1. Prof Dr. Fareed Minhas
Head, Institute of Psychiatry
Rawalpindi General Hospital
Rawalpindi

2.  Syndrome due to disease of brainchronic, progressive nature
 Disturbance of multiple higher cortical
functions such as memory, thinking,
orientation, comprehension,
calculation,learning capacity, language
and judgment
 Consciousness is not clouded
 Associated deterioration in emotional control, social behavior
and motivation
 Decline of intellectual functioning interferes to a variable
extent with personal activities of daily living

3.  Estimated 2 million people in US
suffer from severe dementia and 1 to
5 million experience mild to moderate
dementia at some point.
 5 to 8% people above 65 yrs have
dementia and the number doubles
every 5 yrs
 7.9% of all canadians above 65 yrs have dementia
 In 2001, Australia's population was approximately 19
million, of which an estimated 165 000 people had dementia.
Projections are that by 2041 Australia's population will be 25
million, with an estimated 460 000 people with dementia.

4.  Alzheimer’s Disease (most common form
of dementia) costs the US at least $100
billion per year.
 Average lifetime cost in US per patient
of dementia is $174,000
 The federal government research
appropriation is $500 million per annum
 Half of all nursing home patients in US
suffer from dementia, mostly Alzheimer’s
type. The average per patient cost for
nursing home care averages $42,000/yr
but can increase to $70,000/yr

5.  DEGENERATIVE
Alzheimer’s disease
Pick’s disease
Huntington’s disease
Parkinson’s Disease
Normal pressure hydrocephalus
 VASCULAR
Cerebrovascular disease
Cranial Arteritis
 TOXIC
Alcohol
Occupational exposure
(chemicals etc)
Heavy metals (eg.lead)
 METABOLIC
Uremia
Liver failure
Remote effects of carcinoma

6.  VITAMIN DEFICIENCY
B 12
Thiamine
 TRAUMATIC
Post head injury
Punch drunk syndrome(boxers)
 INTRACRANIAL SPACE
OCCUPYING LESIONS
Subdural hematoma
Tumors
 INFECTIONS
Encephalitis
Creutzfeld-Jacob
HIV infection
Syphilis
 ANOXIC
Cardiac arrest
Respiratory failure
CO poisoning
 ENDOCRINE
Hypothyroidism
Hypocalcaemia

7. DRUGS
Chronic drug abusers have incidence
of dementia. Drugs that cause it
are:
oAnticholinergics
oBarbiturates
oBenzodiazepines
oCough suppressants
oDigitalis
oMonoamine oxidase inhibitors
oTricyclic antidepressants

8.  ADVANCING AGE
 INHERITENCE OF GENETIC
PREDISPOSITION
 UNTREATED INFECTIOUS OR
METABOLIC DISEASES/SUBSTANCE
ABUSE
 BRAIN TUMOR
 HEAD INJURY
 CARDIOVASCULAR DISEASE (eg
hypertension, atheroschlerosis)
 KIDNEY FAILURE / LIVER
DISEASE / THYROID DISEASE
 VITAMIN
DEFICIENCIES
(B12, Thiamine,
Folic Acid)

9. SUSPECT DEMENTIA WHEN…
Cognitive changes
New forgetfulness, more trouble
understanding spoken and
written communication, difficulty
finding words, not knowing
common facts such as the name
of the current U.S. president,
disorientation
Psychiatric symptoms
Withdrawal or apathy,
depression, suspiciousness,
anxiety, insomnia, fearfulness,
paranoia, abnormal beliefs,
hallucinations
Personality changes
Inappropriate friendliness,
blunting and disinterest,
social withdrawal, excessive
flirtatiousness, easy
frustration, explosive spells

10. Problem behaviors
Wandering, agitation, noisiness,
restlessness, being out of bed at
night
Changes in day-to-day
functioning
Difficulty driving, getting lost,
forgetting recipes when cooking,
neglecting self-care, neglecting
household chores, difficulty
handling money, making mistakes
at work, trouble with shopping

11. SIGNS OF DEMENTIA DEVELOPING…
Recent memory loss.
People with dementia
often forget things,
but they never
remember them.
Difficulty
performing familiar
tasks. They might
cook a meal but
forget that they
cooked it
Problems with
language. People who
have dementia may
forget simple words
or use the wrong
words. This makes it
hard to understand
what they want.
Poor judgment.
People who have
dementia, however,
might forget all
about the child and
just leave the house
for the day.
Problems with
language.
People who
have dementia
may forget
simple words
or use the
wrong words.
Problems with
abstract
thinking. They
forget what the
numbers are
and what has to
be done with
them.

12. SIGNS OF DEMENTIA DEVELOPING… Loss of
Misplacing things.
People who have
dementia may put
things in the wrong
places.
Personality
changes. People
who have dementia
may have drastic
changes in
personality. They
might become
irritable,
suspicious/ fearful
Changes in mood.
Everyone is moody at
times, but people
with dementia may
have fast mood
swings, going from
calm to tears to
anger in a few
minutes.
initiative. People
who have
dementia may
become passive.
They might not
want to go places
or see other
people.
Signs specific to subtypes. The details
given in the section of diagnosis

13. ICD 10
Evidence of
decline in
both memory and
thinking sufficient
to impair personal
activities of daily
living
For six months or
More
DSM IV
Development of
Multiple cognitive
Deficits such as
Memory impairment
And apraxia/agnosia
Disturbance of
Executive
functioning
Of gradual onset ,
That does not
Classify better in
an
Axis I disorder

