The Issue Of Pseudodementia

Historically, much emphasis has been given to the distinction of depression from dementia in late life. The term pseudodementia has long been used to denote the cognitive impairment that occurs with depression which reverses with adequate treatment of mood symptoms. However, more recent studies have revealed that many cases of so-called pseudodementia either have cognitive deficits that do not remit despite clinical recovery (Abas, Sahakian, & Levy, 1990) or are found to have irreversible...

Diagnostic Assessment Of Alzheimers Disease

There are currently no guidelines to suggest routine screening of the elderly for dementia, and the clinical evaluation usually begins with a complaint either from the patient or from an observer. Because changes in cognition and memory, which are the most common early signs of AD, can be caused by many medical conditions, especially in the elderly, it is critical that such complaints be evaluated by a medical professional. For the diagnosis of AD, two broad areas must be evaluated cognition...

Psychiatric Diagnosis and Management of Psychosis in Dementia

Alzheimer's disease (AD), the predominant form of dementia, comprises 60 to 80 of all cases of dementia (Stoppe et al., 1999). The number of patients with AD represents a growing public health problem that may reach crisis proportions in the future. In 1993, the estimated AD population in the United States was approximately 4 million, and it is estimated to reach 14 million by the year 2050 (Tariot, Podgorski, Blazina, & Leibovici, 1993). AD has been defined as the neurodegenerative illness...

An Algorithm For Determining The Underlying Causes Of Behavioral Problems

Whenever a problematic behavior occurs and an intervention is requested, it is critical that the first question be Why is this person behaving in this way The answer cannot be Because he she has dementia. That is an extreme example of circular reasoning. (And how do we know that he she has dementia Because he she is behaving in this way.) It is also not conducive to discovering an appropriate intervention. Williams and colleagues (Williams, Wood, Moorleghen, & Chittuluru, 1995) developed a...

Conventional Antipsychotics versus Benzodiazepines

The few studies that compared antipsychotics to benzodiazepines suffered from methodological flaws, particularly with respect to sample selection and study design (Burgio et al., 1992 Covington, 1975 Kirven & Montero, 1973 Stotsky, 1984 Tewfik et al., 1970). The limited data available do not indicate superiority for benzodiazepines over antipsychotics in the treatment of behavioral complications in demented patients. Benzodiazepines can lead to tolerance and dependence, and worsening of...

Summary of Frontotemporal Dementia

The database and knowledge of FTD that has accumulated in only 20 years of research is impressive. Unlike MD and LBD, FTD does not occur concurrently with AD pathology. Rather, it is defined as a group of non-Alzheimer's dementias with focal atrophy of the frontotemporal areas. Subsyndromes include frontal lobe dementia (FLD), Pick's disease, motor neuron disease with dementia, progressive nonfluent aphasia, and semantic aphasia. Important characteristics of FTD make these dementias more...

Mixed Dementia

Recognition of non-Alzheimer's dementias has become essential for experts in geriatrics. Unfortunately, many laypersons and even general practitioners equate the terms Alzheimer's and dementia. In fact, as many as two-thirds of Alzheimer's patients have a coexisting condition (Lim et al., 1999), making pure Alzheimer's far less common than was once thought. This section reviews the more common other dementias, including mixed dementia, which is the co-occurrence of Alzheimer's and VaD. Within...

Demyelinating

Multiple sclerosis (MS), like head trauma, is more frequently encountered as a cause of dementia when younger populations are studied. MS has its peak onset in the third and fourth decades of life and is more common in women than men by 2 1. The risk of MS is significantly higher among those raised in latitudes farther from the equator, particularly for the Northern Hemisphere (Kurtzke, 1985). As with alcoholism, neuropsychological impairment may be detected in 50 of persons with MS, but fewer...

Management Of Dementiapsychiatric Principles

As is evident throughout this volume, the management of patients with dementia is a challenge that spans time as well as an interdisciplinary approach. Psychiatric management requires simultaneous attention to psychiatric syndromes, both clear-cut and mixed comorbid medical illnesses social supports family dynamics and both pharmacologic and nonpharmacologic interventions. The following principles are useful anchors to the effective diagnosis and management of those psychiatric syndromes that...

Case Study I Psychological Perspectives

Regal's first symptom was depression. Late-life depression has been linked, at least as a risk factor and perhaps as a prodrome, to dementia syndromes. It becomes important, then, when assessing and treating a patient for depression to assess cognition. The risks of dementia conversion in the three- to five-year window increase dramatically if there is even mild cognitive impairment at the time of the depression. Serial testing after the depression ceases can be...

Multicultural Issues

A manual for developing Montessori-based activities for persons with dementia has been developed (Camp, 1999b). In the course of having the manual translated into Japanese, the translator brought up a problem. One of the activities involved a tub of rice, in which were hidden objects (i.e., buried treasure). Participants were to use a slotted spoon to pick up one of the buried objects and to sift the rice by gently shaking the spoon until only the object was left in the spoon. The translator...

