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geri:dementia:home [on May 19, 2020]
geri:dementia:home [on October 3, 2022] (current)
psychdb [Approach to Dementia]
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 ===== Primer ===== ===== Primer =====
-**Dementia** is a progressive neurocognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities. It is a broad diagnostic category that includes [[geri:​dementia:​alzheimers|Alzheimer'​s disease]], [[geri:​dementia:​lewy-body|Lewy Body dementia]], [[geri:​dementia:​frontotemporal|frontotemporal dementia]], [[geri:​dementia:​vascular|vascular dementia]], [[geri:​dementia:​parkinsons|Parkinson'​s disease]], and [[geri:​dementia:​creutzfeldt-jakob-disease-cjd|Creutzfeldt–Jakob disease]] (among many others).+**Dementia** is a syndrome characterized by progressive neurocognitive decline of sufficient magnitude to interfere with normal social or occupational functions, or with usual daily activities. It is a broad diagnostic category that includes [[geri:​dementia:​alzheimers|Alzheimer'​s disease]], [[geri:​dementia:​lewy-body|Lewy Body dementia]], [[geri:​dementia:​frontotemporal|frontotemporal dementia]], [[geri:​dementia:​vascular|vascular dementia]], [[geri:​dementia:​parkinsons|Parkinson'​s disease]], and [[geri:​dementia:​creutzfeldt-jakob-disease-cjd|Creutzfeldt–Jakob disease]] (among many others). It also includes [[geri:​dementia:​0-rapid-rpd|rapidly progressive dementias]] that may be fully reversible if the etiology is correctly identified.
  
-==== Prevention ==== +== Epidemiology ​== 
-About 35% of dementia is attributable ​to nine modifiable factors across ​the lifespan.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/28735855|LivingstonG., SommerladA., OrgetaV., CostafredaS. G., HuntleyJ., Ames, D., ... Cooper, C. (2017). Dementia prevention, intervention, ​and careThe Lancet390(10113), 2673-2734.]])] These factors include: education, midlife hypertension,​ midlife obesity, hearing loss, late-life depression, diabetes, physical inactivity, smoking, and social isolation.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/29490494|Steffens, D. C. (2018). A Geriatrics Perspective on Dementia ​Prevention and Treatment.]])]+  * The global prevalence ​of dementia ​from all causes ​is estimated ​to be between 5% and 7% of adults over the age of 60.[([[https://​pubmed.ncbi.nlm.nih.gov/​23305823/|PrinceM., BryceR., AlbaneseE., WimoA., RibeiroW., & Ferri, C. P. (2013). The global prevalence of dementia: a systematic review ​and metaanalysisAlzheimer'​s & dementia9(1), 63-75.]])]
 +    * The incidence of dementia then doubles every 5 years after age 65.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3385995/|Corrada, M. M., Brookmeyer, R., Paganini‐Hill,​ A., Berlau, D., & Kawas, ​C. H. (2010). Dementia ​incidence continues to increase with age in the oldest old: the 90+ study. Annals of neurology, 67(1), 114-121.]])] 
 +  * [[geri:​dementia:​alzheimers|Alzheimer’s disease (AD)]] is the most common cause of dementia worldwide, and dementia rates start at 5-10% at age 70. 
 +    * By age 85, between 25% and 50% of people will exhibit signs of Alzheimer'​s disease. 
 +  * The percentage of all dementias due to Alzheimer'​s disease is at least 50% (with some estimates suggesting 60-90%). 
 +  * Females with dementia outnumber males by 2 to 1
  
 +== Prognosis ==
 +  * Different dementias have different median survival times from first symptom onset:​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2706263/​|Geschwind,​ M. D., Haman, A., & Miller, B. L. (2007). Rapidly progressive dementia. Neurologic clinics, 25(3), 783-807.]])]
 +    * [[geri:​dementia:​alzheimers|]],​ average 11.7 years
 +    * [[geri:​dementia:​frontotemporal|]] average 11 years
 +    * [[geri:​dementia:​corticobasal-degeneration-cbd|]] average 11.8 years
 +    * [[geri:​dementia:​progressive-supranuclear-palsy-psp|]] average 5.6 years
 +    * [[geri:​dementia:​lewy-body|]],​ average 3 years
 +==== Normal Aging and Cognition ====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​
 +See main article: **[[cognitive-testing:​memory|]]**
 +</​alert>​
 +
 +  * Decline in problem-solving,​ processing speed, and minor delays in word-finding can be common in normal ageing. Retrieval-type memory deficits are also commonly reported. In contrast to dementia, semantic memory and visuospatial functioning is generally preserved.
