in the last video we covered the overall concept of dementia before talking about alzheimer's disease in particular in this video we'll pivot to the other forms of dementia that you'll need to be aware of vascular dementia dementia with lewy bodies and frontal temporal dementia it's important to keep these non-alzheimer's dementias on your differential especially when it comes to treatment as attempting to manage every form of dementia like it is alzheimer's disease can be ineffective or even harmful each form of dementia is associated with specific clinical features that can help you to differentiate between them and we'll do our best to highlight the most unique or noteworthy features of each disorder as we go first let's talk about vascular dementia this is the second most common type of dementia after alzheimer's disease accounting for around 20 of all cases it is characterized by a series of repeated strokes causing ischemic damage to the brain leading to cognitive deficits and loss of function because strokes can affect different parts of the brain to various extents vascular dementia is not associated with any specific signs or symptoms instead the clinical hallmark of vascular dementia is that it presents as a series of stepwise decreases in cognition with each drop in functional ability representing another ischemic event this stands in contrast to the gradual but relentless decline seen in alzheimer's disease imaging of the brain will often reveal multiple areas of ischemic damage of varying ages treatment with cholinesterase inhibitors and mementine can be attempted although ultimately the most important step is to address any underlying risk factors for stroke such as high blood pressure to prevent further stepwise losses of cognitive function next dementia with lewy bodies or dlb is the third most common type of dementia after alzheimer's disease and vascular dementia the namesake lewy bodies are microscopic clumps of an intracellular protein known as alpha synuclein that accumulates and causes neuronal damage similar to how senile plaques and neurofibrillary tangles are involved in the pathogenesis of alzheimer's disease one of the most unique symptoms of dementia with louis bodies is the presence of visual hallucinations we'll talk in more detail about the form that these visual hallucinations take in just a bit but for now you should link this hallmark symptom to dementia with lewy bodies by thinking of them as visual hallucinations the term visual hallucinations is just a fancy way of saying that the patient is seeing stuff that isn't there so let's use the horribly misspelled mnemonic cn stuff to list out all the other symptoms and signs that you should be looking for in this disorder first c is for cognitive deficits as you would expect from any form of dementia cognitive deficits are a key feature of dementia with lewy bodies in contrast to alzheimer's disease however memory is not necessarily the first or most prominent cognitive domain that's affected instead patients with dementia with lewy bodies tend to primarily experience deficits in other areas like attention concentration and executive functioning this often presents clinically as distractibility confusion and incoherence when trying to communicate which can easily be mistaken for delirium next n is for a neuroleptic sensitivity when patients present with hallucinations many clinicians instinctively think that they should prescribe an antipsychotic however this would be a grave error as patients who have dementia with lewy bodies are known to be exquisitely sensitive to antipsychotics and are much higher risk of developing severe side effects such as extrapyramidal symptoms confusion catatonia and even a potentially life-threatening side effect known as neuroleptic malignant syndrome for this reason antipsychotics should be strictly avoided in patients who have dementia with lewy bodies this can even be helpful diagnostically as a poor response to antipsychotics is often a clue that the patient has dementia with lewy bodies rather than a primary psychotic disorder or another form of dementia next s is for sleep behavior one of the hallmark symptoms of dementia with lewy bodies is a phenomenon known as rem sleep behavior disorder rem sleep is a stage of sleep when the most vivid dreaming occurs under normal conditions we are prevented from acting out these dreams by the muscle paralysis that also occurs during rem sleep for patients who have dementia with lewy bodies however this paralytic barrier between sleep and movement has broken down and patients will begin to act out their dreams or otherwise engage in various nighttime behaviors such as flailing thrashing yelling or crying while in bed while patients do not always remember doing these things at night their partners are often acutely aware of them so make sure to talk to collateral rem sleep behavior disorder is a very specific sign of dementia with lewy bodies and may even precede the onset of cognitive deficits by several years next t is for timing the timing of dementia's lewy bodies differs from alzheimer's disease in two key ways first it often has an earlier onset with the incidence beginning to increase after the age of 50 instead of 65 as in alzheimer's disease second it has a much more rapid cognitive decline than is seen in alzheimer's disease with cognitive deficits appearing to progress in a matter of months instead of years for this reason you should be on the lookout for dementia with lewy bodies in patients with dementia-like symptoms that first started before the age of 65 and or that appear to be progressing faster than you would expect from alzheimer's disease next u is for unstable in contrast to the progressive but steady decline seen in alzheimer's disease dementia with lewy bodies is characterized by rapid fluctuations in cognition with patients alternating between lucidity and confusion sometimes within the span of several hours a patient with this disorder may appear completely disoriented in the morning and then be entirely lucid and back to the usual self by the afternoon the waxing and waning nature of alertness and dementia with lewy bodies complicates diagnosis significantly as it can easily be mistaken for delirium and often makes clinical evaluations unreliable including cognitive tests like the mocha the fluctuating nature of this disorder is one of its clinical hallmarks so don't put too much weight on what you're seeing any one time and make sure to do multiple serial evaluations and pay close attention to what collateral is telling you next p is for parkinsonism parkinsonism is a collection of motor deficits that tend to go together including tremor muscle rigidity slow movement and postural instability while these signs are traditionally associated with parkinson's disease they play a major role in other disorders as well including dementia with lewy bodies in fact over 80 percent of patients who have dementia with lewy bodies show signs of parkinsonism on exam including a slow or shuffling gait reduced facial expressions and stiff movements for this reason a thorough motor exam should be done on every patient suspected of having dementia with lewy bodies finally h is for hallucinations as noted earlier visual hallucinations are a cardinal symptom of dementia with louis bodies and are found in