Neuropsychological Characteristics of Dementia in PD

Cognitive disturbances may range from relative circumscribed deficits to global dementia. Mild cognitive deficits are common in idiopathic Parkinson's disease (IPD) and are characterized by impaired cognitive flexibility, psychomotor slowing, reduced ability to learn and retrieve new information, and impaired visuospatial skills. The concept of subdividing dementias on clinical grounds into cortical and subcortical dementias has been adapted by many in the field as a clinically useful concept,...

Public Health Aspects Of

Of major public health interest are the results of treatment trials of hypertension and use of statins in the elderly showing decreased incidence of dementia. Treatment of other risk factors for VaD is also indicated, including smoking, hyperfibrinogenemia, orthostatic hypotension, cardiac arrhythmias, congestive heart failure, and obstructive sleep apnea. Blood glucose control in patients with diabetes and lowering of fibrinogen and lipids should be beneficial. Food supplementation with folic...

Location of Patient Being Treated

The location of the patient (nursing home, assisted living, or outpatient) does not alter the choice or dose of medication to be considered in treating psychotic symptoms in dementia. The residential status of a patient is partly dependent on the patient's clinical state and partly on the ability of the caregiver to manage the patient at home. Whether and when the patient is admitted to a nursing home are highly variable factors that may depend as much on the caregiver's tolerance threshold and...

Controlled Treatment Trials

In an eight-week, double-blind, placebo-controlled dose-finding treatment trial of 238 elderly outpatients (mean age 78.6 years) who had AD and psychosis, patients were randomized to a flexible olanzapine dosage (1 mg to 8 mg day) or placebo for eight weeks. Olanzapine was initiated at a dose of 1 mg day, with a 1 mg to 2 mg day increase every 14 days (mean dose 2.4 mg day). On the primary outcome measures, there were no significant differences on efficacy measures (BEHAVE-AD rating scale) or...

Making the Diagnosis

Taking all of the factors complicating the diagnosis of depression in dementia into account, how should diagnosis best be approached In early dementia, assessment of depression is similar to that of elderly patients without cognitive impairment. However, in some cases (especially in the later stages of dementia) spotting depression in dementia might require more detective work. Alexopoulos (1996) and others (Nahas, Kunik, Orengo, Molinari, & Workman, 1997) have suggested that given the...

Clinical Features of PD with Dementia

Celesia and Wanamaker's 1972 study was one of the first to show that older patients exhibit a higher incidence of cognitive impairment and overall dementia compared with younger parkinsonians, and they also exhibit a more rapid course of disease progression. This was subsequently supported by other investigators using standardized neuropsychological tests. Mayeux et al. (1988) found a 40 frequency of dementia in PD patients older than 65 years. Dubois, Pillon, Sternic, Lhermitte, and Agid...

Other Agents For Agitation

As summarized eloquently by Cummings (2000), considerable evidence suggests that cholinergic agents, especially cholinesterase inhibitors, may have psychotropic effects in patients with dementia. The most compelling data come from recent trials. A prospective clinical trial of metrifonate versus placebo found modest reduction in average neuropsychiatric symptoms in the drug group versus placebo group (Morris et al., 1998). Development of this drug, however, has been abandoned due to toxicity....

Pharmacologic Treatments Antidepressants

Many of the treatment studies of depression in dementia are difficult to compare given varying diagnostic categories (symptoms vs. depressive syndromes) and types of studies performed (case reports, case series, chart reviews, open trials). Results of the four placebo-controlled outcome trials of antidepressants in patients with AD who met criteria for major depression are shown in Table 10.3. Current expert recommendations (DeKosky, 1997 Katz, 1998 Lebowitz et al., 1997) describe serotonin...

Special Populations

Determining the cause of cognitive impairment in a patient with HIV can be a diagnostic challenge. Such patients are at risk for opportunistic infections, CNS lymphoma, and dementia from HIV itself. Many opportunistic infections present as an encephalopathy, with altered level of consciousness, rather than as a dementia. Time course and noncognitive symptoms can help distinguish specific etiologies. In most cases, MRI imaging is necessary. If nondiagnostic, a lumbar puncture is usually...

Current Treatment Conventional Antipsychotics

Uncontrolled reports suggest that 25 to 75 of demented patients with behavioral complications respond to antipsychotics (Carlyle, Ancill, & Sheldon, 1993 Kral, 1961 Reisberg et al., 1987 Tewfik et al., 1970). During the past two decades, only a handful of random assignment, double-blind, placebo-controlled trials of antipsychotics in dementia have been conducted and published. Most studies were conducted in inpatient units or in nursing homes. In a four-week trial, thiothixene (< 15 mg...

Choice of Conventional versus Atypical Antipsychotic

The propensity for conventional antipsychotics to cause EPS in dementia and to increase the risk of tardive dyskinesia in elderly psychotic patients (Jeste, Lacro, et al., 1999) has led to a growing preference for atypical anti-psychotics in the treatment of patients with dementia who develop psychosis or behavioral dyscontrol. However, it is important to note that there is no evidence of superior efficacy for any atypical antipsychotic compared to any conventional antipsychotic in the...