 +
 +===== Prevention =====
 +<WRAP group>
 +<WRAP half column>
 +About 35%-40% of dementia cases are attributable to 9 modifiable factors across the lifespan.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​28735855|Livingston,​ G., Sommerlad, A., Orgeta, V., Costafreda, S. G., Huntley, J., Ames, D., ... & Cooper, C. (2017). Dementia prevention, intervention,​ and care. The Lancet, 390(10113), 2673-2734.]])] These factors include:​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29490494|Steffens,​ D. C. (2018). A Geriatrics Perspective on Dementia Prevention and Treatment.]])] More recently, the //2020 Lancet Commission on Dementia Prevention, Intervention and Care// now include 12 potentially modifiable risk factors across the lifespan that can contribute to dementia:​[([[https://​www.thelancet.com/​journals/​lancet/​article/​PIIS0140-6736(20)30367-6/​fulltext|Dementia prevention, intervention,​ and care: 2020 report of the Lancet Commission. Livingston, Gill et al. The Lancet]])]
 +  * Early life (<45 years)
 +    * Less education
 +  * Midlife (age 45 to 65 years)
 +    * Hypertension
 +    * Obesity
 +    * Hearing loss
 +    * [[cl:​tbi|Traumatic brain injury]]
 +    * [[addictions:​alcohol:​home|Alcohol misuse]]
 +  * Late-life (age >65 years)
 +    * [[addictions:​nicotine-tobacco:​home|Smoking]]
 +    * [[mood:​1-depression:​home|Depression]]
 +    * Physical inactivity
 +    * Social isolation
 +    * Diabetes
 +    * Air pollution
 +
 +There remains debate as to how many cases of dementia with modifiable risk factors can truly be prevented even with risk factor modification.[([[https://​pubmed.ncbi.nlm.nih.gov/​32641088/​|Montero-Odasso,​ M., Ismail, Z., & Livingston, G. (2020). One third of dementia cases can be prevented within the next 25 years by tackling risk factors. The case “for” and “against”. Alzheimer'​s Research & Therapy, 12(1), 1-5.]])]
 +
 +</​WRAP>​
 +<WRAP half column>
 +<callout type="​info"​ title="​The World Health Organization (WHO) Dementia Prevention Guidelines"​ icon="​true">​
 The World Health Organization (WHO) Dementia Prevention Guidelines recommends the following to reduce the risk of dementia:​[([[https://​www.who.int/​mental_health/​neurology/​dementia/​guidelines_risk_reduction/​en/​|World Health Organization. (2019). Risk reduction of cognitive decline and dementia: WHO guidelines. In Risk reduction of cognitive decline and dementia: WHO guidelines.]])] The World Health Organization (WHO) Dementia Prevention Guidelines recommends the following to reduce the risk of dementia:​[([[https://​www.who.int/​mental_health/​neurology/​dementia/​guidelines_risk_reduction/​en/​|World Health Organization. (2019). Risk reduction of cognitive decline and dementia: WHO guidelines. In Risk reduction of cognitive decline and dementia: WHO guidelines.]])]
   - Physical exercise (there is some conflicting data[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​30995986|Kivimäki,​ M., Singh-Manoux,​ A., Pentti, J., Sabia, S., Nyberg, S. T., Alfredsson, L., ... & Kouvonen, A. (2019). Physical inactivity, cardiometabolic disease, and risk of dementia: an individual-participant meta-analysis. bmj, 365, l1495.]])])   - Physical exercise (there is some conflicting data[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​30995986|Kivimäki,​ M., Singh-Manoux,​ A., Pentti, J., Sabia, S., Nyberg, S. T., Alfredsson, L., ... & Kouvonen, A. (2019). Physical inactivity, cardiometabolic disease, and risk of dementia: an individual-participant meta-analysis. bmj, 365, l1495.]])])
