G30 Alzheimer'sG31 Picks Disease
G30 Alzheimer's G31 Picks Disease F00-F03 -also coded under underlying pathology eg G30 Alzheimer'sG31 Picks Disease ICD-10 page] ICD-10 search
Dementia (Chronic cognitive dysfunction, neurocognitive disorder) is a clinical syndrome characterised by a chronic (and usually progressive) deterioration of memory, concentration, and judgment and sometimes accompanied by emotional disturbance and personality changes. It's effects are devastating to the patient and those around the patient, especially the carers. The increased care is costly, and is largely borne by families and the tax-payer. Do not confuse with delirium. Be aware that the semantic choice of the term can cause anxiety and has been a subject of controversy so that there is a move with DSM-V due in 2013 to retire it.
The list of causes is long but Alzheimer's disease and vascular dementia top the bill. A prime role of the physician is to look for treatable and reversible causes of dementia and exclude things that look like dementia but aren't. Once this is done the role is to support the patient and family. The use of drugs for Alzheimer's disease is possible. Other drugs are being developed.
Dementia is not one disease so these associations being indirect are likely to be markers for risk factors for the underlying disease or common pathways involved in neuroprotection and degeneration. The association is usually evaluated in context of later development of cognitive impairment. It is important to note that public perceptions of possible associations with dementia in Western society is different from the objective evidence base and many health professionals may be exposed to the same biasing factors as the public. Some associations are:
- Social class and education - lower the more likely
- Pre-morbid IQ - lower the more likely
- Lower motor function and past physical activity  increase risk
- Obesity - there is a J shaped relationship with marked leaness and more importantly with changes in most Western populations with visceral adipose tissue correlating reasonably well with risk. The relationship with BMI is not consistent.
- Metabolic syndrome up to age 75
- HDL - increased levels seem protective for this and is a general predictor of longevity
- Smoking - increases risk of cognitive impairment, but protective for those who later meet the diagnostic criteria for Alzheimer's disease
- Diet - multiple potential correlations as would be expected by underlying aetiologies. The role of cyanobacteria is a current flavour of the month
- Head trauma - especially if repetitive or severe.
- Hormone status eg HRT
- Alcohol exposure - U shaped curve ! 
- Drugs. A wide spectrum of drugs might be expected to influence cognition, and the confounding with the underlying disease can make the associations particularly challenging. Some associations such as prior exposure to NSAIDs and simvastatin being protective and antipsychotics possibly enhancing progression have been analyzed in some detail in models relating to the known increased risk with earlier major psychiatric illness.
It is important to obtain a collateral history as well as assessing the patient. Indeed the history independent of the patient's own perceptions is often the key to early diagnosis and is likely to benefit the patient which can help resolve potential conflicts where capacity to give consent for assessment is an issue, as can occasionally arise. Enquire about rate of intellectual decline, ADLs, social interaction, nutritional status, general health PMH e.g. stroke, any previous head injury, drug history, FHx of dementia, and look for confabulation.
Examination should include a brief mental state examination to screen for depressive pseudodementia and a MMSE. Neurological examination may identify focal signs, involuntary movements, pseudobulbar signs, primitive reflexes or ataxia.
All patients nowadays should have some basic investigations. If the onset has been rapid and associated with idiosyncratic signs eg Myoclonic jerks as seen in CJD then further tests should be done.
- FBC and ESR
- VDRL/FTA to exclude neurosyphilis
- B12 and folate
- Give Thiamine especially in alcoholics
- TFTs - exclude Hypothyroidism
- Assess mood - Depression ?
- CT Head - exclude space occupying lesions, stroke disease. Usually find cerebral atrophy
- MRI scan may be indicated in some
- Lumbar puncture and CSF analysis where encephalitis, meningitis or CJD suspected
- Alzheimer's disease
- Vascular dementia
- Dementia with Lewy Bodies
- Progressive supranuclear palsy
- Creutzfeldt-Jakob disease
- HIV dementia
- Hashimoto's encephalopathy
- Post encephalitis
- Cerebral Hypoxia
- Carbon monoxide poisoning
Also see Pseudodementia
- Mental Health Foundation, publishers of a variety of reports and support material for people with mental health problems, including dementia, and their carers, including Getting on with living.
- ↑ Low LF, Anstey KJ. The public's perception of the plausibility of dementia risk factors is not influenced by scientific evidence. Dementia and geriatric cognitive disorders. 2007; 23(3):202-6.(Link to article – subscription may be required.)
- ↑ Ngandu T, von Strauss E, Helkala EL, Winblad B, Nissinen A, Tuomilehto J, Soininen H, Kivipelto M. Education and dementia: what lies behind the association? Neurology. 2007 Oct 2; 69(14):1442-50.(Link to article – subscription may be required.)
