Diagnosis and Treatment of Dementia in

the Aged

Rentha Monica Simamora

Novira Widajanti

Department of Internal Medicine

Medical Faculty of Airlangga University-Dr Soetomo Teaching Hospital Surabaya
2018
OUTLINE • Definition of Dementia
• Epidemiology
• Patophysiology and Pathogenesis
• Risk Factor
• Diagnosis
• Differential Diagnosis
• Management of Dementia
• Dementia with other geriatric
syndromes
• Prognosis
 PREFACE
• Dementia is one of geriatric syndrome  a clinical
syndrome  difficulties in memory, language and
behaviour  impairments in activities of daily living
• Incidence doubles every 5,9 years
• In 2030 the global cost of dementia care : $1tr
The current problems :
- Diagnosing dementia can be difficult
- Management depends on subtype of dementia
Robinson L, Tang E, & Taylor J, 2015. Dementia: timely diagnosis and early intervention. BMJ (Online)
Logiudice D & Watson R, 2014. Dementia in older people: An update. Internal Medicine Journal, 44(11), 1066–1073.
Rohmah W & Harimuntoro K, 2014. Demensia dalam Buku Ajar Ilmu Penyakit Dalam (Edisi VI). Jakarta: InternaPublishing.
Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6.
Logiudice D & Watson R, 2014. Dementia in older people: An update. Internal Medicine Journal, 44(11), 1066–1073.
Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6.
Logiudice D & Watson R, 2014. Dementia in older people: An update. Internal Medicine Journal, 44(11), 1066–1073.
Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6.
 Epidemiologi
- BAPPENAS 2013: people > 65
yo increased from 5% to 10,8 %
in 2035.

- Vascular dementia: 60,59 %

patient with stroke have
cognition problem ( Indonesian
stroke Registry)

Prince M, Guerchet M. & Prina M, 2015. The Epidemiology and Impact of Dementia: Current State and future trends. First WHO Ministerial Conference on Global Action Against
Dementia, 1–4
Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia
 Patophysiology of Alzheimer’s disease

Four hypothesis for the

development of AD :
- Aβ hypothesis
- Cholinergic hypothesis
- Tau hypothesis
- Inflammation hypothesis

Yamasaki T, Muranaka H, Kaseda Y & Tobimatsu S, 2012. Understanding the Pathophysiology of Alzheimer’s Disease and Mild Cognitive Impairment: A Mini Review on fMRI and ERP Studies.
Neurology Research International.
Kumar A, Singh A, & Ekavali, 2015. A review on Alzheimer’s disease pathophysiology and its management: An update. Pharmacological Reports, 67(2), 195–203
 Patophysiology of Vascular Dementia

- Vascular dementia causes

by ischemic lesion or
brain hemorhaggic

- The most common

vascular lesion is in
FRONTALIS REGIO

Kasper DL, Hauser S, Jameson JL, & Fauci A, 2015. Dementia. Harrison’s Principle of Interna Medicine (19th ed.). New York: McGraw-Hill Education.
Rohmah W & Harimuntoro K, 2014. Demensia dalam Buku Ajar Ilmu Penyakit Dalam (Edisi VI). Jakarta: InternaPublishing.
 UNMODIFIED RISK MODIFIED RISK
Age Smoking
Sex
Physical Inactivity
Ethnic
Genetic RISK Unhealthy Diet
History familial FACTORS Alcohol
disease OF Head Trauma
Intelectual disability DEMENTIA

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.

Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
 HOW TO DIAGNOSE??
Anamnesis
- Careful history from the patient and caregiver
- Ask for risk factor and history of disease
- 75% AD: initial symptoms  memory impairment
- In Vascular Dementia common symptoms are attention
deficit and mood changes

Physical Examination
Look for any focal neurological sign and exclude any
visual or auditory problems.

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.

Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
 DSM IV Diagnostic Criteria

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia

 • MMSE
Cognitive • Clock Drawing Test
test • Montreal Cognitive Assesment

• Blood test, urine, Thyroid function, B12, VDRL

Laboratory • Liver function test, Renal Function test
• Lumbal Puncture (total tau and amyloid beta) , ApoE
Examination
• Head CT scan
• MRI
Imaging • Perfusion SPECT (single photon emusion CT)
• FDG PET
MMSE

CLOCK DRAWING TEST

Brosch J, Farlow M, 2010. Allzheimer Disease. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology (7th ed.).Philadelphia: Elsevier Ink
Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia
NIA CRITERIA FOR AD
NINDS AIREN Criteria for Vascular Dementia
Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.
 Pharmacological management of Alzheimer’s Disease
Donepezil Galantamine Rivastigmine Memantine
FDA Approved Mild Moderate Mild Moderate Mild Moderate Moderate Severe
for
Mechanism Acethyl Acethyl Acethyl NMDA
cholinesterase cholinesterase cholinesterase antagonist
inhibitor inhibitor, inhibitor
Nicotinic
receptor
modulation
Dose Initial dose 5 mg Initial dose 1,5 Initial dose 8 mg Initial dose 5 mg
daily mg b.i.d daily daily
Max dose 10 mg Max dose 6 mg Max dose 24 mg Max dose 20 mg
b.i.d
Adverse effect Nausea, Nausea, Nausea, Headache,
vomitting vomitting vomitting dizziness,
hypertension,
somnolence

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.

Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
 Pharmacological management
of Vascular Dementia

• Acetylcholinesterase inhibitor or memantine : only if suspected

comorbid with Alzheimer’s disease, Parkinson’s disease or
dementia with Lewy Bodies (NICE guideline).
• Acetylcholinesterase inhibitor can be given to Vascular
dementia under a doctor’s control ( Pedoman Praktek
Demensia)
• Controlling vascular risk factor : antihypertension, statin,
aspirin, antidiabetic

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.

Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
 Managing Behaviour&Psychological Symptoms of Dementia
(BPSD)
Agitation, psychosis, agression
- Psycosocial and environment
intervention
-Antipsycotic : Risperidone and Depression and anxiety
Halloperidol -Psycological treatment
-Do not routinely offer
Sleep problems antidepressant
-Do not offer melatonin
-Multicomponent sleep
management  sport, light therapy,
sleep education
Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.
Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
 Non Pharmacological management
• Education to patient and caregiver about dementia
• Activity Daily Living Exercise therapy
• Intervention combination therapy
• Cognitive stimulation therapy
• Cognitive rehabilitation therapy
• Cognitive exercise therapy

Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia, 40(9), 661–673.

Pink J, O’Brien J, Robinson L & Longson D, 2018. Dementia: Assessment, management and support: Summary of updated NICE guidance. BMJ (Online), 361(June), 1–6
Janitra R, 2013. Diagnosis dan Penatalaksanaan Demensia
Dementia with other geriatric syndromes

PAIN
FALLS URINARY
INCONTINENCE
 Alzheimer Disease
PROGNOSIS
- Prognosis  Age, Sex,
Vascular Dementia
Comorbid disease, and
Disability level. - Prognosis depend on
- The median survival : cerebrovascular lesion
4,2 years for men and 5,7 features.
years for woman - The median survival for
- Comorbid DM : 3,8 years, temporal vascular lesion
hipertention 5,0 years, CHF was 3,7 years, without
3,0 years temporal vascular lesion
was 3,9 years.
Knopman D, 2017. Survival Study of Vascular Dementia. Neurology Research International, 60
Larson EB, Shadlen M., Wang L, 2004. Annals of Internal Medicine Article, 501–511
 Summary
• Dementia is an umbrella term used to describe a range of symptoms
associated with cognitive impairment
• The common types of dementia in the aged are AD and VaD
• Diagnostic approach by history taking, physical and laboratory
examination, neurocognitive test, and imaging
• Acetylcholinesterase inhibitors are used to treat mild moderate AD, while
memantine is for severe AD
• Controlling vascular risk are the most important thing in vascular dementia
• The role of caregiver for dementia management is very important
THANK YOU