-  - Tobacco cessation +  - [[addictions:​nicotine-tobacco:​home|Tobacco cessation]] 
-  - Reduce harmful drinking+  - [[addictions:​alcohol:​home|Reduce harmful drinking]]
   - Lose excess weight in midlife   - Lose excess weight in midlife
   - Adhere to healthy diet (a Mediterranean-style diet may reduce dementia risk)   - Adhere to healthy diet (a Mediterranean-style diet may reduce dementia risk)
   - Cognitive training can be tried for adults with normal cognition or mild impairment (but the quality of evidence to support this is low)   - Cognitive training can be tried for adults with normal cognition or mild impairment (but the quality of evidence to support this is low)
   - Social participation and support are important throughout life (but limited evidence to support)   - Social participation and support are important throughout life (but limited evidence to support)
-  - Hypertension,​ diabetes, and depression should be managed according to existing guidelines (but it'​s ​not clear whether doing so will specifically lower dementia risk)+  - Hypertension,​ diabetes, and [[mood:1-depression:​home|depression]] ​should be managed according to existing guidelines (but it is not clear whether doing so will specifically lower dementia risk) 
 +</​callout>​ 
 +</​WRAP>​ 
 +</​WRAP>​
  
-Vitamins B and E, polyunsaturated fatty acids, and multivitamins are not recommended for risk reduction of dementia.[([[https://​www.cochrane.org/​CD011905/​DEMENTIA_vitamin-and-mineral-supplementation-preventing-dementia-or-delaying-cognitive-decline-people-mild|McCleery,​ J., Abraham, R. P., Denton, D. A., Rutjes, A. W., Chong, L. Y., Al‐Assaf, A. S., ... & Di Nisio, M. (2018). Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment. Cochrane Database of Systematic Reviews, (11).]])] +==== Diet ==== 
- +Dietary supplementation to prevent dementia has been a source of controversy due to a lack of convincing evidence from current studies, low quality studies, and multiple confounders in dietary research.[([[https://​pubmed.ncbi.nlm.nih.gov/​31403656/​|Ludwig,​ D. S., Ebbeling, C. B., & Heymsfield, S. B. (2019). Improving the quality of dietary research. Jama, 322(16), 1549-1550.]])] ​Vitamins B and E, polyunsaturated fatty acids, and multivitamins are not recommended for risk reduction of dementia.[([[https://​www.cochrane.org/​CD011905/​DEMENTIA_vitamin-and-mineral-supplementation-preventing-dementia-or-delaying-cognitive-decline-people-mild|McCleery,​ J., Abraham, R. P., Denton, D. A., Rutjes, A. W., Chong, L. Y., Al‐Assaf, A. S., ... & Di Nisio, M. (2018). Vitamin and mineral supplementation for preventing dementia or delaying cognitive decline in people with mild cognitive impairment. Cochrane Database of Systematic Reviews, (11).]])][([[https://​pubmed.ncbi.nlm.nih.gov/​30556597/|RutjesA. W., DentonDA., Di NisioM., ChongL. Y., AbrahamRP., Al‐AssafA. S., ... & McCleery, J. (2018). Vitamin and mineral supplementation for maintaining cognitive function ​in cognitively healthy people in mid and late lifeCochrane database of systematic reviews, (12).]])]
-===== Approach ===== +
-When being asked to see a patient with dementia, it is good to have a systematic approach. The following is one approach to diagnosing dementia.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596200/|LeeL., WestonWW., HeckmanG., GagnonM., LeeFJ., & Sloka, S. (2013). Structured approach to patients with memory difficulties ​in family practiceCanadian Family Physician59(3), 249-254.]])]+
  
 +===== Approach to Dementia =====
 +When seeing a patient with a non-rapidly progressive dementia (otherwise, see the rapidly progressive dementia approach below), it is good to have a systematic approach. The following is one approach:​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596200/​|Lee,​ L., Weston, W. W., Heckman, G., Gagnon, M., Lee, F. J., & Sloka, S. (2013). Structured approach to patients with memory difficulties in family practice. Canadian Family Physician, 59(3), 249-254.]])]
