Quick Start: Vitamins, Herbs, Supplements, and Antiinflammatories Vitamin D: Increased risk of all-cause dementia and Alzheimer’s disease has been observed in those with vitamin D deficiency. We recommend vitamin D supplementation for our patients with vitamin D deficiency. Vitamin E: Two studies were positive in patients with Alzheimer’s disease, but both had issues and many other studies were negative. We do not recommend vitamin E for…

Quick Start: Memantine Mechanism of action and cognitive benefit Memantine (generic and Namenda extended-release [XR]) has two mechanisms of action: (1) modulating glutamate and (2) enhancing dopamine transmission. It improves attention, alertness, apathy, and global functioning. Indications and recommendations Memantine (generic and Namenda XR) is approved for patients with moderate to severe Alzheimer’s disease (about Mini-Mental State Examination <15, Montreal Cognitive Assessment <11). Generic memantine is…

Quick Start: Cholinesterase Inhibitors Mechanism of action and cognitive benefit Cholinesterase inhibitors increase the concentration of acetylcholine at the synapse and improve memory, attention, mood, and behavior. Cholinesterase inhibitors are efficacious and well tolerated. Indications and recommendations For Alzheimer’s disease dementia in mild, moderate, and severe stages, we recommend using one of the following once-a-day cholinesterase inhibitor formulations: Donepezil (generic and Aricept) pill or oral dissolving…

Quick Start: Goals for the Treatment of Memory Loss, Alzheimer’s Disease, and Dementia Treatment of Alzheimer’s disease and other causes of memory loss and dementia is best carried out in a partnership between patient, caregiver, and clinician. Current FDA approved treatments can help improve or maintain the patient’s cognitive and functional status by “turning back the clock” on memory loss. New, disease-modifying treatments are being developed…

Quick Start: Other Disorders that Cause Memory Loss or Dementia Depression and anxiety Although depression and/or anxiety may cause memory loss, many patients with memory loss and depression and/or anxiety have mild cognitive impairment or Alzheimer’s disease. Medication side effects Medication side effects are one of the most common causes of memory complaints and cognitive dysfunction. Disrupted sleep Disrupted sleep is one of the most common…

Quick Start: Creutzfeldt–Jakob Disease Definition Creutzfeldt–Jakob disease (CJD) is one of several prion transmissible neurodegenerative diseases characterized by a rapid cognitive decline that can progress to akinetic mutism over weeks. Creutzfeldt–Jakob disease is the most common type of prion disease; prion diseases are also called transmissible spongiform encephalopathies. Prion diseases have a specific neuropathology characterized by spongiform changes, neuronal death, astrocytosis, and accumulation of a pathological…

Quick Start: Chronic Traumatic Encephalopathy Definition and etiology Chronic traumatic encephalopathy is a progressive neurodegenerative disease associated with repetitive brain trauma. Pathology includes perivascular tau deposition. Cognitive and behavioral symptoms, in order of prevalence at presentation Memory impairment Executive dysfunction Attention and concentration difficulties Sadness/depression Hopelessness Explosivity Language impairment Visuospatial difficulties “Out of control” Physically violent Verbally violent Impulse control problems Suicidal ideation/attempts Summary of diagnostic…

Quick Start: Normal Pressure Hydrocephalus Definition Normal pressure hydrocephalus (often referred to as NPH) is a relatively rare disorder characterized by enlargement of the ventricles, a gait disorder, cognitive impairment, and incontinence. It is thought to result from low-grade scarring or obstruction of the ventricular system or subarachnoid pathways. Prevalence It is a relatively rare disorder, making up between 1% and 5% of patients referred to…

Quick Start: Corticobasal Degeneration And Corticobasal Syndrome Definition Corticobasal degeneration is a neurodegenerative disease of the brain caused by accumulation of hyperphosphorylated 4-repeat tau isoforms. Corticobasal syndrome is a clinical diagnosis characterized by asymmetric cortical dysfunction, which may include difficulties with motor control of a limb (apraxia), executive dysfunction, nonfluent aphasia, speech disruption, rigidity, a jerky postural tremor, myoclonus, dystonia, and a gait disorder. Not all…

Quick Start: Progressive Supranuclear Palsy Definition Progressive supranuclear palsy (often abbreviated to PSP) is a neurodegenerative disease caused by the accumulation of hyperphosphorylated tau protein isoforms in the brain. Main features include abnormalities of vertical eye movements (supranuclear palsy), along with postural instability with backwards falling, gait like “a drunken sailor,” axial rigidity, frontal lobe signs and symptoms, and eventually difficulty talking and swallowing (pseudobulbar palsy).…