14.  Multi-infarct dementia - stepwise
deterioration and patchy distribution of
deficits, focal neurological signs and evidence
of vascular disease as indicated by history,
physical examination and laboratory testing.
Abrupt onset
Stepwise progression
Fluctuating course
Nocturnal confusion
Relative preservation of personality
Depression
Somatic complaints
Emotional incontinence
History of hypertension
History of stroke
Focal neurological signs
Focal neurological symptoms
2
1
2
1
2
1
1
1
1
2
2
2
Modified
Hachinski
Ischemia
Score
(ATLEAST 4
SCORING FOR
DIAGNOSIS)

15.  Lewy Body Dementia - The central
feature is progressive cognitive decline
with resultant functional impairment.
Persistent memory impairment may occur
with disease progression. Deficits on
tests of attention, frontal­subcortical
skills and visuospatial ability may be
prominent.
Essential Features
Two of the following core features:
- Fluctuating cognition and pronounced
variations in attention and alertness
- Recurrent visual hallucinations that are
typically well formed and detailed
- Spontaneous motor features of
parkinsonism
Features Supportive of
the Diagnosis:
- Repeated falls
- Syncope
- Transient loss of
consciousness
- Neuroleptic sensitivity
- Systematized
delusions
- Hallucinations

16.  Fronto-temporal dementia –
∀− Uninhibited and socially inappropriate behavior
· - Inappropriate sexual behavior
· - Loss of concern about personal appearance
and hygiene
· - Compulsive eating and oral fixation
· - Apathy, loss of initiative, lack of concern
for others
· - Speech and language difficulties /memory
loss
 Binswanger’s (subcortical) - 2 of the following required :
-Hypertension or known systemic vascular disease (for example,
coronary artery disease, peripheral vascular disease)
-Evidence of cerebrovascular disease (for example, stroke)
-Subcortical brain dysfunction (for example, abnormal gait,
muscular rigidity, neurogenic bladder)

17. - Urinalysis and microscopy
- Complete blood cell count (anemia)
- Serum electrolyte levels, including Mg
- Serum chemistry panel, including LFTs
- Thyroid function tests
- Serum vitamin B12
- Erythrocyte sedimentation rate*
- Serologic tests for syphilis (or similar)
- Chest radiography*
- Electrocardiography*
- Toxicology screening*
- Urine toxicology
- Serum toxicology (alcohol, salicylates,
other)

18. Mini-Mental State Examination
Max Score
score
Orientation
5
What is the (year) (season) (date) (day) (month)
5
(hospital)
Where are we: (state) (county) (town or city)
(floor)?
Registration
3
Name three common objects (e.g., "apple," "table,"
"penny"):
(Take one second to say each. Then ask the patient to repeat all
three after you have said them. Give one point for each correct
answer. Then repeat them until he or she learns all three. Count
trials and record.
Attention and clalculation
5
Spell "world" backwards. The score is the number of
letters in correct order.
(D___L___R___O___W___)

19. Max
Score
3
one
objects
Score
Recall
Ask for the three objects repeated above. Give
point for each correct answer.
(Note: recall cannot be tested if all three
were not remembered during
registration.)
Language
2
Name a "pencil" and "watch."
Repeat the following: "No ifs, ands or buts."
Follow a three-stage command:
3
and
"Take a paper in your right hand, fold it in half
put it on the floor."
1
Close your eyes.
1
Write a sentence.
1
Copy the following design.
Total
score:____

20. ADDITONAL WORKUP FOR THE
DIAGNOSIS OF DEMENTIA…
Test
Electroencephalography
Lumbar puncture
preceding
Indication
Possible seizures; Creutzfeldt-Jakob
disease
Onset of dementia within the
six months; dementia rapidly
progressive
Heavy metal screen
History of potential exposure
HIV
History of potential exposure
Lyme disease titer
History of exposure and compatible
clinical picture
Ceruloplasmin,
Wilson's disease, metachromatic
arylsulfatase, electrophoresis leukodystrophy, multiple myeloma

21. Test
Slit lamp examination
Apolipoprotein E
Genetic testing for
Alzheimer genes,
dementia genes
Indication
History and examination suggest
Wilson's disease
Need to increase likelihood that
diagnosis of Alzheimer's disease
is correct
Family history is strong, and
onfirmation is clinically other
necessary

23.  DELIRIUM – acute transient
disturbance of mental functioning
 PSEUDODEMENTIA – a type
of severe depression common in
elderly
 DEPRESSION - A mental
disorder, depression can cause
difficulty in remembering,
thinking clearly and
concentrating. Sometimes
depression occurs in conjunction
with dementia. In those cases
emotional and intellectual
deterioration can be especially
severe.

24. There are 5 aspects to the
management of dementias :
 Treating any underlying disorder
Vascular dementia  lifelong aspirin
 Treating the cognitive deficits in patients with AD
Anticholinergics (Tacrine; Donepezil)
 Ameliorating associated behavioral disturbances
 Reducing the consequences of disability
 Addressing the needs of the caregivers

25. Tier 1
No dementia, management is
prevention
Tier 2
Dementia with no BPSD,
Management : selected
prevention
Teir 3
Dementia with mild BPSD eg. Wandering, sleep problem
Depression, apathy, repetition
Management : Primary health workers

26. Tier 4
Dementia with moderate BPSD
Management:Specialist in PHC
Tier 5
Dementia with severe BPSD
Management:Dementia-nursing homes / case managers
Tier 6
Dementia with very severe BPSD
Management:Psychogeriatric/ neurobehavioral units

27.  HMG Co-A Reductase
Inhibitors (lipid-lowering
agents) found to reduce the
risk of dementia
 High Homocysteine Levels
May Double Risk of Dementia,
Alzheimer’s Disease, New
Report Suggests ( Feb 2002)
 Rates of dementia increase
among older women on
combination hormonal therapy