   - **Rule out [[cl:​1-delirium|delirium]].** Is there an acute onset and fluctuating course + inattention + disorganized thinking? Is there altered level of consciousness?​   - **Rule out [[cl:​1-delirium|delirium]].** Is there an acute onset and fluctuating course + inattention + disorganized thinking? Is there altered level of consciousness?​
-    * Urinary ​Tract Infections ([[https://​www.aafp.org/​afp/​2011/​1001/​p771.html|UTIs]]) ​are especially ​common in the elderly and frequent culprits ​of delirium! ​Don't forget that a negative urine culture does not always mean there is no UTI, especially if the patient ​is symptomatic.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​28457846|Heytens,​ S., De Sutter, A., Coorevits, L., Cools, P., Boelens, J., Van Simaey, L., ... & Claeys, G. (2017). Women with symptoms of a urinary tract infection but a negative urine culture: PCR-based quantification of Escherichia coli suggests infection in most cases. Clinical Microbiology and Infection, 23(9), 647-652.]])]+    * Urinary ​tract infections ​are common in the elderly and can be causes ​of delirium! ​Additionally, ​a negative urine culture does not always mean there is no UTI, especially if the patient ​has classic symptoms of a UTI.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​28457846|Heytens,​ S., De Sutter, A., Coorevits, L., Cools, P., Boelens, J., Van Simaey, L., ... & Claeys, G. (2017). Women with symptoms of a urinary tract infection but a negative urine culture: PCR-based quantification of Escherichia coli suggests infection in most cases. Clinical Microbiology and Infection, 23(9), 647-652.]])] On the other hand, however, asymptomatic bacteriuria should not be treated with an antibiotic, due to adverse risks such as //C. Diff// infections and lack of evidence for changing outcomes.[([[https://​pubmed.ncbi.nlm.nih.gov/​30895288/​|Nicolle,​ L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., ... & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria:​ 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110.]])]
   - **Rule out [[mood:​1-depression:​home|depression]]** ("​pseudodementia"​). Consider atypical presentations:​ anxiety, irritability,​ unexplained physical complaints, worsening cognition. Once the depression is treated, the dementia symptoms go away!   - **Rule out [[mood:​1-depression:​home|depression]]** ("​pseudodementia"​). Consider atypical presentations:​ anxiety, irritability,​ unexplained physical complaints, worsening cognition. Once the depression is treated, the dementia symptoms go away!
-  - **Rule out any substance use disorders** +  - **Rule out any [[addictions:​home|substance use disorders]]** 
-  - **Rule out any reversible causes** +  - **Rule out any reversible causes, by ordering investigations such as:** 
-    * Order CBC (anemia), TSH (hypothyroidism), ​creatinineelectrolytes (hyponatremia), calcium ​(hypercalcemia), glucose ​(hyperglycemia)and vitamin ​B12 (vitamin ​B12 deficiency+    * **CBC** (to rule out anaemia and some cancers that can may present with fatigueweight loss, and other depressive symptoms) 
-    * Creatinine ​(to assess renal function ​and ability ​to clear medications+    * **TSH** (to rule out [[cl:​thyroid-disorders:​hypothyroidism|hypothyroidism]] that can cause a depressive syndrome) 
-    * Consider neuroimaging ​such as [[neurology:​ct-scan|CT]] or [[neurology:​mri|MRI]] +    * **Creatinine** (to rule out renal disease that can present with fatigueweight losspoor concentration,​ and other depressive symptoms, and to assess for overall renal function) 
-    * Consider rapid plasma reagin ​(RPR), LFTs+    * **Electrolytes** 
 +      * Sodiumin particular for hyponatremia ​(which can present with fatigue, poor concentration,​ and other depressive symptoms) 
 +      * Calcium ([[cl:hypercalcemia-hyperparathyroidism|hypercalcemia]] may result in neuropsychiatric symptoms including psychosis and depression) 
 +    * **Parathyroid hormone ​(PTH)** and **vitamin ​D** (because increased PTH and decreased ​vitamin ​D may be associated with depressive symptoms
 +    * **Glucose** ​(to rule out diabetes that can present with fatigue, weight loss, and other depressive symptoms) 
 +    * **Ferritin/​iron** (for fatigue and cognitive impairment) 
 +    * [[cl:​vitamin-b12-cyanocobalamin-deficiency|Vitamin B12]] (to rule out low B12 that can cause a depressive syndrome
 +    * **Folate level** (to rule out low folates that can cause a depressive syndrome) 
 +    * **Neuroimaging** ​such as [[neurology:​ct-scan|CT]] or [[neurology:​mri|MRI]] 
 +    * **VDRL** ​(screening for [[cl:​neurosyphilis|syphillis]]) 
 +    * **[[cl:​hiv|HIV]]** (for HIV-associated neuropsychiatric presentations or HIV-associated cognitive impairment) 
 +    * **Serum albumin** (to assess nutritional status and rule out diseases that can present with depressive symptoms) 
 +  - **Medication Review** 
 +    * Medication-induced "​dementia"​ 
 +    * Is there polypharmacy that could be contributing to the cognitive impairment?​ 
 +    * Is there the use of any anticholinergic medications (and [[meds:​toxidromes:​anticholinergic-cholinergic|anticholinergic toxicity]]?​) 
 +    * Is there the use of other medications that could cause cognitive issues? 
