alzheimer's%20disease%20-and-%20dementia
ALZHEIMER'S DISEASE AND DEMENTIA
Treatment Guideline Chart
Dementia is a clinical syndrome characterized by impairment of multiple higher cortical functions that include memory, orientation, thinking, comprehension, calculation, capacity for learning, language, judgment,  executive function and visuo-spatial function. It is usually accompanied or preceded by deterioration in emotional control, social behavior or motivation.
Alzheimer's disease is the most common cause of dementia. Sporadic cases usually present after >60 year while familial types are rare and present in <60 year of age (early-onset dementia).
Short-term memory loss is the most common early symptom. Other spheres of cognitive impairment manifest after several years.

Alzheimer's%20disease%20-and-%20dementia Diagnosis

Diagnosis

  • In order for a diagnosis of dementia to be made, the cognitive impairment should be sufficient to cause a decline in the occupational and social functioning of the individual

Diagnostic Guidelines

  • Diagnosis of subtype of dementia is done by using international standard criteria (DSM-V)
  • Clinical assessment is the basis of diagnosis
    • Neuropsychological testing is used when dementia is not clinically obvious

Alzheimer’s Disease

  • Diagnosis of Alzheimer’s disease should be made when typical degenerative syndrome is present
    • Definitive diagnosis is only confirmed on microscopic exam of the brain (usually at autopsy)
    • MRI findings of hippocampal atrophy (medial temporal atrophy) and/or global cortical atrophy may help in the diagnosis of Alzheimer’s disease in a patient with typical clinical presentation
    • Amyloid positron emission tomography (PET) scan and cerebrospinal fluid amyloid and tau levels may help in the diagnosis of Alzheimer's disease

Vascular Dementia

  • Diagnosed by history, focal neurological signs and symptoms and/or imaging studies with clear evidence of cerebrovascular events

Dementia with Lewy Bodies

  • Histopathologically, Lewy inclusion bodies are present in the cerebral cortex
  • May be diagnosed on history, physical and  neurological examination, and ancillary procedures, such as structural MRI, brain fluorodeoxyglucose (FDG)-PET scan, Dopamine Transporter single-photon emission computed tomography (SPECT) scan and metaiodobenzylguanidine (MIBG) myocardial scintigraphy
    • MRI will show absent or minimal medial temporal lobe atrophy, generalized cortical atrophy with relatively normal hippocampal size

Assessment

Clinical Assessment

Should include, but is not limited to, the following:

  • Careful evaluation of medical, psychiatric, neurological, medication and social history
  • Detailed review of cognitive and behavioral symptoms from patient and caregiver

Physical Examination

  • Exclude treatable causes which may be contributing to dementia
  • Neuropsychological and neuropsychiatric assessment

Laboratory Tests

Diagnostic Tests

  • Complete blood count (CBC), serum electrolytes, liver function test, renal function tests, glucose, thyroid function, vitamin B12 and folate levels, and syphilis serology (if syphilis is suspected)
  • Electroencephalography (EEG) may be useful if suspicious of CJD, underlying seizure disorder or in delirium
  • Neuroimaging [magnetic resonance imaging (MRI), computed tomography (CT) scan]
    • Helps to determine dementia subtypes and rule out intra-cerebral pathology
    • Brain MRI is the preferred modality to assist with early diagnosis and detect subcortical vascular changes
    • Brain CT or MRI should be performed in hypertensive patients with cognitive decline to detect silent infarct, microbleed, or white matter lesion
  • Neuropsychological testing
  • Determination of cerebrospinal fluid (CSF) biomarkers and plasma markers are not recommended in the diagnosis of mild cognitive impairment
  • Genetic testing and use of genetic marker APOE with or without plasma lipid is not routinely recommended

Cognitive and Mental State Examination

  • Montreal Cognitive Asssessment, 7-Minute Screen, Memory Impairment Screen, Mini-Mental State Exam, Abbreviated Mental Test or Clock Drawing Test
  • Score interpretations should also consider other factors that may affect the performance (eg educational level, social class, cultural background, literacy, language or other communication difficulties)
  • Refer to memory clinic with multidisciplinary collaborative care for early and accurate diagnosis and management of dementia
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