#33 The Dementia Episode You Won’t Forget

April 3, 2017 | By Matthew Watto, MD

Dominate the diagnosis and management of dementia with tips from international expert Dr. Stephen Dekosky, Professor of Neurology, and deputy director of the McKnight Brain Institute at the University of Florida. Filled with clinical pearls, we cover everything from basic testing to advanced imaging modalities, as well as current and future therapies for dementia. This episode is a must listen. Big thanks to the American Academy of Neurology for setting up this interview.

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Clinical Pearls:

1. Definition: Dementia is loss of cognitive function greater than expected for age, and level of education.
2. MOCA looks at language, visuospatial, and executive function. MMSE was developed for patients with mental illness, not dementia. Testing for three item delayed recall is highest yield if short on time (e.g. Mini Cog).
3. Mild cognitive impairment (MCI): Memory loss in isolation. AD requires at least two areas of cognition (e.g. judgement and language)
4. MCI: CSF or PET (with amyloid tracer) can predict who will develop AD.
5. MCI: No benefit using cholinesterase inhibitors, or memantine.
6. Alzheimer’s dementia (AD) classic progression: Short term memory loss, and word finding difficulty, precedes loss of executive function (e.g. poor judgement, inappropriate social behaviors).
7. Vascular cognitive impairment (aka vascular dementia): Dementia in patient with vascular risk factors, abnormal CNS imaging, and stepwise, or absent progression.
8. Physical exam of patient with dementia: Is there lateralization? Do they have Parkinsonian features? If not, then AD likely.
9. CNS Imaging: Neurology guidelines recommend an MRI without gadolinium for patient with dementia to rule out hemorrhage and significant vascular disease.
10. Cerebrospinal fluid (CSF) studies: Low normal beta amyloid and high levels of tau = signature for Alzheimer’s disease (AD). Amyloid low because it crystallizes/aggregates. Tau high because dying neurons leak it into CSF.
11. PET scans: Three amyloid tracers approved by FDA, but not covered by Medicare or private insurance. Cost $3,000-4,000.
12. Genetics: Three known mutations that alter amyloid metabolism and cause AD. Apolipoprotein E4 homozygosity (APOE E4) has 12x increased risk for AD.
13. Preclinical AD: diagnose via PET, or CSF studies. No current medical therapy to prevent progression.
14. AD prevention: Engaged with wide circle of friends, intellectual exercises (cross-word, sudoku, etc.), active lifestyle, control blood pressure, and avoid excess weight gain. Poor evidence for Vitamin E, Gingko biloba, axona (fractionated coconut oil).
15. AD Treatment: Initiate cholinesterase inhibitor once AD criteria met. Initiate memantine once moderate to severe AD (e.g. MOCA 15 or less).
16. Anticholinergic medications (e.g. benadryl): Probably do not cause dementia, but impair cognitive function (even in normal brains), thus avoid in the elderly.

Goal: Listeners will develop a practical approach to the diagnosis and management of dementia in the primary care setting.

Learning objectives:
By the end of this podcast listeners will:

1. Differentiate between and choose the appropriate cognitive testing for dementia
2. Distinguish Alzheimer’s disease from mild cognitive impairment
3. Select the appropriate basic lab, and/or advanced lab testing for dementia
4. Utilize the appropriate basic and/or advanced CNS imaging studies
5. Initiate prevention strategies in healthy patients
6. Employ a standardized approach to medical therapy for AD

Disclosures:
Dr. DeKosky reports the following relevant financial disclosures:

Time Stamps
00:00 Intro
02:20 Rapid fire questions
04:40 Defining dementia
08:40 Choosing a clinical test for dementia
17:20 Diagnostic labs
19:00 Genetic and CSF testing
25:46 Advanced brain imaging
28:18 Preclinical Alzheimer’s disease (AD)
32:17 Routine CNS imaging
36:18 Initiating medical therapy
39:35 Differentiating MCI and dementia
41:45 Vascular Dementia
44:10 CSF testing for AD
45:15 Vitamins, supplements, and foods as treatment or prevention
50:56 Mental exercise for AD prevention
52:36 Anticholinergic, benzos and dementia
54:46 Future directions
57:55 Outro

Links from the show:

1. Link to Dr. DeKosky bio
2. Concussion (movie)
3. American Academy of Neurology Practice Guidelines for Dementia 2001
4. Lancet. 2016 Jul 30;388(10043):505-17. doi: 10.1016/S0140-6736(15)01124-1. Epub 2016 Feb 24. Alzheimer’s disease. Scheltens P1, Blennow K2, Breteler MM3, de Strooper B4, Frisoni GB5, Salloway S6, Van der Flier WM7.
5. Mayo Clin Proc. 2013 Nov;88(11):1213-21. doi: 10.1016/j.mayocp.2013.07.013. Epub 2013 Oct 1. Statins and cognition: a systematic review and meta-analysis of short- and long-term cognitive effects. Swiger KJ1, Manalac RJ, Blumenthal RS, Blaha MJ, Martin SS.
6. JAMA Intern Med. 2015 Sep;175(9):1450-8. doi: 10.1001/jamainternmed.2015.2152. Cognitive Tests to Detect Dementia: A Systematic Review and Meta-analysis. Tsoi KK1, Chan JY2, Hirai HW1, Wong SY2, Kwok TC3.