Depression in Dementia Effects on Cognition

Our understanding of whether the presence of depression in persons with dementia, particularly in those with AD, is associated with excess cognitive disabilities is limited. Ross, Arnsberger, and Fox (1998) reported that although a group of depressive and nondepressive patients with AD had similar MMSE scores, cognition was significantly related to depression diagnosis beyond psychosocial and demographic predictors. Their study, from the California Alzheimer's Disease Cooperative, consisted of...

Dementia With Lewy Bodies Historical Perspective

In 1961, Okazaki, Lipkin, and Aronson, published the first case reports of two individuals who presented at ages 69 and 70 with dementia and severe extrapyramidal rigidity who, on autopsy, demonstrated diffuse Lewy body (LB) pathology in the cerebral cortex. Between the early 1960s and 1984, 34 similar cases were reported in Japan by Dr. Kosaka, who coined the term DLB in 1978. The term was used to describe the typical distribution of LB in the cortex and subcortical regions (Kosaka, Yoshimura,...

Phenomenology Of Depression In Dementia

Understanding the unique aspects of depression in dementia can assist clinicians and researchers in the detection and treatment of this syndrome. Lazarus, Newton, Cohler, Lesser, and Schweon (1987) were one of the earlier research groups to examine the phenomenology of depression in dementia. In their investigation of 44 persons with dementia, 18 participants were diagnosed as depressed via the Hamilton Rating Scale. Interrater reliability was .68 for this study. The authors reported that those...

Further Workup

In addition to history, physical examination, review of systems, and laboratory testing to rule out other medical causes of symptoms such as sleep changes or amotivation are useful. This workup should be keyed to the patient's comorbid illnesses and other symptoms identified on review of systems. Common medical triggers for acute behavioral changes include medical conditions such as thyroid disease or urinary tract infections and medication changes side effects (Teri & Logsdon, 2000).

Clinical Diagnosis

Despite the apparent inaccuracy of clinical diagnosis of MD, as reviewed later, it is important to examine how the clinical diagnosis of MD is most often reached. The Hachinski Ischemia Scale (HIS), originally developed to diagnose VaD, has also been used to classify MD. The presence of dementia and low scores on this scale (4 or lower) are classified as AD and high scores (7 or higher) as VaD (Hachinski et al., 1975). However, the validity of using intermediate scores from this scale to...

Comparisons among Conventional Antipsychotics

Earlier studies comparing low-potency to high-potency antipsychotics did not show consistent differences in efficacy (Barnes et al., 1982 Carlyle et al., 1993 Cowley & Glen, 1979 Petrie et al., 1982 Rosen, 1979 Smith, Taylor, & Linkous, 1974 Tsuang, Lu, Stotsky, & Cole, 1971). These studies were often limited by the lack of a placebo control and diagnostic heterogeneity in sample selection. Overall, there is little evidence to indicate superior efficacy for a specific class of...

Pathophysiology Infectious

The pathogen in HIV dementia is the RNA retrovirus itself. HIV penetrates the CNS at or near the time of seroconversion, likely through infected mononuclear cells. Productive infection occurs much later, when the host is immunosuppressed (McArthur, 2000). The pathologic hallmark of HIV infection is the multinucleated giant cell. The periphery of this cell is ringed with nuclei and has vacuolated cytoplasm. The multinucleated giant cell contains HIV nucleic acids and may reflect viral...

Selecting A Medication

Because there is little empirical evidence to guide decision making in selecting a medication, we begin by formulating a working hypothesis as to the nature of the patient's psychopathology where the target symptom pattern is roughly analogous to a more typical drug-responsive syndrome. We have previously termed this the psychobehavioral metaphor (Leibovici & Tariot, 1988), a phrase that emphasizes the heuristic and tentative nature of the process. We then select a psychotropic to match the...

Toxic Metabolic

Toxins and metabolic abnormalities should be considered in all cases of dementia, but especially in the elderly, who have a higher prevalence of systemic illness and medication use. The list of toxic metabolic causes of dementia is extensive (see Table 8.2). Many of these conditions produce an acute confusional state more often than a dementia. Nonetheless, they are not infrequently identified in epidemiological studies of dementia. In 200 elderly patients with symptoms for three or more...

Health Care Utilization

Patients with coexisting depression and dementia were found by our group to use inpatient health care and nursing home care at a significantly higher rate than patients with either condition alone (Kales, Blow, Copeland, Bingham, & Kammerer, 1999). From a health services perspective, the combined comorbidity appeared to function as the worst of both worlds with high inpatient medical and psychiatric and nursing home utilization and low outpatient utilization. It was our hypothesis that there...

