Paulus Anam Ong Memory Clinic - Hasan Sadikin Hospital Bandung Padjadjaran University - Indonesia
Outline of Presentation
Introduction Aging in Indonesia Progression of normal aging to MCI Early detection is the main role Clinical Diagnostic of MCI Definition of MCI Clinical diagnostic of MCI MMSE CDR GDS
Conclusion
Aging in Indonesia
(WHO, 1998)
60000 50000
N (1000s) 40000
Indonesia
The 4th populous elderly after China, India and South America We will encounter large numbers of dementia cases in the future Massive medical, social, and economic problems in the future
.
Brain Aging
Normal Cognition
R e v e r s i b l e
Prodromal Dementia
Dementia
Other Dementias
Alzheimers Disease
Vascular Dementia
Progression of normal aging to dementia A minority of persons diagnosed with MCI remain stable or improve over time The majority of declining MCI patients convert to AD, besides mixed with vascular and other dementia
Golumb J, Kluger A, Ferrsis SH. Mild Cognitive Impairment: Identifying and treating the earliest stage of Alzheimer s disease
Early detection of MCI cases is the main role Correct diagnosis in its early stages can be: Beneficial of treatment Prevent costly and inappropriate treatment resulting from misdiagnosis Give patients and families time to prepare for the challenging financial, legal, and medical decisions that may lie ahead.
Definition of MCI
Memory Complaints confirmed by an informant Normal activities of daily living General cognitive preserved Abnormal memory for age and education norms (1,5 SD below normative values ) Not demented
MCI Tenets :
Not all MCI represent AD All AD patients go through an MCI stage AD symptoms progress from MCI to greater severity of dementia Conversions ( MCI to AD ) is a clinical construct
AD
Quality of clinical information ( informants ) and labeling threshold of clinician determines diagnosis
Clinical approach :
CCVD and risk factor Endocrine disorders Chronic infections Life style
General neurologic history Specific conditions Which could be responsible for dementia
Clinical approach :
Psychiatric history :
Clinical approach :
Vital signs Risk factor for vascular events Metabolic and endocrine
Neurological examination
Neuropsychological examinations
Minimental State Examination ( MMSE ) : u 24 Clinical Dementia Rating Scale ( CDR ) 0,5
Memory Orientations Judgment and problem solving Community affairs Home and hobbies Personal care
Screening test to provide brief, objective measure of cognitive function. Administered in 10-15 minutes, scores 10range from 0 to 30
No
Tes ORIENTASI Sekarang (tahun), (musim), (bulan), (tanggal), hari apa? Kita berada dimana? (negara), (propinsi), (kota), (rumah sakit), (lantai/kamar) REGISTRASI Sebutkan 3 buah nama benda ( Apel, Meja, Koin), tiap benda 1 detik, pasien disuruh mengulangi ketiga nama benda tadi. ATENSI DAN KALKULASI Kurangi 100 dengan 7. Nilai 1 untuk tiap jawaban yang benar. Hentikan setelah 5 jawaban. Atau disuruh mengeja terbalik kata WAHYU
1 2
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6 7 8 9 10 11
2 1 3 1 1 1 30
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Penilaian MMSE
Nilai: 24 -30: Tidak ada gangguan kognitif 17 -23: Probable gangguan kognisi 0 - 16: Definite gangguan kognisi
Most widely accepted screening test Good internal consistency Good test-retest reliability testHigh validity: good sensitivity and specificity Correlates well with other screening tests e.g. clock drawing test and Short Blessed test Can be used for diagnostic, follow up, measurement of therapeutic outcome
An integrated approach to the management of AD. Eur J Neurol.5 (suppl 4). S9-17
Limitation
Confounded by age, education and culture.
