SECONDARY DEMENTIAS A.O. CHARWAY-FELLI MD, PhD OUTLINE 1.Evaluation 2.Work up 3.Syndromes in which dementia is prominent . VASCULAR DEMENTIA . NEUROINFECTIONS . THYROID GLAND DYSFUNCTION . NUTRITION DEFICIENCY SYNDROMES . NEOPLASMS . SUBDURAL HAEMATOMA . DEPRESSION EVALUATION • HISTORY!!!!! • FULL, THOROUGH NEUROLOGICAL EXAMINATION • Identification of potentially reversible causes of cognitive impairment DIFFERENTIAL DIAGNOSIS • Vascular Dementia • Hypothyroidism • Drug/ toxin induced • Paraneoplastic syndrome • B12 Deficiency • Normotensive Hydrocephalus • Chronic subdural hematoma • Chronic neuroinfection • Depression INVESTIGATIONS (LAB) MANDATORY OPTIONAL • erythrocyte sedimentation rate • Syphillis serology • full blood count (VDRL/TPHA) • Serum Vit B12 • HIV test • electrolytes • Borrelia serology • calcium • Glucose • renal and liver function • thyroid stimulating hormone. NEUROPSYCHOLOGICAL EVALUATION 1. Mini – Mental State Examination 2. Clock Drawing test 3. Frontal Assessment Battery 4. Trail making tests/ Schulte/ Stroop 5. Appropriate depression/neuropsychiatric scales MMSE – Drawing (constructionalpraxis/ spatial orientation/ perception) Clock Drawing Test 13:50/ 1:50 12 11 1 10 2 9 3 8 4 7 5 6 FRONTAL ASSESMENT BATTERY • CONCEPTUALISATION _/3 • VERBAL FLUENCY _/3 • RECIPROCAL PRAXIS/COORDINATION (FIST-RIB-PALM) _/3 • GO-NO GO (SIMPLE CHOICE) _/3 • GO-NO GO (COMPLEX CHOICE) _/3 • GRASP _/3 _/18 <12/18 : Frontal dysexecutive syndrome OTHER SIMPLE TESTS FOR FRONTO-SUBCORTICAL DYSFUNCTION SCHULTE’S TEST INVESTIGATIONS (NEUROIMAGING) • CT scan + contrast enhancement • MRI (T1, T2, FLAIR, DWI, ADC) + Gad. Enhancement VASCULAR DEMENTIA • History!!!! • Risk factors • Vascular changes on imaging • Fronto-subcortical cognitive deficit HACHINSKI ISCHAEMIC SCALE 1. Sudden onset 2 points • ≤4 points – 2. Step-wise course 1 point unlikely 3. Fluctuations 2 points Vascular 4. Nocturnal confusion 1 point Etiology of 5. Relative preservation of personality 1 point Cognitive 6. Depression 1 point 7. Somatic complaints 1 point impariment 8. Labile mood 1 point • ≥7 probably 9. Hypertension 1 point vascular 10. Stroke in history 2 points etiology of 11. Evidence of systemic atherosclerosis 1 point cognitive 12. Subjective neurologic complaints 2 points impairment 13. Objective neurologic deficit 2 points (Hachinski V. C., Iliff L. D., Zilkha E. et al., 1975) VASCULAR DEMENTIA SUBTYPES . STROKE IN A STRATEGIC ZONE . MUTLI-INFARCT DEMENTIA . LACUNAR DEMENTIA/ SUBCORTICAL LEUKOENCEPHALOPATHY/ BINSWANGER’S DISEASE Characteristics of onset . Sudden Onset – stroke in strategic zone . Step-wise Deterioration – multi-infarct dementia . Insidious Progressive – Binswanger’s disease Strategic infarction Middle cerebral artery Parieto-temporal or temporo-occipital association areas; angular gyrus Posterior cerebral artery Paramedian thalamic; inferior medial temporal lobe Watershed infarctions Superior frontal or parietal Lacunar infarctions Bilateral thalamic Stroke in a strategic zone Stroke in a strategic zone cont. White matter/ small vessel disease PHARMACOLOGIC MANAGEMENT PHARMACOLOGIC MANAGEMENT (Vascular dementia) NORMOTENSIVE HYDROCEPHALUS • Gait impairment • Urinary incontinence • Cognitive impairment NB - TAP TEST Management – Neurosurgical (vetriculoperitoneal shunt) Subdural Haematoma ! Any Change in cognitive status in the elderly, with or without a history of a fall warrants neuroimaging!! Management - SURGICAL Neuroinfections (With/without HIV) • Neurosyphillis • HIV • TB Encephalopathy (Meningitis/meningoencephalit is/vasculitis/Granulomata) • Lyme disease • Cryptococcal Meningitis • Toxoplasmosis • Cerebral Abscess Neoplasms, paraneoplastic syndromes B1, B12, other nutritional deficiencies • B12 deficiency dementia (with or without elements of subacute combined degeneration, Polyneuropathy) can occur with a normal peripheral film picture! • Wernicke Encephalopathy (in Alcoholics, starvation) Hypo, Hyperthyroidism • History! • Neurologic Examination • General examination DEPRESSION • Mild fronto-subcortical dysfunction • Bradyphrenia • No neurologic deficit • Normal Imaging • Significant response from antidepressive therapy Case 1 • JD, 75 year old female • 1 yr history of forgetfulness • She has an anterior neck swelling • Has been hypertensive for 6yrs • Has been treated for depression and anxiety for 4yrs • DrHx: Amlodipine, amitriptyline Physical examination: Patient conscious and alert. No focal neurological deficit. Anterior neck swelling, both lobes 60x40cmm and isthmus (20x10mm) palpable, surface nodular. BP- 120/80 • All other systems normal. Neuropsychological/ Mental Status evaluation • MMSE – 12/30 • CDT – 0/10 • Trail making test – perseveration on initial stages, unable to complete. • FAB – 12/18 MRI (T2, T1) JD, 75yrs JD was started on Aricept 5mg daily On follow up, global cognitive status remained unchanged with notable improvements in spheres of executive function, spatial agnosia Case 2 • Patient IO, 65 yr old, well educated male. • HIV+ on HAART for the past 3yrs, compliant; Diabetic, Hypertensive. • 2month Hx of inappropriate behaviour (walks around naked, argumentative) • NEUROLOGICAL EXAM – no focal neurologic deficit Case 2 cont. • Neuropsychological Evaluation: • MMSE – 23/30 (poor orientation in time, impaired count) • FAB – 11/18 CSF analysis (including VDRL, indian ink Stain, PCR for TB, Lyme, HV) - Normal “Of all the things I have lost, I miss my mind the most.“ ~Mark Twain Thank you!!.