Hydrocephalic

Cerebrospinal fluid (CSF) normally circulates out the ventricular system to the subarachnoid space, flowing over the cerebral convexities before being absorbed into the venous sinus system. When there is an impediment to CSF flow, intraventricular pressure rises above convexity pressure and results in ventricular enlargement. Over time, the ventricular and convexity pressures equilibrate, and a chronic state of ventricular dilatation with normal pressure develops. Although opening pressure is...

Frontotemporal Dementia

Our understanding of the epidemiology of frontotemporal dementia (FTD) has been limited by confusion and controversy in what constitutes FTD both clinically and pathologically. The original descriptions of the prototypic FTD, Pick's disease, occurred in a series of papers between 1892 and 1906 by Arnold Pick. Pick described several patients with prominent behavioral disturbances and expressive language impairments that had very circumscribed atrophy of the frontal lobes. Alois Alzheimer...

Principle 3 A Correct Diagnosis Is Essential for Providing Accurate Information about Prognosis and Initiating an

The major causes of dementia in the elderly (e.g., Alzheimer's disease, vascular dementia, dementia with Lewy bodies, frontotemporal dementia) have unique causes, clinical features, and natural histories. Despite individual patient differences, there are important similarities in presentation, disease course, and response to treatment in those patients with the same cause of dementia. By making a specific dementia diagnosis, a clinician can better predict a patient's prognosis and expected...

Other Clinical Features of DLB

REM sleep behavior disorder can also be seen in association with DLB (Boeve et al., 1998 Turner, 2002), and some medical literature suggests that the pathologic substrate of idiopathic REM sleep behavior disorder may involve neuronal loss and LBs in the brainstem monoaminergic nuclei important in regulating sleep phenomena. Neuroleptic supersensitivity is another common feature in DLB. It is important to properly recognize DLB because patients with this disorder can be at high risk for...

Environmental Strategiesmodifications

Another approach to modifying behavioral disturbances is modification of the environment to accommodate the AD patient. Products may focus on alleviating difficult behaviors, such as wandering, as well as provide opportunities for enjoyable activities for patients. Activities that naturally serve as recreational activities may also provide sensory stimulation, for example, the game Bingo (Sobel, 2001). The therapeutic kitchen has been used to support day programs in residential facilities...

Cerebral Imaging and Blood Flow Correlates

Extrapolating from studies of poststroke depression, depression in vascular dementia is thought to be associated with left frontal or subcortical lesions (Robinson, Kubos, Starr, Rao, & Price, 1984 Robinson, Starkstein, & Price, 1988 Starkstein, Robinson, & Price, 1987 Starkstein, Robinson, & Price, 1988). Lyketsos, Treisman, Lipsey, Morris, and Robinson (1998) noted that while cognitive deficits in VaD are a function of both the location and the amount of brain tissue affected,...

Cognitive Differentiation Of Vascular And Alzheimers Dementia

The most common studies of cognition in VaD have been attempts to distinguish it from AD. This line of research has most often investigated whether semantic abilities in AD are worse than in those with VaD and whether the deficits noted in VaD cases are consistent with a frontal-subcortical dementia (Mast, MacNeill, & Lichtenberg, 2002). A number of studies have attempted to differentiate dementia groups via cognitive patterns and overall abilities. These are reviewed more thoroughly in the...

Alzheimers Dementia

There is wide variation in prevalence estimates for major depression in AD, ranging from 0 to 86 (Burns, Jacoby, & Levy, 1990 Wragg & Jeste, 1989). This variation likely reflects several factors population studied ( lower in community and neurological settings than psychiatric inpatient or nursing home settings), diagnostic approaches (Diagnostic and Statistical Manual of Mental Disorders DSM criteria, rating scales, caregiver report, etc.), dementia stage, exclusion of patients with...

Multicultural Issues In Assessing And Managing Ad

There are a number of multicultural issues in dementia care and the AD patient, including cultural differences in disease presentation and the caregiver experience. Disease presentation may vary according to race. In a large observational study, Shadlen, Larson, Gibbons, McCormick, and Teri Nonpharmacological Approaches to Treating Alzheimer's Disease 35 (1999) found that African American patients had significantly lower MMSE test scores as compared with Caucasians and were more impaired upon...

Epidemiology And Prevalence

In AD, psychotic and behavioral complications are common and heterogeneous in their presentation (Reisberg et al., 1987 Rubin, Morris, & Berg, 1987). Psychotic symptoms are very common, with the prevalence, depending on the study, ranging from 10 to 73 (Cohen et al., 1993 Cummings, Miller, Hill, & Neshkes, 1987 Gormley & Rizwan, 1998 Mega, Cummings, Fiorello, & Gornbein, 1996 Wragg & Jeste, 1989). The prevalence of delusions has been reported to range from 0 to 40 in AD (Bucht...

Depression And Excess Disability In Dementia The Activity Limitation Framework

A major issue of scientific and clinical importance to understanding dementia is determining in what ways depression affects cognitive and noncognitive symptoms. Family caregivers report that the noncognitive symptoms of dementia (e.g., apathy, agitation) have greater impact on the family unit's day-to-day life than do the cognitive symptoms of dementia (Riley & Snowden, 1999). Of concern, then, is how depressive syndromes affect the behaviors of the person with dementia and whether...

