 months and it is progressing.
 The pt also c/o of urinary incontinence+
 Neurolog exam- no focal deficits
 MMSE- 23/30

40. MRI- DIAGNOSIS ?

41. NORMAL PRESSURE HYDROCEPHALUS
 Triad
1. Dementia: typically subcortical
2. Gait instability
3. Urinary incontinence
 Walk with “feet stuck to floor”
 Symptoms progress over weeks to months
 CT shows ventricular enlargement with no
eviddence of cortical atrophy

42.  Most important test – therapeutic LP
1. Remove large amount of CSF
2. Examine gait and cognitive function
 Ventriculoperitoneal shunt may correct if:
 Patients improve within minutes to hours of removal of 30
to 40 mL of spinal fluid
 Trauma or subarachnoid hemorrhage
 Cause is derangement of CSF hydrodynamics
NORMAL PRESSURE HYDROCEPHALUS

43. CASE 6
 50 YR old woman was admitted with c/o
progressive memory loss and gait problem ,slurred
speech within one month; The pt also had
behavioral problem – insomnia,agitation,aggression
duration of 3 weeks.the pt also c/o abnormal jerky
hand movements for past 1 month
 o/e- limb & gait ataxia +, reflexes-exagg.
- tone increased all limbs, plantar b/l extensor
- no focal weakness
MMSE- 16/30

44. MRI- DIAGNOSIS?

45. CRUETZFELDT-JAKOB SYNDROME(CJD)
 Rapid progressive dementing prion disorder
 Focal cortical signs, rigidity
 Onset between 40- 75 years
 90% has MYOCLONUS vs 10% in AD
 Progressive dementia and personality changes
over weeks to months
 Death <1 year from first symptom
 EEG- diffuse slowing and periodic sharp waves or
spikes
 MRI- basal gangla abnormalities
 CSF- detect specific aminoacid sequence (PrPSc)

46.  Aging
 Mild loss of memory: names and dates
 Most sensitive indicator of cognitive change: poor
performance on delayed-recall tasks
 Verbal fluency remain intact and vocabulary may
increase
DISORDERS OF MEMORY FUNCTION
(AMNESTIC DISORDERS)

47. Transient global amnesia
 Dramatic memory disturbance
 Affects patients >50 years
 Usually have only one episode, lasting 6 to 12 hrs.
 Complete temporal and spatial disorientation
 Orientation for person preserved
 May be confused with psychogenic amnesia, fugue state, or partial
complex status epilepticus
 May be due to vascular insufficiency to hippocampus or midline
thalamic projections
DISORDERS OF MEMORY FUNCTION

48. DISORDERS OF MEMORY FUNCTION
 Head injury
 Retrograde amnesia > antegrade amnesia
 With time, memories usually return but rarely to recall events
surrounding trauma
 Korsakoff’s syndrome
 Near-total inability to establish new memory
 Patients confabulate about recent events
 Immediate memory NL,attention NL
 Most common cause: thiamine and other nutritional
deficiencies with chronic alcoholism

49. PSEUDO DEMENTIA
 Severe depression
 Memory & language intact
 Vegetative symptoms –insomnia,anergy,
- loss of appetite
 Abrupt onset

51. THANK YOU