DETEKSI DINI GANGGUAN KOGNITIF AKIBAT GANGGUAN VASKULAR

Diatri Nari Lastri Divisi Neurobehavior Departemen Neurologi FKUI-RSCM

Introduksi
Populasi usia lanjut: 1 sampai 2% menjadi demensia pertahun

Populasi Mild Cognitive Impairment population: 6 to 25% per tahun menjadi dementia 50% dalam 3-5 tahun menjadi demensia

Diagnosis dini gangguankognitif sangat penting untuk mencegah penurunan kognitif yang lebih buruk lagi
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Introduksi
Lebih dari 34% kasus demensia menunjukkan gambaran patologis vaskular yang bermakna.1 Faktor risiko vaskular2
Risiko menjadi CVD Risiko terjadinya gangguan kognitif

Strong interaction between cerebrovascular and AD pathologies. Individuals having both frequently show greater cognitive impairment than those having either pathology alone.3
1. Arch Neurol. 2003; 60:569-575 J Neurol Sci.2004;226:13-17 2. Arch Neurol. 2005; 62:1556-1560 J Am Geriatr Soc. 2005;53:1101-1107 3. J Am Geriatr Soc. 2004;52:1442-1448 Ann Neurol. 2005;57:98-103
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Vascular Cognitive Impairment

Vascular Cognitive Impairment (VCI) gangguan kognitif yang disebabkan atau berhubungan dengan faktor-faktor vaskular
Hachinski VC, Bowler JV. Vascular Dementia. Neurology. 1993;43:2159-2160 Bowler JV, HachinskiVC, eds. Vascular Cognitive Impairment. Oxford University Press; 2003

Faktor risiko vaskular dapat dikendalikan Kemungkinan untuk mencegah, memperlambat, dan menghentikan VCI dementia
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Vascular Cognitive Impairment

Individu dengan faktor risiko vaskular (hipertensi, diabetes, gagal jantung, dan dislipidemia) sering mengalami gangguan fungsi kognitif dibandingkan individu normal Penyandang hipertensi memiliki skor kognitif yang lebih rendah dibanding individu normal Kekerapan gangguan kognitif penyandang hipertensi meningkat 7- 9% bila tekanan darah tidak terkontrol Sidi P, Puskesmas Tebet dan Pasar Minggu: 84% penyandang hipertensi menunjukkan gangguan kognitif non demensia (MMSE dan CERAD)
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Vascular Cognitive Impairment

The Continum of Cognitive Decline

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Vascular Cognitive Impairment

Gangguan Kognitif karena CVD Subcortical Ischemic Vascular Disease (SIVD)
Gambaran yang tersering Meningkat dengan pertambahan usia dan faktor risiko vaskular

Gambaran SIVD:
Gangguan fungsi eksekutif / fleksibilitas mental Perlambatan kognitif Depresi dan Apati

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NINDS Neuroimaging Criteria for VaD

Topography
Large vessel stroke Extensive white matter change Lacunes (frontal/basal gangglia) Bilateral thalamic lesions

Severity
Large vessel lesion of dominant hemisphere Bilateral strokes WML > 25% white matter
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Brain Imaging of VaD

3 types of VaD

Multiple large vessel infarcts

Bilateral strategic thalamic infarcts

Binswanger s disease

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Hiperintensitas Subkortikal

None

Mild

Moderate

Severe

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Vascular Cognitive Impairment

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) and hereditary cerebral hemorrhage with amyloidosisDutch type (HCHWA-D). CADASIL is a syndrome of subcortical small vessel disease
lacunar strokes Migraine dementia

The disease results from mutations in the Notch 3 gene which is normally expressed in vascular smooth muscle cells and pericytes (including those of the cerebral vasculature)

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VaD: VaD: A Heterogeneous Disorder

Cardiovascular Risk Factors
Hypertension Diabetes Genetics Hypercholesterolemia Heart Disease

Ischemic Damage to Cerebral Vasculature

Multiple Distinct Pathologies

Large Vessel Infarcts
Strategic Single Infarcts Multi-infarct Dementia

Small Vessel Infarcts

Multiple Lacunar Binswanger s Disease CADASIL

Hemorrhage
Chronic SDH SAH ICH

Hypoperfusion
Global (e.g., cardiac arrest) Hypotension

Final Common Pathway

Damage to critical cortical and subcortical structures q Cholinergic transmission Damage/interruption of subcortical circuits and projections

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PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR Erkinjuntti T. CNS Drugs, 1999.12 ASTON RASUNA JAKARTA

VaD

VCI/VaD: VCI/VaD: Pathology and Clinical Presentation

Pathology
Lesion location Neurological signs and symptoms

Large vessel disease

Large cortico-subcortical corticoinfarcts Focal

Small vessel disease

Subcortical infarcts in strategic locations (e.g., thalamus) 40% No focal signs or mild UMN signs (e.g., arm drift, etc.)

