Dementias other than Alzheimer s Disease. Genie Pritchett, MD Geriatrician, Senior Care of Colorado Vice President Medical Services, Colorado Access

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1 Dementias other than Alzheimer s Disease Genie Pritchett, MD Geriatrician, Senior Care of Colorado Vice President Medical Services, Colorado Access

2 Dementia Reduced mental skills impacting daily living, manifested by changes in: Memory Behavior Language Understanding (executive functioning) Emotions

3 Three stories: The baby is inside Doctor goes to high school reunion Mayor of small town

4 Where is the Pathology?

5 What Kind of Insult? Slow Process Quick Event

6 How to Make a Diagnosis Clinical observation Genetic Biomarkers Protein Biomarkers Neuroanatomy

7 Conundrum High degree of overlap in presenting symptoms Compelling reason to identify specific diagnosis < 10 % cases reversed

8 Types of Dementia Frontotemporal Dementia - FTD Vascular Dementia Dementia with Lewy bodies Other dementias: alcoholic, CJD, others

9 Frontotemporal Lobar Degeneration

10 FTD diagnostic features Second most common variant, age < 65 years old Mean age 60 years old Survival 2 8 years Genetic in 40% of familial cases Common protein pathology with other dementias (Corticobasal degeneration, PSP, ALS, MND) (TDP-43 protein, FUS inclusions)

11 Progressive Non-fluent Aphasia Slow, Effortful speech, Stuttering, Misuse of grammar, Verbs>Nouns, Eventual mutism

12 Semantic Dementia Fluent but empty speech, Over-learned phrases, Loss of object identity, naming impairment, Loss of empathy

13 Behavioral Variant Decline in social conduct, inappropriate remarks, risk taking, impulsive, loss of insight, emotional blunting, poor personal hygiene, compulsive use of instruments, poor attention and control, commonly misdiagnosed as depression or mental illness

14 Biology of FTD Mutation of an arm of chromosome 17 causing disruption of gene progranulin Aggregation of Tau, Ubiquitin proteins ultimately destroying neuron. PNFA - Tau pathology Semantic - Ubiquitin pathology Behavioral - both

15 What can we do? No cure, treatment for symptoms SSRI beneficial for disinhibition, depression, repetitive behaviors Antipsychotics for aggressive, impulsive behaviors Caregiver needs, Support groups, Counseling Focus on functional needs, Social stressors, Behavioral management, Coordination of care, FTD Association

16 Dementia with Lewy Bodies

17 Lewy Body

18 Spectrum of Lewy Body diseases Dementia with Lewy Bodies (DLB) and Parkinson s Disease with Dementia (PDD) Similar genetic and environmental risk factors: Pesticide exposure, High soil manganese, Synthetic heroin, Neuroleptics Both dopamine and choline deficits Aggregation of alpha-synuclein protein = lewy body

19 Symptoms Both cognitive and motor symptoms Executive, visual-spatial deficits, Hallucinations, Delusion, Agitation, Memory preserved early on. Dramatic fluctuations within the course of a day, Fatigue and agitation Falls common, Autonomic dysfunction (Hypotention, Incontinence), Dizziness, Brady-Kinesia, Rigidity, Postural Instability, REM sleep disorder

20 Useful Tests Frontal executive and visual-spatial deficits Clock Drawing Test Diagnostic test: SPECT (dopamine binding) CSF analysis for tau and amyloid (normal tau, low amyloid)

21 Vascular Dementia

22 Vascular Dementia Multi-infarct or stroke related Risk factors: HTN, Smoking, DM, CAD, AFIB By the time the disease manifests, modifying risk factors may be too late Aneurysm, cerebral hypoxemia, genetic vascular disease also vascular related Lesions occur throughout brain - many manifestations

23 Vascular Dementia Cortical - primary damage in the cortex. Memory, language, thinking, and behavior Subcortical Below the cortex, emotions, movement, memory

24 Common symptoms Memory impairment, language disorder, motor weakness, gait abnormality, pseudobulbar palsy (emotional lability) Most common: psychomotor slowing, attention deficits, executive dysfunction Stepwise deterioration

25 CADASIL Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Small artery disease - newly described mean age 45 Sx: migrane with aura, subcortical ischemic events, mood disorder, apathy NOTCH 3 gene on Chromosome 19 (AD) got gene, got disease Pathologic hallmark: granules in media of arterioles (seen on skin biopsy) Genetic testing: ethical issues