most cases even during early stages of the disease these visual hallucinations are typically quite vivid and well-formed with people or animals being a common theme such as seeing a bunch of mice walking in a line across the floor compared to schizophrenia patients are not typically bothered by these hallucinations in the same way that a psychotic patient is bothered by their voices in addition patients who have dementia with lewy bodies often have insight into the fact that these hallucinations are not real representations of the world look for these subtle nuances when evaluating a patient suspected of having dementia with lewy bodies to help confirm the diagnosis dementia with lewy bodies is rarer than alzheimer's disease with only around 0.5 percent of people above the age of 65 having this diagnosis men and women appear to be equally affected the prognosis for this disease is generally poor even compared to other forms of dementia with high rates of disability poor quality of life and death the survival time appears to be less than for alzheimer's disease with only around four years of life expectancy from the time of diagnosis as with alzheimer's disease treatment of dementia with lewy bodies is palliative rather than curative there are no specific medication treatments for dementia with lewy bodies with most drugs being borrowed from other conditions such as using acetylcholinesterase inhibitors to treat cognitive dysfunction or anti-parkinson's drugs to treat motor symptoms however these medications are generally less effective when used for dementia with lewy bodies and often impose a heavy side effect burden for this reason the focus of treatment should be similar to alzheimer's disease helping the patient to maximize their functional ability while working with family to provide support and create a safe environment next frontotemporal dementia or ftd is a form of dementia characterized by degeneration of the frontal and temporal lobes of the brain in most cases this leads to a syndrome characterized not only by a decline in cognition but also by a prominent pattern of inappropriate and impulsive behavior you can use the mnemonic oh dear to remember the key features of this disorder first o is for obliviousness one of the earliest signs of frontotemporal dementia is an impairment in social ability that manifests as a lack of empathic ability and an obliviousness to the emotions of other people this often leads to behavior that ranges from merely upsetting or embarrassing such as making refeeded social faux pas or saying things in an incredibly awkward or tactless way all the way to even physically hurting other people or violating their boundaries without seeming to care too much about having done this unlike the antisocial behavior seen in psychopathy this obliviousness to the emotions of others is unintentional and is a notable change from previous patterns of social interaction next h is for hyper orality hyperorality is a distinct pattern seen in frontal temporal dementia with patients often trying to put things into their mouths sweets and other carbohydrate-rich foods are a common target although in some cases this can involve other things including even inedible objects other dietary changes such as eating the same food over and over to the exclusion of all other foods are often seen as well next d is for disinhibition the frontal lobe is the part of the brain that says no to the base or instincts of the rest of the brain when it becomes dysfunctional it loses the ability to rein in these inappropriate impulses leading to a pattern of disinhibited pleasure-seeking and often inappropriate behavior in addition to the hyper orality noted earlier behavior in front of temporal dementia is often hypersexual such as taking off clothes in public grabbing body parts or sexually propositioning others at extremely inappropriate times like while at work or at a family function next e is for executive dysfunction the most profoundly affected cognitive domain in frontotemporal dementia is executive function with many of the higher order functions of the brain like engaging in complex planning learning new information and thinking abstractly being lost in contrast memory and visual spatial abilities are relatively preserved compared to alzheimer's disease and there isn't the same fluctuation in cognitive symptoms as is scene in dementia with louis bodies next a is for apathy when not engaging in impulsive hyper oral or hypersexual behavior patients with frontotemporal dementia often show a profound apathy and don't appear to care what is going on around them this is often accompanied by a deep inertia or a lack of purposeful or goal-directed activity this combination of apathy and inertia can be incredibly disconcerting to family and friends and in some cases it may be mistaken for depression finally r is for repetitive behavior patients with frontal temporal dementia often show a pattern of ritualistic stereotyped or compulsive behavior the specific behaviors can vary from simple movements such as pacing tapping or picking at one's skin to more involved actions such as hoarding food cleaning the same spot over and over or calling the same person on the phone repeatedly speech can also become restricted and stereotyped such as repeating the same phrase or sound for minutes or hours on end in addition to these core signs and symptoms a variety of exam findings suggestive of upper motor neuron damage can be seen these include frontal release signs like the babinski sign which are normally seen only in very young infants whose frontal lobes have not yet fully developed frontotemporal dementia is an uncommon cause of dementia and accounts for less than 10 of all cases however it tends to begin between the ages of 45 and 65 moving it higher on your differential in cases of early onset dementia men and women appear to be equally affected although studies on this are inconsistent like other forms of dementia frontal temporal dementia is progressive with a generally poor prognosis the average survival time from the point of diagnosis is between 2 and 10 years with many patients ending up dependent upon caregivers in the final years of life treatment is primarily symptomatic rather than curative given that cholinergic neurons are not involved like they are in alzheimer's disease cholinesterase inhibitors have little effect here instead medication management of frontotemporal dementia typically involves serotonin boosting medications like ssris as some evidence suggests that they are helpful for improving behavior antipsychotics are also used at times but they are not very effective and come with many side effects so they should generally be seen as an option of last resort instead the main form of treatment involves providing caregiver support and creating a safe environment for not only the patient but their family as well okay we've covered a lot in these last two videos on dementia the best way to make sure you've truly learned the information is to test your knowledge through clinical cases and practice questions my book memorable psychiatry has dozens of practice questions as well as some detailed discussions on differential diagnosis so consider picking that up to learn more in the meantime subscribe to the channel for more videos like this thanks again for watching