Diagnostic Standards

Two international conferences on frontotemporal dementia culminated in clinical and neuropathological diagnostic criteria for frontotemporal dementia (Brun et al., 1994), often referred to as the Lund-Manchester criteria in the literature. Using the broad term frontotemporal dementia (FTD), the clinical criteria of FTD include core diagnostic features, which include behavioral disturbances, affective symptoms, speech disturbance, intact spatial orientation and praxis, physical signs, and...

Lewy Body Dementia

In 1961, Okazaki and colleagues first described diffuse Lewy bodies in two demented patients with parkinsonism and psychiatric symptoms. Lewy body dementia may rarely occur as a pure disease or, more commonly, in combination with AD or Parkinson's disease. Numerous terms have been used, including diffuse Lewy body dementia, Lewy body variant of AD, and Parkinson's disease with dementia (Drachman & Swearer, 1998). The generic term, dementia with Lewy bodies (LBD), is recommended by the...

Principle 3 Treatment Interventions Should Be Based on Conceptual Frameworks and Tested Empirically to Determine

Behavioral and psychosocial interventions with persons with dementia and with family and professional caregivers are based on the conviction that persons with dementia, similar to those with any chronic disease, can have an improved quality of life. Because dementia attacks both cognitive and noncognitive aspects of functioning, interventions are geared to both. Learning theory and cognitive-behavioral theory are the underpinnings of many successful interventions with persons with dementia....

Psychiatric Assessment and Treatment of Depression in Dementia

The interface of depression and dementia is a challenging but critical area in the assessment and treatment of dementia. The traditional focus of this interface has been an emphasis on avoiding the misdiagnosis of dementia in elderly patients having depression with associated cognitive impairment, so-calledpseudodementia. However, it is increasingly recognized that a more common and often more difficult clinical quandary is accurately diagnosing depression in existing dementia (Draper, 1999)....

Principle 2 Comorbidity Is Common in Dementia

In discussing interdisciplinary teams and how models of functioning can lead to conflicts, Lichtenberg (1994) reported that whereas the medical model emphasizes a ruling out ' ' of influences until a diagnostic entity is determined, the psychosocial model emphasizes a ruling in of influences on behaviors. In applying the psychosocial model to dementia, psychological practitioners need to be aware of the relatively common occurrence of comorbidities. Depression often accompanies dementia....

Psychological and Neuropsychological Aspects of Vascular and Mixed Dementia

MacNeill, and Mary E. Haines Vascular dementia (VaD) has been estimated to range from the second to the fourth most common form of dementia. Similar to Alzheimer's disease (AD), VaD is a clinical diagnosis that is confirmed only on autopsy. Unlike the clinical criteria for AD, however, there is wide variability in the clinical criteria established to diagnose VaD. Coupling that with autopsy studies showing that most clinical cases of VaD turn out to be mixed...

Principle 1 Accurate Assessment of Both Cognitive Abilities and Noncognitive Behaviors Is Based on Thorough Knowledge

The assessment of cognition and, in particular, memory loss, has been found to be one of the most sensitive measures of early cognitive decline and dementia. Psychological techniques include the valid interpretation of thorough psychometric testing. Whereas it is common in physician offices to use very brief mental status measures (e.g., Mini-Mental State Exam) to document cognitive decline, psychological techniques more thoroughly assess cognitive functioning and, in particular, domains of...

Principle 4 Psychiatric Symptoms and Hence the Indicated Treatment May Change over the Course of the Patients Illness

Dementia patients, over the course of their illness, may experience various combinations of psychiatric syndromes, so diagnostic approaches and treatment strategies must be flexible to meet patients' needs over time. For example, patients may develop depression early in their illness, with good response to an antidepressant, but later may require antipsychotic or mood stabilizer treatment. Alternatively, patients may develop anxiety and agitation early on, becoming more withdrawn and depressed...

Poststroke Dementia

In addition to the previous forms of strategic single-stroke dementia, the most common form of poststroke VaD is MID, occurring when dementia develops after multiple strokes. The incidence of poststroke dementia is ascertained by performing cognitive tests after stroke (typically, at three months postictus). According to Tatemichi et al. (1990), Pohjasvaara et al. (1997), and Barba et al. (2000), the most important risk factors for poststroke VaD are older age, lower educational level,...

The Nindsairen Criteria

The diagnosis of VaD according to the consensus criteria of the National Institute of Neurological Disorders and Stroke (NINDS) and the Association Internationale pour la Recherche et l'Ensignement en Neurosciences (AIREN) (see Table 6.1) requires three basic elements 1. Dementia, that is, impairment of memory and two other cognitive domains, such as executive function, attention, or orientation. The deficit should be severe enough to interfere with activities of daily living and not be...