 +       * e.g. - steroid dementia syndrome related to glucocorticoid use. 
 +  - **Neurological Review**  
 +    * Do a [[neurology:​neuro-exam:​home|neurological exam]] if appropriate 
 +    * Consider other neurological disorders including [[neurology:​approach-normal-pressure-hydrocephalus-nph|normal pressure hydrocephalus]]
   - **Is it dementia, mild cognitive impairment (MCI), or normal aging?**   - **Is it dementia, mild cognitive impairment (MCI), or normal aging?**
-    * Dementia: objective findings of cognitive loss with impairment of ADLs +    * [[cl:​2-major-neurocog-disorder|Major neurocognitive disorder]] (dementia): objective findings of cognitive loss with impairment of ADLs 
-    * [[cl:​3-mild-neurocog-disorder|Mild ​Cognitive Impairment]]: objective findings of cognitive loss without impairment of ADLs+    * [[cl:​3-mild-neurocog-disorder|Mild ​cognitive impairment]]: objective findings of cognitive loss without impairment of ADLs
     * Normal cognitive aging: no objective findings of cognitive loss     * Normal cognitive aging: no objective findings of cognitive loss
-===== Dementia Subtypes ​=====+ 
 +==== Rapidly Progressive Dementias ​==== 
 +<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See main article: **[[geri:​dementia:​0-rapid-rpd]]**</​alert>​ 
 +<WRAP group> 
 +<WRAP half column>​ 
 +**Rapidly Progressive Dementias (RPDs)** are dementias that progress quickly -- over the course of weeks to months (in rarer cases, may be over a period of 1-2 years).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3613204/​|Paterson,​ R. W., Takada, L. T., & Geschwind, M. D. (2012). Diagnosis and treatment of rapidly progressive dementias. Neurology: Clinical Practice, 2(3), 187-200.]])] Treatment of an RPD is dependent on the etiology of the dementia, some of which are fully treatable. This makes early recognition critical. Broadly, RPDs can be broken down into different etiologies:​ 
 +  - **Prion disease** (e.g. - [[geri:​dementia:​creutzfeldt-jakob-disease-cjd|]]) 
 +  - **Neurodegenerative diseases** (e.g. - early onset [[geri:​dementia:​alzheimers|]]) 
 +  - **Autoimmune** 
 +  - **Infectious** 
 +  - **Psychiatric** 
 +  - **Neoplastic** 
 +  - **Toxic-Metabolic** 
 +  - **Vascular** 
 +  - **Leukoencephalopathies** (e.g. - [[cl:​multiple-sclerosis|]],​ Progressive Multifocal Leukoencephalopathy) 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​ 
 +Evaluating for RPDs requires a detailed and systematic approach, and a mnemonic can be useful to do this. The mnemonic ''​**VITAMINS**''​ can be used to remember the  
 + 
 +<​HTML><​br><​br></​HTML>​ 
 +  * ''​**V**''​ - Vascular 
 +  * ''​**I**''​ - Infectious 
 +  * ''​**T**''​ - Toxic-Metabolic 
 +  * ''​**A**''​ - Autoimmune 
 +  * ''​**M**''​ - Metastasis/​Neoplastic 
 +  * ''​**I**''​ - Iatrogenic 
 +  * ''​**N**''​ - Neurodegenerative 
 +  * ''​**S**''​ - Systemic/​Seizures 
 +</​callout>​ 
 +</​WRAP>​ 
 +</​WRAP>​ 
 +==== Common Dementias ==== 
 +The most common dementia subtypes are below: 
 <panel type="​info"​ title="​Common Dementia Subtypes and Presentation"​ footer="​*Includes mixed dementia types (Vascular and Alzheimer'​s). Mixed types become more common in later–life dementia."​ no-body="​true">​ <panel type="​info"​ title="​Common Dementia Subtypes and Presentation"​ footer="​*Includes mixed dementia types (Vascular and Alzheimer'​s). Mixed types become more common in later–life dementia."​ no-body="​true">​
 +<​mobiletable 1>
 ^ Subtype ​                           ^ Percent of Dementia Cases                                                                                                                                                                                                                                                                                                              ^ Typical presentation ​                                                                    ^ ^ Subtype ​                           ^ Percent of Dementia Cases                                                                                                                                                                                                                                                                                                              ^ Typical presentation ​                                                                    ^
