Dementia
H&P
- symptoms onset, rapid -> CJD
- family history
- medications in use
Neurocognitive tests
- During consult: MOCA and MMSE
- Neuropsychological evaluation, especially if spanish speaking
Neurocognitive labs
- CBC, BMP (Ca), vitamins (B12, MMA, HMC, folate, D), TSH, HIV, RPR
- CBC, BMP (Ca), vitamins (B12, MMA, HMC, folate, D), TSH, HIV, RPR
- ATN profile
Neuroimaging
- Brain MRI w/ NeuroQuant
> evaluate hipoccampus size
> evaluate c/f NPH
Therapies
Donepezil
Memantine
Monoclonal antibodies
-aducanumab (Aduhelm) was dcded Jan 2024 2/2 ARIA risk
-full contraindication for TNK
-basic labs & cognitive assessment-> bMRI w/ NQ & ATN profile -> amyloid PET
*CSF only if inconclusive ATN; needs special tube
*LP, if c/f NPH
-amyloid PET
> 2 things RCTU (regional cortical tracer uptake) and BAPL (brain amyloid load)
RCTU: 1 (no cortical uptake); 2 (moderate); 3 (pronounced). In 4 areas: temporal cortex; frontal cortex; posterior cingulate and precuneus; parietal cortex
BAPL: 1 (no β-amiloid deposition); 2 (moderate); 3 (pronounced)
-lecanemab (Leqembi) vs donanemab (Kisunla)
>explain risk benefit regarding ARIA, amyloid clearance, and therapy time
-registry enrollment; ARIA surveillance tracking system
-checklist example for every infusion
>cognitive & functional assessments: MMSE/MoCA and FAQ/DSRS at baseline and q6 months while on therapy.
>amyloid PET: at baseline (when available), after ~18 months of lecanemab therapy, and after ~12 months of donanemab therapy. Use PET to measure target engagement and assess for TRAC (treatment-related amyloid clearance) to stop therapy for donanemab and guide treatment decisions for lecanemab.
>fluid-based biomarkers: not recommended for monitoring ATT response at this time.