Dementia

Reversible Causes

Dementia: cognitive impairment (attention, concentration, speech), memory loss; chronic, insiduous, permanent
Delirium: cognitive impairment, memory loss; acute, overt, wax/wane, reversible
Amnesia: no cognitive impairment, memory loss

Normal aging	mild cognitive impairment	Dementia
cognitive test -	test +	test +
function normal (act independently)	function normal	function -

population
- 1/3 people at 90 years old
- 1/10 people at 80 year old
- 1/20 people at 70 year old
Normal aging: slowing over time, short term memory should be ok
Dementia = cognitive impairment (moca) and functional impairment (IADL/ADL)
Diagnoses based on functional status and not based on MOCA alone
IADL: driving, meds, finances
ADL: bathing, dressing, eating
Takes 10 years on average to go from early to late dementia
Typical Dementia Sx
- delusion, hallucinations
- aggressions
- paranoid
- memory loss
Early dementia:
- only IADL impaired
- tangential, paucity of thoughts
- short term memory loss, execution problems
- MOCA < 20 or 15
Moderate dementia:
- some ADL impairment
- speak 1-2 sentences
Late dementia:
- all ADL impairment
- problems with ambulation, eating, falling
- 2-3 words
Death: from pneumonia, fall, hip fx

carbidopa-levodopa: carbidopa for CNS. Levodopa for peripheral.
basically dopamine
take on empty stomach only
half life 4 hours
need it during the day
- wake up => 10-50
- lunch => 10-50
- dinner => 10-50
no sinemet at night
Dosing
- start 10-25 or 10-50
- then 25-100
- then 50-100 at lunch or 50-200 at lunch
- no BID dosing

SSRI, first line for all of the dementia sx:
- sertraline 25mg week 1, go up to 50 then reassess in 2-3 weeks, go up to 100 or 150
- Celexa (least drug drug): 10-40mg, minimum drug drug interaction, no CYP
- Lexapro (least cardiac): 5-20mg, no QTC prolongation
Remeron
Antipsychotic: seroquel 25 (really need to 200mg for effect), risperidol 0.5, zyprexa 20. Not using these for psychosis. Take off very slowly, 25% every 2-3 weeks. Always try to go down on antipsychotics
Mood stabilizers: depakote 25mg QHS, BID, 125 mg - 250 mg for sundowning

mostly treat sun downing, apathy, agitation, outbursts, aggression, appetite changes, sleep, acting out dreams (Lewy body),
- hallucinations (LBD), puppies, children
- LBD: less tremors, more bradykinesia/rigidity
- Alzheimers: delusion
- Vascular: disinhibition
also has apathy, agitation, outbursts, aggression
Memantine, behavior manage
some respond
SE: agitation

path: frontotemporal degeneration
Symptoms: personality goes first (hypersexual, hyperaggressive), retain memory at first
diagnosis: clinical. Imaging shows frontal temporal degen
treatment: supportive

path: lewy body
symptoms: parkinsonian symptoms with dementia. Dementia predominant. Visual hallucination.
diagnosis: clinical. Rapid eye movement sleep behavior disorder distinguishes from Alzheimer
treatment: supportive

path: stroke
symptoms: step wise decline with each stroke
diagnosis: presence of infart on imaging not enough, must have step wise decline
treatment: treat stroke