 ^ [[geri:​dementia:​alzheimers|]] ​     | ~50%                                                                                                                                                                                                                                                                                                                                   | Initial short-term memory loss                                                           | ^ [[geri:​dementia:​alzheimers|]] ​     | ~50%                                                                                                                                                                                                                                                                                                                                   | Initial short-term memory loss                                                           |
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 ^ [[geri:​dementia:​frontotemporal|]] ​ | 3%                                                                                                                                                                                                                                                                                                                                     | Younger age, behavioural symptoms, or language impairment ​                               | ^ [[geri:​dementia:​frontotemporal|]] ​ | 3%                                                                                                                                                                                                                                                                                                                                     | Younger age, behavioural symptoms, or language impairment ​                               |
 ^ [[geri:​dementia:​parkinsons|]] ​     | 0.5%[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16041803|Aarsland,​ D., Zaccai, J., & Brayne, C. (2005). A systematic review of prevalence studies of dementia in Parkinson'​s disease. Movement disorders: official journal of the Movement Disorder Society, 20(10), 1255-1263.]])] (most cases of Parkinson'​s will progress to dementia) ​ | Dementia occurring > 1 year after onset of Parkinson disease motor symptoms ​             | ^ [[geri:​dementia:​parkinsons|]] ​     | 0.5%[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16041803|Aarsland,​ D., Zaccai, J., & Brayne, C. (2005). A systematic review of prevalence studies of dementia in Parkinson'​s disease. Movement disorders: official journal of the Movement Disorder Society, 20(10), 1255-1263.]])] (most cases of Parkinson'​s will progress to dementia) ​ | Dementia occurring > 1 year after onset of Parkinson disease motor symptoms ​             |
 +</​mobiletable>​
 </​panel>​ </​panel>​
 +
 +==== Rare Dementias ====
 +Rarer dementia subtypes include the following:
  
 <panel type="​info"​ title="​Rare Dementia Subtypes and Presentation"​ no-body="​true">​ <panel type="​info"​ title="​Rare Dementia Subtypes and Presentation"​ no-body="​true">​
 +<​mobiletable 1>
 ^ Subtype ​                                              ^ Prevalence ​                                                                                                                                                                                                                                                                                                                                                ^ Typical presentation ​                                                                                                                   ^ ^ Subtype ​                                              ^ Prevalence ​                                                                                                                                                                                                                                                                                                                                                ^ Typical presentation ​                                                                                                                   ^
 ^ [[geri:​dementia:​corticobasal-degeneration-cbd]] ​      | 5 per 100,000 [([[https://​www.ncbi.nlm.nih.gov/​pubmed/​9007094|Bergeron,​ C., Pollanen, M. S., Weyer, L., Black, S. E., & Lang, A. E. (1996). Unusual clinical presentations of cortical‐basal ganglionic degeneration. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 40(6), 893-900.]])] ​ | Progressive asymmetric movement disorder with symptoms initially affecting one limb, plus cognitive or behavioural disturbances. ​       | ^ [[geri:​dementia:​corticobasal-degeneration-cbd]] ​      | 5 per 100,000 [([[https://​www.ncbi.nlm.nih.gov/​pubmed/​9007094|Bergeron,​ C., Pollanen, M. S., Weyer, L., Black, S. E., & Lang, A. E. (1996). Unusual clinical presentations of cortical‐basal ganglionic degeneration. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 40(6), 893-900.]])] ​ | Progressive asymmetric movement disorder with symptoms initially affecting one limb, plus cognitive or behavioural disturbances. ​       |