26 Rapidly Progresive Dementias Creutzfelt Jacob Disease - Mad Cow Disease Limbic and Hashimoto encephalopathy Infectious, autoimmune, paraneoplastic

27 Creutzfelt Jacob Disease - Mad Cow Disease

28 Creutzfeldt Jacob Prion protein 5-12 month course y/o Gravest prognosis in neurology The great mimicker Cortical cognitive Cerebellar motor Extrapyramidal behavioral and movement (tremor, myoclonus, dystonia) Characteristic EEG, myoclonus, pulvinar sign on MRI

29 Limbic Encephalitis Inflammatory encephalitis caused by antibodies reacting against a tumor - most common is the anti-hu associated with small cell lung cancer, can cause memory loss, panic attacks, cerebellar degeneration, vertical gaze palsy, limb rigidity, dystonia, narcolepsy, REM sleep disorder

30 Hashimoto s encephalopathy Abnormal high levels of thyroid antibodies Often have other autoimmune diseases such as diabetes, lupus, Sjogren Tremor, ataxia, hallucinations, stroke-like episodes, confusion, mood and behavioral disorder MRI findings are non-specific, generalized atrophy, cortical and subcortical changes

31 Other Causes Infectious causes syphilis, lyme disease, HIV associated dementia, Whipples Toxic/ metabolic Vit B12, Thiamine, niacin, folate deficiencies, uremic encephalopathy, hepatic encephalopathy, heavy metals (bismuth, lithium, mercury, arsenic, lead) Autoimmune - paraneoplastic limbic encephalitis, hashimoto encephalopathy, lupus cerebritis, sarcoid

32 Wernicke-Korsakoff Let granny have her drink Frontal lobe greatest impact: poor judgement, difficulty with decisions, lack insight Also have memory and motor symptoms TX - replace thiamine

33 Diabetes and Dementia Insulin induced hypoglycemia - rapid cognitive changes Chronic hyperglycemia - cerebral microvascular disease Type 2 DM has a fold increase risk of dementia Central pontine myelinolysis (osmotic demyelination) rapid correction of low sodium locked in syndrome

34 Prevention Causal disease prevention (stroke, blood pressure, alcoholism, head injury, HIV/AIDS) Early detection

35 Planning Caregiver support End of Life Issues

36 Chocolate Anyone?????

37 Mollenhauer, B., Förstl, H., Deuschl, G., Storch, A., Oertel, W., & Trenkwalder C., (2010). Lewy body and Parkinsonian Dementia: common, but often misdiagnosed conditions, Deutsches Ärzteblatt International, 107 (39), Rosenbloom, M.H., & Atri, A., (2011). The evaluation of rapidly progressive Dementia, The Neurologist, 17 (2), Reilly, J., Rodriguez, A.D., Lamy, M., & Neils-Strunjas, J., (2010). Cognition, language, and clinical pathological features of non-alzheimer s dementias: an overview, Journal of Communication Disorders, 43, Hervé, D., & Chabriat, H., (2010). CADASIL, Journal of Geriatric Psychiatry and Neurology, 23 (4), Rossor, M.N., Fox, N.C., Mummery, C.J., Schott, J.M., & Warren, J.D., (2010). The diagnosis of young-onset dementia, Lancet Neurology 9, Burrell, J.R., & Hodges, J.R., (2010). From FUS to fibs: what s new in frontotemporal Dementia?, Journal of Alzheimer s Disease, 21, Cardarelli, R., Kertesz, A., & Knebl, J.A., (2010). Frontotemporal Dementia: a review for primary care physicians, American Family Physician, 82 (11), Rabinovici, G.D. & Miller, B.L., (2010). Frontotemporal lobar degeneration: epidemiology, pathophysiology, diagnosis and management, CNS Drugs, 24 (5), Petersen, R.C., (2011). Mild cognitive impairment, The New England Journal of Medicine, 364, Zekry, D., & Gold, G., (2010). Management of mixed Dementia, Drugs Aging, 27 (9),

2016 Programs & Information

Mayo Alzheimer s Disease Research Clinic Education Center 2016 Programs & Information BROCHURE TITLE FLUSH RIGHT for Persons & Families impacted by Mild Cognitive Impairment Alzheimer s Disease Dementia