Cholinesterase Inhibitors

The Food and Drug Administration has approved four ChEIs for the treatment of AD tacrine, donepezil, rivastigmine, and galantamine. These agents are being used for the behavioral and cognitive treatment of DLB (trials using galantamine have not been published). Patients with DLB may respond more favorably compared to those with AD. There is greater dysfunction of the cholinergic system in DLB, and the activity of choline acetyltransferase, the enzyme used to synthesize acetylcholine, is lower...

Epidemiology Prion Diseases

The most common human prion disease is Creutzfeldt-Jakob Disease (CJD). Death rates for CJD have been estimated from vital statistics in the United States. From 1979 to 1998, 4,751 deaths due to CJD were reported in the United States, resulting in an average annual death rate of 0.97 deaths per million persons (Gibbons, Holman, Belay, & Schonberger, 2000). Mortality data analysis is an efficient way of monitoring CJD incidence because CJD is invariably fatal within a short period (almost...

Mood and Behavioral Disturbances

Overall, the behavioral and psychological symptoms of dementia are such a salient feature of the disease that there is now a push to include this as a diagnosis or syndrome in the International Classification of Diseases (ICD Zaudig, 2000). Depression and anxiety are common in dementia, and these can be the first symptoms of a dementia in the absence of initial cognitive deficits (Reding, Haycox, & Blass, 1985). The clinician should suspect a mood or anxiety disorder in individuals...

Anticonvulsants

Carbamazepine and valproate are the best-studied psychotropic agents in this class. The bulk of available evidence supports the conclusion that they are likely to have anti-agitation efficacy essentially equivalent to other effective psychotropics. Carbamazepine has been examined in four placebo-controlled studies. Chambers, Bain, Rosbottom, Ballinger, and McLaren (1982) performed an eight-week crossover study in 19 women with mild agitation who also received antipsychotics This brief report...

Autopsy Studies

Definitive diagnosis requires postmortem pathological examination. As with MD, there is some discordance between clinical diagnoses and definitive pathology examination at autopsy. The sensitivity and specificity of the current diagnostic criteria, established by the consortium (McKeith et al., 1996), appear superior to other clinical criteria proposed before the consortium (Mega et al., 1996). Nevertheless, in a review of autopsy studies examining the accuracy of the current diagnostic...

Symptoms Cognitive Deficits

The dissimilarities of the cognitive deficits associated with FTD and AD reflect their distinct pathologies. AD affects the limbic system and parietotemporal association cortex, causing characteristic signs of amnesia, visuospatial impairment, apraxia, and aphasia. In contrast, the regional specificity of FTD is not manifested with these global cognitive deficits (Neary & Snowden, 1996). The most commonly documented cognitive impairments of FTD include progressive expressive aphasia seen as...

Risperidone

Two large multicenter trials have been completed in nursing home patients with fairly severe dementia (Mini-Mental State Examination MMSE 6 to 7). Both studies were three months in duration and included patients with AD and or VaD who experienced agitation and or psychotic features. The first study compared risperidone at doses of 0.5, 1, and 2 mg day with placebo in 625 institutionalized subjects (Katz et al., 1999). Reasons for discontinuation included adverse events (15.4 ), lack of efficacy...

Diagnostic Criteria For Vascular Dementia

Four major clinical criteria are used in the diagnosis of VaD. The National Institute of Neurological Disorders and Stroke Association Internationale de Recherche et l'Ensignement en Neurosciences (NINDS-AIREN) criteria contain explicit statements about the diagnosis of dementia, the evidence for stroke, and the relationship between stroke and dementia (Rom n et al., 1993). Dementia, using this criteria, is defined as memory impairment and impairment in two other cognitive domains (i.e.,...

References

Alzheimer, A. (1907). ber eine eigenartige Erkrankung der Hirnrinde (Translation A characteristic disease of the cerebral cortex). Allgemeine Zeitschrift fur Psychiatrie und Psychisch-gerichtliche Medizin, 64, 146-148. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC Author. Askanas, V., & Engel, W. K. (2001). Inclusion-body myositis Newest concepts of pathogenesis and relation to aging and Alzheimer's disease. Journal...

Nonpharmacological Treatment For Depression In Dementia

Nonpharmacological treatment for depression in dementia has focused on the dyad of both the caregiver and the person with dementia. In a randomized controlled trial of short-term supportive counseling aimed at reducing caregiver burden (not depression in persons with dementia), Mittelman, Ferris, Shulman, Steinberg, and Levin (1996) reported that the intervention led to delayed nursing home admissions for the person with dementia. The most rigorous research on improving depression in persons...

Summary

The clinical picture of vascular dementia has become more clear and more cloudy in recent years. As we described, while there is agreement that stroke often immediately precedes dementia, the criteria for a clinical diagnosis of VaD are widely variable. In addition, the relationship of stroke to Alzheimer's disease is also unclear. Thus, VaD is viewed today as being much less common than was originally thought. Instead, mixed dementia appears far more common than VaD. Clinical awareness of MD...