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 ^ [[geri:​dementia:​primary-progressive-aphasia-ppa]] ​    | 2.7 to 15 per 100,​000[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3637977/​|Grossman,​ M. (2010). Primary progressive aphasia: clinicopathological correlations. Nature Reviews Neurology, 6(2), 88.]])] ​                                                                                                                                                | Begins with gradual, subtle language deficits that progresses to a nearly complete inability to speak. ​                                 | ^ [[geri:​dementia:​primary-progressive-aphasia-ppa]] ​    | 2.7 to 15 per 100,​000[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3637977/​|Grossman,​ M. (2010). Primary progressive aphasia: clinicopathological correlations. Nature Reviews Neurology, 6(2), 88.]])] ​                                                                                                                                                | Begins with gradual, subtle language deficits that progresses to a nearly complete inability to speak. ​                                 |
 ^ [[geri:​dementia:​progressive-supranuclear-palsy-psp]] ​ | 5.8 to 6.5 per 100,​000[([[https://​www.ncbi.nlm.nih.gov/​books/​NBK526098/​|Agarwal,​ S., & Gilbert, R. (2018). Progressive Supranuclear Palsy. In StatPearls [Internet]. StatPearls Publishing.]])] ​                                                                                                                                                           | Characterized by early postural instability,​ leading to falls, and a characteristic vertical supranuclear-gaze palsy on physical exam.  | ^ [[geri:​dementia:​progressive-supranuclear-palsy-psp]] ​ | 5.8 to 6.5 per 100,​000[([[https://​www.ncbi.nlm.nih.gov/​books/​NBK526098/​|Agarwal,​ S., & Gilbert, R. (2018). Progressive Supranuclear Palsy. In StatPearls [Internet]. StatPearls Publishing.]])] ​                                                                                                                                                           | Characterized by early postural instability,​ leading to falls, and a characteristic vertical supranuclear-gaze palsy on physical exam.  |
 +</​mobiletable>​
 </​panel>​ </​panel>​
  
-== Overlap ​==+==== Mixed Presentations ====
 Dementia is often due to more than one pathology. Some studies have shown that in a general population, 40% of patients have a combination of [[geri:​dementia:​alzheimers|]] and [[geri:​dementia:​vascular|vascular dementia]], while only 30% had pure Alzheimer'​s and 12% had pure vascular dementia (VaD). About 12% had Alzheimer'​s combined with [[geri:​dementia:​parkinsons|]] (PD) or [[geri:​dementia:​lewy-body|]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17879383|Sonnen,​ J. A., Larson, E. B., Crane, P. K., Haneuse, S., Li, G., Schellenberg,​ G. D., ... & Montine, T. J. (2007). Pathological correlates of dementia in a longitudinal,​ population‐based sample of aging. Annals of neurology, 62(4), 406-413.]])] Dementia is often due to more than one pathology. Some studies have shown that in a general population, 40% of patients have a combination of [[geri:​dementia:​alzheimers|]] and [[geri:​dementia:​vascular|vascular dementia]], while only 30% had pure Alzheimer'​s and 12% had pure vascular dementia (VaD). About 12% had Alzheimer'​s combined with [[geri:​dementia:​parkinsons|]] (PD) or [[geri:​dementia:​lewy-body|]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17879383|Sonnen,​ J. A., Larson, E. B., Crane, P. K., Haneuse, S., Li, G., Schellenberg,​ G. D., ... & Montine, T. J. (2007). Pathological correlates of dementia in a longitudinal,​ population‐based sample of aging. Annals of neurology, 62(4), 406-413.]])]
-</​WRAP>​ 
-</​WRAP>​ 
  
-===== Behavioural and Psychological Symptoms of Dementia ​=====+ 
 +==== Behavioural and Psychological Symptoms of Dementia ====
 <alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[geri:​dementia:​1-bpsd|]]**</​alert>​ <alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[geri:​dementia:​1-bpsd|]]**</​alert>​
 Behavioural and Psychological Symptoms of Dementia (BPSD) will develop in more than 90% of individuals diagnosed with dementia. Symptoms include delusions, hallucinations,​ aggression, screaming, restlessness,​ wandering, depression, and anxiety. Behavioural and Psychological Symptoms of Dementia (BPSD) will develop in more than 90% of individuals diagnosed with dementia. Symptoms include delusions, hallucinations,​ aggression, screaming, restlessness,​ wandering, depression, and anxiety.