- ↑ Fritsch T, Smyth KA, McClendon MJ, Ogrocki PK, Santillan C, Larsen JD, Strauss ME. Associations between dementia/mild cognitive impairment and cognitive performance and activity levels in youth. Journal of the American Geriatrics Society. 2005 Jul; 53(7):1191-6.(Link to article – subscription may be required.)
- ↑ Buchman AS, Wilson RS, Boyle PA, Bienias JL, Bennett DA. Grip Strength and the Risk of Incident Alzheimer's Disease. . 2007 Oct 8; 29(1-2):66-73.(Epub ahead of print) (Link to article – subscription may be required.)
- ↑ Laurin D, Verreault R, Lindsay J, MacPherson K, Rockwood K. Physical activity and risk of cognitive impairment and dementia in elderly persons. Archives of neurology. 2001 Mar; 58(3):498-504.
- ↑ Gunstad J, Paul RH, Cohen RA, Tate DF, Spitznagel MB, Gordon E. Elevated body mass index is associated with executive dysfunction in otherwise healthy adults. Comprehensive psychiatry. 2007 Jan-Feb; 48(1):57-61.(Link to article – subscription may be required.)
- ↑ Kuo HK, Jones RN, Milberg WP, Tennstedt S, Talbot L, Morris JN, Lipsitz LA. Cognitive function in normal-weight, overweight, and obese older adults: an analysis of the Advanced Cognitive Training for Independent and Vital Elderly cohort. Journal of the American Geriatrics Society. 2006 Jan; 54(1):97-103.(Link to article – subscription may be required.)
- ↑ van den Berg E, Biessels GJ, de Craen AJ, Gussekloo J, Westendorp RG. The metabolic syndrome is associated with decelerated cognitive decline in the oldest old. Neurology. 2007 Sep 4; 69(10):979-85.(Link to article – subscription may be required.)
- ↑ van Exel E, de Craen AJ, Gussekloo J, Houx P, Bootsma-van der Wiel A, Macfarlane PW, Blauw GJ, Westendorp RG. Association between high-density lipoprotein and cognitive impairment in the oldest old. Annals of neurology. 2002 Jun; 51(6):716-21.(Link to article – subscription may be required.)
- ↑ Swan GE, Lessov-Schlaggar CN. The effects of tobacco smoke and nicotine on cognition and the brain. Neuropsychology review. 2007 Sep; 17(3):259-73.(Link to article – subscription may be required.)
- ↑ Papapetropoulos S. Is there a role for naturally occurring cyanobacterial toxins in neurodegeneration? The beta-N-methylamino-L-alanine (BMAA) paradigm. Neurochemistry international. 2007 Jun; 50(7-8):998-1003.(Link to article – subscription may be required.)
- ↑ Van Den Heuvel C, Thornton E, Vink R. Traumatic brain injury and Alzheimer's disease: a review. Progress in brain research. 2007; 161:303-16.(Link to article – subscription may be required.)
- ↑ Ancelin ML, Ritchie K. Lifelong endocrine fluctuations and related cognitive disorders. Current pharmaceutical design. 2005; 11(32):4229-52.
- ↑ Ngandu T, Helkala EL, Soininen H, Winblad B, Tuomilehto J, Nissinen A, Kivipelto M. Alcohol drinking and cognitive functions: findings from the Cardiovascular Risk Factors Aging and Dementia (CAIDE) Study. Dementia and geriatric cognitive disorders. 2007; 23(3):140-9.(Link to article – subscription may be required.)
- ↑ Szekely CA, Thorne JE, Zandi PP, Ek M, Messias E, Breitner JC, Goodman SN. Nonsteroidal anti-inflammatory drugs for the prevention of Alzheimer's disease: a systematic review. Neuroepidemiology. 2004 Jul-Aug; 23(4):159-69.(Link to article – subscription may be required.)
- ↑ Wolozin B, Wang SW, Li NC, Lee A, Lee TA, Kazis LE. Simvastatin is associated with a reduced incidence of dementia and Parkinson's disease. BMC medicine. 2007; 5:20.(Epub) (Link to article – subscription may be required.)
- ↑ Cooper B, Holmes C. Previous psychiatric history as a risk factor for late-life dementia: a population-based case-control study. Age and ageing. 1998 Mar; 27(2):181-8.
- ↑ Xie J, Brayne C, Matthews FE. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up. BMJ (Clinical research ed.). 2008 Feb 2; 336(7638):258-62.(Link to article – subscription may be required.)
- ↑ Caroline Cantley & Monica Smith. Getting on with living. Feb 2007. Mental Health Foundation (or direct link to pdf).