The Influence Of Setting Home Settings

Although behavior problems among persons with dementia are traditionally associated with long-term care settings, such problems exist among persons with dementia residing in the community (Teri, Borson, Kiyak, & Yamagishi, 1989). Care to persons with dementia residing at home is typically provided by family caregivers, home health aids, or some combination of the two. Managing behavior problems at home can be challenging to family members for a variety of reasons, one of which is that home...

Historical Aspects

Although age-related progressive cognitive decline has been known since antiquity, a case report by Alois Alzheimer described the neuropathology This work was supported by the Department of Veterans Affairs Geriatrics Research Education and Clinical Center, grants from the Alzheimer's Association and NIA NIH (P50 AG08671), and a Beeson Faculty Scholar in Aging Research Award from the American Federation for Aging Research. The author thanks Dr. M. L. Steinhilb for artwork in Figure 1.1....

Genetics Prion Diseases

Point mutation and insertions in the prion protein gene on chromosome 20 can produce autosomal dominantly inherited prion diseases. Approximately 10 of prion diseases are inherited in this way. At least 23 different mutations have been found to segregate with inherited prion diseases (Collins, Boyd, Fletcher, Byron, et al., 2000 Prusiner & Hsiao, 1994). Three major phenotypes are seen in inherited prion diseases, specifically GSS, CJD, and FFI. GSS is characterized by progressive ataxia and...

Diagnosis

The clinical diagnosis of AD remains rooted in a thorough history and physical examination. The history must be obtained from both the patient and a reliable family member or historian and should include a review of centrally active medications and inquiries as to stroke, head trauma, alcoholism, educational and occupational attainment, and family history of neurologic or psychiatric disease. Cognitive decline, functional decline, behavioral changes, and impact on daily life should all be...

Case Study III Psychological Perspectives

This case, which began as a seemingly straightforward case of progressive dementia, demonstrates the influence of multiple comorbidities (depression and delirium) that are integral to dementia care. As Mrs. Walker experienced significant loss ( her best friend) and stress ( her husband's illness and daughter's divorce), she became depressed. It is interesting to note that along with Mrs. Walker's overt vegetative symptoms of depression (e.g., not eating, losing weight, not bathing), she was...

Case Study II Neurological Perspectives

Information in this case suggests that further neurologic evaluation would be warranted to better define the cause or causes of this patient's dementia and to determine whether additional treatment is needed. Specifically, the presence of significantly impaired executive cognitive functioning as measured by the Trailmaking A and B tests at a time when language and visual spatial skills are relatively intact would be somewhat atypical for an uncomplicated case of AD. However, AD complicated by...

Cadasil

The first genetic form of VaD to be clearly identified (Bousser & Tournier-Lasserve, 1994 Tournier-Lasserve, Iba-Zizen, Romero, & Bousser, 1991 Tournier-Lasserve et al., 1993) was CADASIL, a systemic autosomal dominant arteriopathy mapped to chromosome 19 as a mutation of the Notch 3 gene (Tournier-Lasserve et al., 1993). Onset of the disease is in early adulthood (mean age 46 years), leading to VaD and death about 20 years after onset. The underlying vascular lesion is a nonamyloid,...

Neuroimaging in DLB

Structural imaging using magnetic resonance imaging (MRI ) has been used in AD to look particularly at hippocampal volume measurements as an early indicator of disease. O'Brien et al. (2001) looked at 28 patients with DLB, AD, VaD, and age-matched controls. The authors found accelerating atrophy with increasing severity of cognitive impairment, but there were no differences among the three dementia groups. Barber, Panikkar, and McKeith (2001) examined the relationship between white matter...

Diagnosis Prion Diseases

The dramatic and atypical features of human prion diseases can be recognized readily in classic presentations of the common phenotypes. However, there is a wide range of clinical presentations and prion phenotypes that can make antemortem diagnosis very difficult in some patients. Clinical features that suggest prion disease, ancillary tests that can be of value in supporting a diagnosis of a prion dementia, and pathologic findings that confirm a diagnosis of a prion disease are discussed next....

Basic Principles Neurological Perspective

The neurologic chapters in this handbook stress three general principles of neurology as applied to dementia. These principles are not unique to neurology, but are routinely used by neuroscientists and clinical neurologists. These chapters and approaches emphasize the biomedical model of disease causation and treatment and demonstrate that their application can result in more accurate diagnosis and more appropriate and effective treatments. Principle 1 Biomedical Research Can Lead to a Better...

Assessment of Psychosis in Alzheimers Disease

Using one of the neuropsychiatric batteries to help determine target symptoms should occur after reversible medical conditions (e.g., occult infection, metabolic imbalance) and iatrogenic or medication-induced symptom production are ruled out. Several assessment batteries are available to identify and reliably quantify target symptoms for treatment. The most common rating scales available to measure neuro-psychiatric symptoms of AD include the Neuropsychiatric Inventory (NPI Cummings et al.,...