  
 +==== Dementia, Depression, or Delirium? ====
 +{{page>​cl:​1-delirium#​dementia-depression-or-delirium&​nouser&​noheader&​nodate&​nofooter}}
  
 +===== Neuroimaging =====
 +For older patients with cognitive symptoms, neuroimaging ([[neurology:​mri|MRI]] preferred over [[neurology:​ct-scan|CT]]) is recommended if the following criteria is present:​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3516356/​|Gauthier,​ Serge et al. “Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4)” Canadian geriatrics journal : CGJ vol. 15,4 (2012): 120-6.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​32725777/​|Ismail,​ Z., Black, S. E., Camicioli, R., Chertkow, H., Herrmann, N., Laforce Jr, R., ... & CCCDTD5 participants. (2020). Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia. Alzheimer'​s & Dementia, 16(8), 1182-1195.]])]
 +  * Onset of cognitive signs/​symptoms within the past 2 years, regardless of the rate of progression
 +  * Unexpected and unexplained decline in cognition and/or functional status in a patient already known to have dementia
 +  * Recent and significant head trauma
 +  * Unexplained neurological manifestations (new onset severe headache, seizures, Babinski sign, etc.), at onset or during evolution (this also includes gait disturbances)
 +  * History of cancer, in particular if at risk for brain metastases
 +  * Risk for intracranial bleeding
 +  * Symptoms suggestive of [[neurology:​approach-normal-pressure-hydrocephalus-nph|normal pressure hydrocephalus]]
 +  * Significant vascular risk factors
 +  * Unusual or atypical cognitive symptoms or presentation (e.g. progressive aphasia)
 +===== Guidelines =====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[teaching:​clinical-practice-guidelines-cpg|]]**</​alert>​
 +
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​dementia&​nouser&​noheader&​nodate&​nofooter}}
 ===== Resources ===== ===== Resources =====
- 
 <WRAP group> <WRAP group>
-<WRAP third column> 
-== For Providers == 
-  * [[https://​www.bcmj.org/​articles/​twelve-tips-assessing-and-managing-mild-cognitive-impairment-and-major-neurocognitive|Balogh,​ K., & Wong, R. Y. (2017). Twelve tips for assessing and managing mild cognitive impairment and major neurocognitive disorder in older people. British Columbia Medical Journal, 59(3), 158-164.]] 
-  * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596200/​|Lee,​ L., Weston, W. W., Heckman, G., Gagnon, M., Lee, F. J., & Sloka, S. (2013). Structured approach to patients with memory difficulties in family practice. Canadian Family Physician, 59(3), 249-254.]] 
-</​WRAP>​ 
 <WRAP third column> <WRAP third column>
 == For Patients/​Family == == For Patients/​Family ==
 +  * [[https://​memory.ucsf.edu/​what-dementia|UCSF:​ What is Dementia?]]
   * [[https://​igericare.healthhq.ca/​|iGeriCare - Online Resource For Patients/​Family]]   * [[https://​igericare.healthhq.ca/​|iGeriCare - Online Resource For Patients/​Family]]
   * [[https://​www.rgptoronto.ca/​resources/​|Regional Geriatric Progam of Toronto Resources]]   * [[https://​www.rgptoronto.ca/​resources/​|Regional Geriatric Progam of Toronto Resources]]
   * [[https://​www.youtube.com/​watch?​v=0FE30a4J38Q|YouTube:​ 1929 - Interviews With Elderly People Throughout The US]]   * [[https://​www.youtube.com/​watch?​v=0FE30a4J38Q|YouTube:​ 1929 - Interviews With Elderly People Throughout The US]]
 +</​WRAP>​
 +<WRAP third column>
 +== For Providers ==
 +  * [[https://​journals.lww.com/​continuum/​toc/​2018/​06000|Continuum:​ Behavioral Neurology and Psychiatry June 2018, Volume 24, Issue 3]]
 +  * [[https://​www.bcmj.org/​articles/​twelve-tips-assessing-and-managing-mild-cognitive-impairment-and-major-neurocognitive|Balogh,​ K., & Wong, R. Y. (2017). Twelve tips for assessing and managing mild cognitive impairment and major neurocognitive disorder in older people. British Columbia Medical Journal, 59(3), 158-164.]]
 +  * [[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3596200/​|Lee,​ L., Weston, W. W., Heckman, G., Gagnon, M., Lee, F. J., & Sloka, S. (2013). Structured approach to patients with memory difficulties in family practice. Canadian Family Physician, 59(3), 249-254.]]
 </​WRAP>​ </​WRAP>​
 <WRAP third column> <WRAP third column>
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 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
- 
-