Dementia: A Comprehensive Update

Learning Objectives

• Describe current understanding of epidemiology, risk factors, pathobiology, societal costs, clinical differences, gaps in knowledge, and challenges in distinguishing and managing the spectra of normal cognitive aging, mild cognitive impairment (MCI), Alzheimer’s disease (AD), and other neurodegenerative dementias.
• Summarize tiered diagnostic and management approaches, including the new Clinical Practice Guidelines sponsored by the Alzheimer's Association for the diagnostic evaluation of patients with cognitive impairment. Summarize current and future experimental therapeutics strategies under consideration for risk reduction, prevention, diagnosis and treatment of the AD spectrum.
• Differentiate, based on neuropathology, affected neural systems, clinical criteria and biomarkers, AD and its atypical variants from other common dementias including Dementia with Lewy Bodies (DLB), Vascular Cognitive Impairment (VCI)/Vascular-Ischemic Dementia, Frontotemporal Degeneration (FTD), Parkinson’s disease with Dementia (PDD), Parkinson’s-Plus Syndromes and less common dementias.
• Identify and explain the importance of evidence-based and coordinated individualized approaches to the evaluation and management of MCI, AD and neurodegenerative dementias that stress combining: (i) early and accurate detection, assessment and monitoring; (ii) psycho-education and non-pharmacological interventions; (iii) pharmacological strategies; and (iv) caregiver, psychosocial/environmental, quality of life, ethical, medico-legal and end-of-life considerations.
• Apply data-supported diagnostic, behavioral, pharmacological, and environmental strategies, including appropriate and tiered use of cognitive tests/measures, labs, and imaging studies/biomarkers; and delineation of expectations, roles (i.e., indications and benefits), cautions (i.e., risks, side-effects, warnings) and treatment nuances in the interdisciplinary management of CI, AD and neurodegenerative dementias.
• Explain the roles of office-based screening instruments, mental status exam (MSE) and neuropsychological evaluation in the diagnosis and management of dementia; develop efficient approaches to MSE and use of screening instruments (e.g. MOCA); and interpret and compare cognitive testing/neuropsychological performance patterns for different conditions and clinical syndromes (e.g. MCI, AD, FTD, primary progressive aphasias, posterior cortical atrophy, DLB).
• Utilize appropriate laboratory tests, imaging studies, and neuropsychological testing for the diagnosis of dementia in clinical practice; incorporate appropriate use of clinical biomarkers (e.g. CSF a-beta/tau, MRI, FDG- and Amyloid-PET) in evaluation of neurodegenerative dementias to differentiate AD and non-AD processes; and explain clinical versus research use, and apply appropriate use criteria/guidelines for the clinical use of biomarkers in the diagnosis of AD-like syndromes.
• Apply data-supported pharmacologic management strategies including the roles (i.e., indications and benefits), cautions (i.e., risks, side-effects, warnings) and potential alternatives to using cholinesterase inhibitors, memantine, antipsychotics and antidepressants in dementia and AD.
• Integrate a holistic approach to management of problem behaviors and neuropsychiatric symptoms (e.g. aggression, apathy, anxiety, depression, psychosis) in individuals with dementia that stresses education, and behavioral and non-pharmacological interventions as first-line approaches.
• Discuss the important role, and the challenges and risks caregivers face; describe strategies to help dementia caregivers cope and better care for themselves and for patients with dementia including psychosocial counseling, community support resources, and respite care.
• Develop appropriate practices concerning medico-legal and safety issues surrounding patients with dementia, including capacity with regards to medical care, finances, contracts, independent living, and driving; and integrate medico-legal and safety practices to support and safeguard patients and families, and the public-at-large.
• Describe issues related to dementia neuroethics, and implement effective practices in the long-term care/nursing-home environment and in end-stage dementia regarding medical, legal, and ethical issues including recognition and treatment of delirium/encephalopathy and pain, providing palliation and hospice care, and managing end-of-life issues related to dementia.
• Demonstrate neural processes and functional networks that support perception and cognitive systems including memory, language, attentional, frontal/executive, visuo-spatial, and motor systems.
• Distinguish pre-clinical AD, MCI due to AD/prodromal AD, and AD dementia phases.
• Identify delirium/encephalopathy and Chronic Traumatic Encephalopathy(CTE) as a dementia risks or entities.