Assessing Behavioral And Psychiatric Symptoms

While behavioral disturbances are not part of the diagnostic symptomatology, they are very common in AD, particularly as the disease progresses. Early in the disease, depression is noted, which may be minimally disturbing to patients and family. Later symptoms such as agitation, psychosis, and wandering can be disturbing and threaten patient safety. While clinicians often deal with these symptoms, there is less information on how to assess, prepare patient and family members, and treat in the...

Summary of Lewy Body Dementia

Although pathologically distinct from Alzheimer's disease, LBD usually occurs in combination with the neurofibrillary tangles and plagues of AD, suggesting an etiological connection between these two forms of dementia that has not yet been discovered. Epidemiological characteristics such as the low rate of pure LBD cases, the higher rate of LBD in males than females, and the more rapid course of LBD compared to pure AD, may provide clues into the risk and etiological factors of LBD. The most...

Neurobiological Mechanisms of Psychosis in Dementia

Based on neuroimaging studies, an association between delusions in dementia and dysfunction in the paralimbic area of the frontal cortex has been found (Sultzer, 1996). Using neuropathological and neuochemical investigations in patients with primary dementia, those with psychosis have been found to have significantly more plaques and tangles in the medial temporal-prosubicular area and the middle frontal cortex (Zubenko et al., 1991) and four to five times higher levels of abnormal paired...

Depression in PD

Depression is the most common neuropsychiatric disturbance in IPD. A comprehensive review of the literature by Cummings (1992) found rates of depression to average 40 with the range being 4 to 70 depending on the specific population assessed and the rating scales used. Of these, approximately half met criteria for major depression and the other half had chronic dysthymia. Another recent literature review between 1922 and 1998 by Slaughter, Slaughter, Nichols, and Martens (2001) found an overall...

Psychiatric Assessment and Treatment of Nonpsychotic Behavioral Disturbances in Dementia

Michael Ryan, M. Saleem Ismail, and Pierre N. Tariot In addition to core cognitive and functional deficits, neuropsychiatry symptoms, emotional disorders, and behavioral alterations are ubiquitous among patients with dementia syndromes. Clinicians should be concerned with the behavioral signs and symptoms of Alzheimer's disease (AD) and other dementias because they are prevalent, distressing to the patient, and upsetting to caregivers. Often they contribute...

Clinical Presentation and Diagnosis of DLB

DLB has been recognized as a clinical entity that overlaps in clinical, pathological, and genetic features with AD and PD. Much of the literature describing the characteristic clinical profile of the DLB patient has come from evaluating patients presenting to memory disorders clinics, old age psychiatry clinics, or via retrospective chart review of autopsied confirmed cases. However, many patients with DLB present to movement disorders specialists, neurologists, and community physicians for...

Aphasia Agnosonosia

In late dementia, communication of depressive mood states may be difficult secondary to aphasia. Here, making a diagnosis of depression may depend more on caregiver reporting (see later discussion) as well as careful observation. Behavioral disturbances including aggression, vocal disruption, as well as food refusal can all represent depressive equivalents and should prompt the search for other depressive symptoms. Additionally, some patients with dementia experience agnosonosia (denial of...

The Caregiver Role In Managing Ad

The efficient diagnosis and successful management of AD depends on identifying a caregiver. Typically, family members and friends take on some part of the role and self-identify at the time of the initial presentation by providing a history of the cognitive problem. At this early stage, it is important to establish permission to speak openly with the caregiver to acknowledge and reinforce the notion that the caregiver is the advocate for the patient. Caregivers may be spouses of affected...

Diffuse Lewy Body Dementia DLBD

Prevalence rates for depression in DLBD are less studied. Depression may be more common in DLBD than in AD (Ballard et al., 2002). Rates of depressive symptoms have been reported to be up to 50 of DLBD patients (Klatka, Louis, & Schiffer, 1996) with the proportion of major depression estimated at 14 to 33 (Ballard et al., 1995 McKeith, Perry, Fairbairn, Jabeen, & Perry, 1992). A study comparing clinical and neuropathological cohorts using Diagnostic and Statistical Manual of Mental...

Epidemiology

AD now affects approximately 2 to 3 of individuals at age 65, with an approximate doubling of incidence for every five years of age afterward. Thus, the prevalence of AD in one study (Evans, Funkenstein, Albert, Scherr, Cook, et al., 1989) approaches 50 of those over age 85. AD is not inevitable with aging, however, and escapees warrant further study. In 1990, there were an estimated 4 million people in the United States with AD. Because of an expanding population and increasing life expectancy...

Behavioral Management Techniques

Literature that compares drug treatment to behavior management therapy BMT indicates that, in some instances, BMT can be as effective in managing symptoms as pharmaceutical interventions. Teri et al. 2000 compared pharmacological and nonpharmacological treatments in managing agitation and depressive symptoms for AD patients. In this study, no significant differences were found among treatment with haloperidol, trazodone, BMT, or placebo, and results indicated that behavioral changes were seen...