Highly educated people with obvious dementia may score 27 or above (ceiling effect) Non demented subjects with modest educational attainment may score as low as 24 (floor effect)
Can not be used as a single tool for diagnosis and it has to be interpreted within context of clinical history and examination
Useful in quantitatively estimating the severity of cognitive impairment ...in serially documenting cognitive change
SemiSemi-structured interview with the patient/subject and a well-informed wellcollateral source (informant). For diagnosis, staging, and changes (for clinical trial) More than 90% sensitivity and specificity. Validated against neuropathology information (Morris et al, 1988) One of the Gold Standard of Global rating of dementia in trial of patients with AD
Advantages of CDR
Face validity: measures decline relative to the validity: individual that interferes with usual functions Multidimensional Clinically meaningful, even when neuropsychological test is normal Avoids confounds factors e.g. education, age; age; practice effects that affect cognitive tests Less affected by ceiling and floor effects Reliable
Morris JC, Clinical Dementia Rating, 3rd Asia-Pacific Regional Meeting of !WGH, Bangkok 24th -26th March 2004
Disadvantages of CDR
Rely on availability of a good collateral source (eg. caregiver) (eg. Interviews are time-consuming timecompared to brief cognitive tests Require clinical judgment
Morris JC, Clinical Dementia Rating, 3rd Asia-Pacific Regional Meeting of !WGH, Bangkok 24th -26th March 2004
0.5
Questionable
1
Mild
2
Moderate
3
Severe
Memory Orientation Judgment and problem solving Community Affairs Home & Hobbies Personal Care
Moderate memory lose; more marked for recent events; defect interferes with everyday activities
Severe memory loss; only highly learned material retained, new material rapidly lost Usually disoriented to time, often to place
Orientation
Fully oriented
Some difficulty with time relationship; oriented for place& person at examination, but may have geographic disorientation
Moderate difficulty in handling problem, similarities and differences; social judgement usually maintained
Severely impaired in handling problems, similarities and differences; social judgement usually impaired
Community affair
Unable to function independently at these activities although may still be engaged in some; appears normal to causal inspection
No pretense of independent function outside home. Appears well enough to be taken to functions outside a family home
No pretense of independent function outside home. Appears too ill to be taken to functions outside a family home
Mild but definite impairment of function at home; more difficult chores abandoned; more complicated hobbies and interest abandoned Needs prompting
Personal care
CDR
Diagnosis
Three classification
No dementia = CDR 0 Uncertain dementia = CDR 0.5 (questionable dementia / MCI) Dementia
CDR
= = = =
..for subjects who are neither clearly demented nor healthy. Many in this group have syndromes compatible with the benign senescent forgetfulness of Kral while others probably have normal cognitive function but may be mildly depressed or concerned over minor forgetfulness. Still others are probably in an early stage of SDAT Hughes et al. Brit J Psychiat 1982;140;566-572
Morris JC, Clinical Dementia Rating, 3rd Asia-Pacific Regional Meeting of !WGH, Bangkok 24th -26th March 2004
A seven-point rating scale sevenStage 1: normal cognitive capacity Stage 2: normal aging Stage 3: mild memory impairment (MCI) Stage 4: Mild AD Stage 5: Moderate AD Stage 6:Moderately severe AD Stage 7: Severe AD
1 No Subjective complaints of memory deficit Normal No memory deficit evident on clinical interview 2 Subjective complaints of memory deficit, Normal Most frequently in the following areas: aging forgetting where one has placed familiar objects forgetting names one formerly knew well No objective evidence of memory deficits on clinical interview No objective deficit in employment or social situations Appropriate concern with respect to symptomatology
Earliest subtle deficits Manifestations in more than one of the following areas: patient may have become lost when traveling to an unfamiliar location Mild memory Co-workers become aware of patients relatively poor performance impairme Word and name finding deficit become evident to intimates nt Patient may read a passage or book and retain relatively little material Patient may demonstrate decrease facility for remembering names upon introduction to new people Patient may have lost or misplaced an object of value Concentration deficit may be evident on clinical testing Objective evidence of memory deficit obtained only with an intensive interview Deceased performance in demanding employment and social setting Denial begins to become manifest in patients Mild to moderate anxiety frequently accompanies symptoms