Dementia-related changes
Cognition
Executive dysfunction (slowing, initiation, planning, organizing, sequencing, monitoring, set shifting, abstraction, judgement) Memory impairment: cortical dysfunction (aphasia, apraxia, agnosia, visuospatial dysfunction)

Memory impairment

Common

Classic

Personality Insight Affective/mood disturbances

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Preserved until late Retained until late Less common (although some depression)

Change Can be impaired Depression, apathy, anxiety, emotional lability

13 Cummings JL. Dementia, 1994.

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Diagnostic Approach: Clinical Evaluation

Demographics
The minimum data: sex, birth date, race/ethnicity and education

Informant
Basic information regarding the informant s demographics

Family history
First degree relatives for a history of stroke, vascular disease or dementia

Health history
Historical question concerning cardio/cerebrovascular conditions, hypertension, hyperlipidemia, DM, alcohol-tobaco use, physical inactivity, and medication

Evaluation
Individual general health Changes in memory, speed of thinking and acting, or mood Functional abilities instrumental activities of daily living
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Diagnostic Approach of VCI

Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated

Canadian Consensus Conference on Dementia: Dementia:

Memory Complaints should be evaluated and the individual followed to assess progression (B) Complaints should be considered very seriously if confirmed by caregivers / informants. Cognitive assessment and careful follow-up is recommended (A)
Petterson: Can J. Neuro Sci; 28 (Suppl 1) 5:3-16
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Diagnostic Approach of VCI Sign and Symptoms

Physical Neurologic Deficits Disturbances of gait (slow and unsteady) Hyperreflex, extensor plantar response Hemiparetic Hemisensory deficits Visual problems Pseudobulbar syndrome (dysarthria, dysphagia, etc)
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Mental Status
Level alertness Orientation Attention, cooperation Language Memory: recent memory, remote memory Visuospatial Executive Function Delusions, hallucination, mood
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NEUROPSYCHOLOGICAL BATTERY FOR VCI

There is no generally accepted test battery for identifying or classifying patients with VCI Deficits:
Large vessel cortical strokes
Region specific syndromes: aphasia, apraxia, amnesia

Subcortical small vessel disease

Subtle and temporally progressive deficits Deficits in strategic processing and speed : attention, planning, memory

Patients may perform :

normally on simple tasks reveal deficits as tasks increase in complexity

Neuropsychological testing for VCI testing executive function

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Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir Hachinski Stroke 2006;37;248-255.
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Criteria for Neuropsychological Test Selection

The pattern of VCI cognitive deficits may include all cognitive domains, specifically executive function: Slowed information processing Impairment in the ability to shift from one task to another Deficits in the ability to hold and manipulate information (i.e., working memory)

Neuropsychological protocols must therefore sensitive to wide range of abilities and especially attuned to the assessment of executive function
Stroke 2006;37;2220-2241
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NEUROPSYCHOLOGICAL BATTERY FOR VCI

There is no generally accepted test battery for identifying or classifying patients with VCI Deficits:
Large vessel cortical strokes
Region specific syndromes: aphasia, apraxia, amnesia

Subcortical small vessel disease

Subtle and temporally progressive deficits Deficits in strategic processing and speed : attention, planning, memory

Patients may perform :

normally on simple tasks reveal deficits as tasks increase in complexity

Neuropsychological testing for VCI testing executive function

Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir Hachinski Stroke 2006;37;248-255. PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR
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Fungsi Eksekutif
Melibatkan area frontal subkorikal Fungsi:
Inisiasi Planning Shifting of idea Abstraksi Problem solving Inhibisi, dll

Kemampuan kognitif kompleks (tingkat tinggi)

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NEUROPSYCHOLOGICAL BATTERY FOR VCI

MMSE is often insensitive to the effects of subcortical small vessel disease, particularly in the earlier stages because the MMSE is to a great deal dependent on over learned abilities, which are relatively spared in VCI. Tests that would be most sensitive to VCI are those that require strategic processing:
verbal learning tests particularly ones that include recall as well as recognition measures VCI patients generally perform better overall on tests of verbal recall than do AD patients, so that these tests cannot be considered selective for VCI verbal fluency tests which also are considered measures of strategic processing VCI patients performed less well on these tests than did AD patients

Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir Hachinski

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Stroke 2006;37;248-255.
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NEUROPSYCHOLOGICAL BATTERY FOR VCI

Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated

Canadian Consensus Conference on Dementia: Dementia:

Memory Complaints should be evaluated and the individual followed to assess progression (B) Complaints should be considered very seriously if confirmed by caregivers / informants. Cognitive assessment and careful follow-up is recommended (A)
(Patterson: Can J. Neuro Sci 2001; 28 (Suppl. 1) S 3-16).
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Cognitive profiles
Vascualar Dementia/VCI
Executive problems Attention Psychomotor speed Emotional lability Apraxia Aphasia Depression

Alzheimer s disease/MCI
Anterograde memory Spatial abilities Gait and motor OK

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Screening for VCI/VaD VCI/VaD

Dementia screening tools (AD): MMSE MOCA Clock drawing Trails B Luria kinetic melody (hand test) Questioning of patient/caregiver about activities of daily living Identification of symptoms of executive dysfunction
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Montreal Cognitive Assessment (MOCA)

Comprehensive Many more domains than MMSE Comprehensive: (good for AD and non AD) Minor adjustment for education (add 1 point if grade 12) Much better discrimination Normal vs MCI and Dementia 26 < 26 < 26 (usually 21-25) (usually < 20) function OK function affected

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Montreal Cognitive Assessment (MOCA)

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Montreal Cognitive Assessment (MOCA)

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MoCAMoCA-Ina
Penelitian Departemen Neurologi FKUI-RSCM (2009) FKUI Uji validitas dan Reliabilitas Montreal Cognitive Assesment Versi Indonesia (MoCA-INA): Dr. Nadia Husein (dr. Sylvia FL, dr. Yetty R) Uji Validitas (transkultural) Penamaan:
Singa Gajah

Memori:
Beludru Sutera Aster Anggrek Gereja Masjid

Kelancaran berbahasa:
F S

Modifikasi pengulangan kalimat

Reliabilitas
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NEUROPSYCHOLOGICAL BATTERY FOR VCI Grooved Pegboard Test

a method for evaluating psychomotor function by measuring how quickly a subject can insert pegs into

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NEUROPSYCHOLOGICAL BATTERY FOR VCI

STROOP TEST
Anatomical basis The cingulate cortex has been related to the processing of the Stroop effect EEG and Functional neuroimaging studies of the Stroop effect :
have consistently revealed activation in the frontal lobe more specifically in the anterior cingulate cortex and dorsolateral prefrontal cortex

two structures hypothesized to be responsible for conflict monitoring and resolution.[

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NEUROPSYCHOLOGICAL BATTERY FOR VCI TRAIL MAKING TEST A

The Trail-making test is a neuropsychological test of visual attention and task switching. The task requires a subject to 'connect-the-dots' of 25 consecutive targets on a sheet of paper or computer screen. The goal of the subject is to finish the test as quickly as possible, and the time taken to complete the test is used as the primary performance metric.

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NEUROPSYCHOLOGICAL BATTERY FOR VCI TRAIL MAKING TEST B

Associated with many types of brain impairment; in particular frontal lobe lesions The task requires a subject to 'connect-the-dots' in which the subject alternates between numbers and letters (1, A, 2, B, etc.). The goal of the subject is to finish the test as quickly as possible, and the time taken to complete the test is used as the primary performance metric.

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NEUROPSYCHOLOGICAL BATTERY FOR VCI FUNGSI EKSEKUTIF

ROCFT Planning Alternating pattern Shifting of Idea

Luria kinetic melody (hand test) Keterampilan psikomotor

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NEUROPSYCHOLOGICAL BATTERY FOR VCI SKRINING TES LURIA NEBRASKA (STLNB)

Pemeriksaan skrining neuropsikologi multi domain 15 pertanyaan:
Atensi/konsentrasi Memori Visuospasial Bahasa Fungsi eksekutif

Waktu: 20 menit Total skor 0-7: Normal Total skor 8 : Gangguan kognitif
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SIMPULAN
Faktor risiko vaskular merupakan risiko gangguan kognitif Diagnosis dini gangguan kognitif sangat penting untuk mencegah dan memperlambat terjadinya demensia

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