deteksi dini gangguan kognitif akibat gangguan vaskular
TRANSCRIPT
DETEKSI DINI GANGGUAN KOGNITIF AKIBAT
GANGGUAN VASKULARDiatri Nari Lastri
Divisi NeurobehaviorDepartemen Neurologi FKUI-RSCM
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Introduksi
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Populasi usia lanjut:1 sampai 2% menjadi demensia pertahun
Populasi Mild Cognitive Impairment population:6 to 25% per tahun menjadi dementia50% 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
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3. J Am Geriatr Soc. 2004;52:1442-1448 Ann Neurol. 2005;57:98-103
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
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Vascular Cognitive Impairment
“Vascular Cognitive Impairment” (VCI) gangguan kognitif yang disebabkan atau
berhubungan dengan faktor-faktor vaskular
Faktor risiko vaskular dapat dikendalikan
Kemungkinan untuk mencegah, memperlambat, dan menghentikan VCI
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Hachinski VC, Bowler JV. Vascular Dementia. Neurology. 1993;43:2159-2160Bowler JV, HachinskiVC, eds. Vascular Cognitive Impairment. Oxford University Press; 2003
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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 ImpairmentThe 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 amyloidosis-Dutch 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: A Heterogeneous DisorderCardiovascular Risk Factors
Hypertension Diabetes Genetics Hypercholesterolemia Heart Disease
Ischemic Damage to Cerebral Vasculature
Multiple Distinct Pathologies
Large Vessel Infarcts Small Vessel Infarcts Hemorrhage Hypoperfusion
• Strategic Single Infarcts• Multi-infarct Dementia
• Multiple Lacunar• Binswanger’s Disease• CADASIL
• Chronic SDH• SAH• ICH
• Global (e.g., cardiac arrest)
• Hypotension
Final Common Pathway
Damage to critical cortical and subcortical structures Cholinergic
transmission
Damage/interruption of subcortical circuits and
projections
VaD Erkinjuntti T. CNS Drugs, 1999.30/01/2011 12PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR ASTON RASUNA JAKARTA
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Neurological signs and symptoms
VCI/VaD: Pathology and Clinical Presentation
Large vessel disease Small vessel disease
Lesion location Large cortico-subcortical infarcts
Subcortical infarcts in strategic locations (e.g., thalamus)
Focal40% No focal signs or mild UMN signs (e.g., arm drift, etc.)
Dementia-related changes
Pathology
Common Classic
Preserved until latePersonalityInsight Affective/mood disturbances
Retained until lateLess common(although some depression)
Change
Executive dysfunction (slowing, initiation, planning, organizing, sequencing, monitoring, set shifting, abstraction, judgement)
Depression, apathy, anxiety,emotional lability
Memory impairment: cortical dysfunction (aphasia, apraxia,agnosia, visuospatial dysfunction)
Cognition Memory impairment
Can be impaired
Cummings JL. Dementia, 1994.30/01/2011PENYUSUNAN DRAFT DETEKSI DINI GANGGUAN KOGNITIF-VASKULAR
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Diagnostic Approach: Clinical Evaluation• Demographics
The minimum data: sex, birth date, race/ethnicity and education
• InformantBasic information regarding the informant’s demographics
• Family historyFirst degree relatives for a history of stroke, vascular disease or dementia
• Health historyHistorical 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
Canadian Consensus Conference on 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)
Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated
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Petterson: Can J. Neuro Sci; 28 (Suppl 1) 5:3-16
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Diagnostic Approach of VCISign 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)
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
Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir HachinskiStroke 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
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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 HachinskiStroke 2006;37;248-255.
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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
Stroke 2006;37;248-255.
Gabrielle G. Leblanc, James F. Meschia, Donald T. Stuss and Vladimir Hachinski
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
Canadian Consensus Conference on 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).
Any Memory Concerns Expressed by the Caregivers Should be Comprehensively Evaluated
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Cognitive profilesVascualar Dementia/VCI
• Executive problems• Attention• Psychomotor speed• Emotional lability
Alzheimer’s disease/MCI Anterograde
memory Spatial abilities Gait and motor OK Apraxia
Aphasia Depression
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Screening for 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 (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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MoCA-InaPenelitian Departemen Neurologi FKUI-RSCM (2009)• 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
a method for evaluating psychomotor function by measuring how quickly a subject can insert pegs into
Grooved Pegboard Test
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
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.[
STROOP TEST
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
• 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.
TRAIL MAKING TEST A
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
• 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.
TRAIL MAKING TEST B
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
ROCFT• Planning
Alternating pattern • Shifting of Idea
Luria kinetic melody (hand test)
• Keterampilan psikomotor
FUNGSI EKSEKUTIF
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NEUROPSYCHOLOGICAL BATTERY FOR VCI
• 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
SKRINING TES LURIA NEBRASKA (STLNB)
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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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TERIMA KASIH
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