Clear-cut deficit on careful clinical interview Deficit manifest in following areas: Mild AD Decrease knowledge of current and recent events May exhibit some deficit in memory of ones personal history Concentration deficit elicited on serial subtractions Decreased ability to travel, handle finances, etc Frequently no deficit in the following areas: Orientation of familiar persons and faces Ability to travel to familiar locations nability to perform complex task Denial is dominant defence mechanism Flattering of affect and withdrawal from challenging situation occur
Patient can no longer survive without some assistance Patient is unable during interview to recall a major relevant aspect of their current life. For example: Moderate Their address or telephone number for many years AD The names of closes members of their family (e.g grandchildren) The name of the high school or college from which they graduated Frequently some disorientation to time (date, day of the week, season, etc) or to place An educated person may have difficulty counting back from 40 by for fours or from 20 by twos Person at this stage retain knowledge of many major facts regarding themselves and others They invariably know their own names and generally know their spouses and childrens names They require no assistance with toileting or eating, but may have difficulty choosing the proper clothing to wear
May occasionally forget the name of the spouse upon whom they are entirely dependent for survival Moderately Will be largely unaware of all recent events and experiences in their lives severe Retain some knowledge of their surroundings; the yea, the season etc AD May have difficulty counting by ones from 10, both backward and sometimes forward Will require some assistance with activities of daily living May become incontinent Will require travel assistance but occasionally will be able to travel to familiar location Diurnal rhythm frequently disturbed Almost always recall their own name Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment
Personality and emotional changes occur, these are quite variable and include: Moderately Delusional behaviour (eq, patients may accuse their spouse of being an imposter; may talk to imaginary fiqures in the environment, or to severe their own reflection in the mirror) AD Obsessive symptoims (eg. Person may continually repeat simple cleaning activities) Anxiety symptoms, agitation, and even previously non-existent violent behaviour may occur Cognitive abulia (eg. Loss of willpower because an individual can not carry a thought long enough to determine a purposeful course of action)
All verbal abilities are lost over the course of this stage Early in this stage words and phrases are spoken but speech is very circumscribed Moderately Later there is no speech at all- only babbling severe Incontinent of urine, requires assistance toileting and feeding AD Basic psychomotor skill (eq, abililty to walk), are lost with the progression o this stage (sambunga The brain appears to no longer be able to tell the body what to do n) Generalized and cortical neurological signs and symptoms are frequently present
Reisberg B, Ferris FH, de Lean MJ et al. The global deterioration scale for assessment of primary degenerative dementia
The best diagnostic test is a careful history and physical and mental status examination by a physician with a knowledge of and interest in dementia and the dementing disease. Such an evaluation is time consuming, but nothing can replace it
Differential diagnosis of dementing diseases.NIH Consensus Statement. JAMA 1987, 258:3411-3416 258:3411-
Conclusion
1. Early detection and correct diagnosis in early stages can be beneficial of:
Treatment efficacy Preventing costly and inappropriate treatment resulting from misdiagnosis Giving patients and families time to prepare for the challenging financial, legal, and medical decisions that may lie ahead
Conclusion
2. The best diagnostic test is a careful history, physical and mental status examination by a physician with a knowledge of and interest in dementia and the dementing disease. Such an evaluation is time consuming, but nothing can replace it
1. Memory impairment * 2. Aphasia (language disturbance) 3. Agnosia (impaired recognition/knowledge) 4. Apraxia (disability in performance of previously learned skills or tasks) 5. Executive dysfunction
Laboratory testing
Urinalysis Complete blood count, ESR Liver enzymes BUN, creatinin Electrolytes, blood glucose Vitamin B12, folic acid TSH, free thyroid index Syphilis serology, HIV testing, ApoE?
Ya TIDAK
Penilaian SDG 15
Skor: Hitung jumlah jawaban yang bercetak tebal dan huruf besar
Setiap
jawaban bercetak tebal dan berhuruf besar mempunyai nilai 1 Skor antara 5-9 menunjukkan kemungkinan besar depresi Skor 10 atau lebih menunjukkan depresi
Cognitive Progression
Presymptomatic
Neuropsychological
MCI
Progression
Functional