Quick Start: Posterior Cortical Atrophy Definition and etiology Posterior cortical atrophy (PCA) is a clinical syndrome characterized by progressive visual and visuospatial dysfunction. Most patients present between the ages of 50 and 65 years (mean age 59 years), although some present in their 70s and 80s. Underlying Alzheimer’s disease pathology is most common. Other common pathologies include Lewy body disease and corticobasal degeneration. Prevalence Posterior cortical…

Quick Start: Behavioral Variant Frontotemporal Dementia Definition Behavioral variant frontotemporal dementia is a progressive neurodegenerative disorder with more than a dozen different pathologies. Prevalence Behavioral variant frontotemporal dementia is found in about 5% of cases of dementia. It most commonly presents in midlife, with a mean age of onset at 58 years, although it can present from the third to the tenth decade. Its prevalence reaches…

Quick Start: Primary Progressive Aphasia and Apraxia of Speech Definition and etiology Primary progressive aphasia (PPA) is a clinical syndrome characterized by progressive language dysfunction. There are three variants: Logopenic variant is most often associated with Alzheimer’s disease pathology. Semantic variant (also called semantic dementia or temporal variant frontotemporal dementia) is most often associated with TDP-43 pathology. Nonfluent/agrammatic variant (also called progressive nonfluent aphasia) is most…

Quick Start: Dementia With Lewy Bodies Definition Dementia with Lewy bodies (DLB) is a neurodegenerative disease of the brain characterized: clinically by dementia, fluctuating attention and alertness, visual hallucinations, rapid-eye movement (REM) sleep behavior disorder, and parkinsonism, and pathologically by Lewy body formation and abnormal alpha-synuclein metabolism. Mild cognitive impairment with Lewy bodies is similar to DLB but with preserved or minimally affected function. Prevalence DLB…

Quick Start: Vascular Cognitive Impairment and Vascular Dementia Definition Vascular cognitive impairment is the overarching term used when cognitive dysfunction is due to cerebrovascular disease (i.e., strokes). Vascular dementia (VaD) occurs when cerebrovascular disease causes cognitive dysfunction that significantly impairs daily functioning. Vascular mild cognitive impairment (VaMCI) occurs when cerebrovascular disease causes cognitive dysfunction that does not significantly impair daily functioning. The exact cerebrovascular disease that…

Quick Start: Limbic-Predominant Age-Related TDP-43 Encephalopathy Definition In limbic-predominant age-related TDP-43 encephalopathy (LATE), phosphorylated transactive response DNA binding protein of 43 kDa (TDP-43) is found in neuronal cytoplasmic inclusions in the setting of neuronal loss and gliosis in the amygdala, hippocampal CA1 subfield, subiculum, and sometimes inferior temporal and frontal neocortex. Some cases of LATE are associated with hippocampal sclerosis. Prevalence LATE is a common cause…

Quick Start: Primary Age-Related Tauopathy Definition In primary age-related tauopathy (PART), neurofibrillary tangles accumulate in entorhinal cortex and limbic regions without amyloid plaques or other pathology. It may be a common cause of cognitive deficits in normal aging, subjective cognitive decline, mild cognitive impairment, and mild dementia. Prevalence Because the tangles in PART cannot be distinguished from those in Alzheimer’s disease, it can only be diagnosed…

Quick Start: Alzheimer’s Disease Definition Alzheimer’s disease is a neurodegenerative disease of the brain characterized by progressive amnestic dysfunction with specific microscopic pathology including senile plaques and neurofibrillary tangles. Prevalence Alzheimer’s disease is the most common cause of dementia, affecting approximately 3% of people aged 65 to 74, 17% of people aged 75 to 84, and 32% of people aged 85 and older. Approximately two-thirds of…

Quick Start: Subjective Cognitive Decline, Mild Cognitive Impairment, And Dementia A three-step approach to evaluate patients with cognitive decline is suggested: Determining if dementia, mild cognitive impairment, or subjective cognitive decline is present Determining which clinical syndrome is present Determining the disease or diseases that are the cause. This three-step approach expands upon the two-step approach proposed in Diagnostic and Statistical Manual of Mental Disorders, 5th…

Quick Start: Evaluating The Patient With Memory Loss Or Dementia Talking with the family (or other caregivers) is critical to obtaining an accurate history. Important elements of the history to investigate include: Characterization of the onset and course of the disorder Memory loss and memory distortions Word-finding Fluctuations in attention Getting lost in a new or familiar environment Problems with reasoning and judgment Changes in behavior…