13. Dementia and Epilepsy

Question 1

What is dementia?

Answer 1

Progressive decline in higher cortical function leading to a global impairment of memory, intellect and personality which affects the individuals ability to cope with activities of daily living.

Question 2

What are the areas of presentation of dementia?

Answer 2

Memory deficit, behavioural, physical, language disorder, visuospatial disorder, apraxia.

Question 3

What are the memory deficits in dementia?

Answer 3

Struggle to learn new information, short term memory loss.

Question 4

What are the behavioural changes in dementia?

Answer 4

Personality, disinhibition, labile emotion, wandering.

Question 5

What are the physical changes in dementia?

Answer 5

Incontinence, reduced oral intake, difficulty swallowing.

Question 6

What are the language disorders of dementia?

Answer 6

Anomic aphasia, difficulty understanding language.

Question 7

What are the visuospatial disorders of dementia?

Answer 7

Unable to identify visual and spatial relationships between objects.

Question 8

What are the apraxic features of dementia?

Answer 8

Difficulty with motor planning so inability to perform learned purposeful movements.

Question 9

What investigations are needed in dementia?

Answer 9

Full history and mini mental score examination; full neurological examination; blood tests; CT/MRI of head; memory clinic follow up.

Question 10

What is the difference between presentation of delirium and dementia?

Answer 10

Delirium has altered mental state but dementia doesn’t.

Question 11

What does the confusion assessment method look at?

Answer 11

Acute change of fluctuating mental status, altered consciousness, inattention, disorganised thinking.

Question 12

How does the rate of progression of cognitive decline differ in vascular, Alzheimer’s, and lewy body dementia?

Answer 12

Vascular - steady until next vascular insult then sudden decline to new steady state.
Alzheimer’s - consistent rate of fast decline.
Lewy body - fluctuates, can even improve for some time.

Question 13

What are the macroscopic features of Alzheimer’s disease?

Answer 13

Loss of cortical and subcortical white matter - gyral atrophy, narrow gyri, wide sulci. Ventricular dilation from loss of white matter.

Question 14

What is the microscopic pathology of Alzheimer’s disease?

Answer 14

Amyloid-beta plaques, neurofibrillary tangles.

Question 15

What are the three stages of Alzheimer’s disease?

Answer 15

Mild for 2-4 years, minor memory loss; moderate for 2-10 years, withdrawn and confused; severe for 1-3 years, incapacitated, don’t recognise people, can be violent.

Question 16

What is the pathology of dementia with lewy bodies?

Answer 16

Lewy bodies in cortex and substantia nigra.

Question 17

What are the clinical features of dementia with lewy bodies?

Answer 17

Substantial fluctuation in degree of cognitive impairment over time, Parkinson’s symptoms, visual hallucinations, frequent falls.

Question 18

What are the key clinical features of vascular dementia?

Answer 18

Abrupt, step-wise decline in cognitive function related to vascular episodes.

Question 19

What is the pathology of vascular dementia?

Answer 19

Arteriosclerosis of blood vessels to brain, small vessel disease vs infarcts, decreased/cut off blood supply to brain.

Question 20

How is vascular dementia managed?

Answer 20

Cardiovascular risk is assessed - treat hypertension/high cholesterol.

Question 21

What are the clinical features of frontotemporal dementias?

Answer 21

Alteration of social behaviour and personality (agitated and depressed); impaired judgement and insight - gambling, taking off clothes, inappropriate comments; speech output falls to mutism.

Question 22

What are the targets for management of dementia?

Answer 22

Holistic - social care; drugs; memory aids; therapies (pets + babies).

Question 23

What is a seizure?

Answer 23

A sudden irregular discharge of electrical activity in the brain causing physical manifestation like sensory disturbance, unconsciousness or convulsions.

Question 24

What is a convulsion?

Answer 24

Uncontrolled shaking movements of the body due to rapid and repeated contraction and relaxation of muscles.

Question 25

What is an aura?

Answer 25

Perceptual disturbance prior to a seizure.

Question 26

What is epilepsy?

Answer 26

Neurological disorder marker by sudden recurrent episodes of sensory disturbance, LOC or convulsions, associated with abnormal electrical activity in the brain.

Question 27

What is status epilepticus?

Answer 27

Epileptic seizures occurring continuously without recovery of unconsciousness inbetween.

Question 28

What are the two broad types of seizure?

Answer 28

Partial and generalised.

Question 29

What are the types of partial seizure and the difference between them?

Answer 29

Simple (consciousness kept) or complex (consciousness impaired).

Question 30

When does temporal lobe epilepsy most commonly occur?

Answer 30

In 1st/2nd decade.

Question 31

What are the features of temporal lobe epilepsy?

Answer 31

Auras - auditory hallucinations.

Question 32

What are the features of frontal lobe epilepsy?

Answer 32

Abnormal movement when motor areas are affected to contralateral side.

Question 33

What is a tonic clonic seizure?

Answer 33

A generalised seizure of two parts - first tonic (increased tone, rigid), then clonic (convulsions).

Question 34

What is an absence seizure?

Answer 34

A generalised seizure that presents as daydreaming.

Question 35

What is a myoclonic seizure?

Answer 35

A generalised seizure that involves brief shock-like muscle jerks.

Question 36

What is an atonic seizure?

Answer 36

A generalised seizure that presents with no tone, drop attack.

Question 37

What is a tonic seizure?

Answer 37

A generalised seizure presenting with increased tone.

Question 38

What are the investigations needed in epilepsy?

Answer 38

Clinical history, EEG, and MRI.

Question 39

What are the important components of a history from someone with seizures?

Answer 39

Before, during, and after the seizure. Collateral history if possible.

Question 40

What should be asked in the before a seizure section of a history?

Answer 40

PMH, FH, triggers, aura, first sign/symptom.

Question 41

What should be asked in the during a seizure section of a history?

Answer 41

Description of the seizure, duration, abrupt or gradual end?

Question 42

What should be asked in the after a seizure section of a history?

Answer 42

Post-ictal state, tongue biting, incontinence, neurological deficit.

Question 43

What are the differential diagnoses of epilepsy?

Answer 43

Vascular - stroke, TIA; infection - abscess, meningitis; trauma - intracerebral haemorrhage; autoimmune - SLE; metabolic - hypoxia, electrolyte imbalance, hypoglycaemia, thyroid dysfunction; iatrogenic - drugs, alcohol withdrawal; neoplastic - intracerebral mass.

Question 44

What is the use of EEGs in investigating seizures?

Answer 44

Supports diagnosis, assesses risk of seizure recurrence.

Question 45

If an EEG is unclear for epilepsy, what should be considered?

Answer 45

Repeated EEG, sleep EEG, long-term video or ambulatory EEG.

Question 46

What does a standard EEG assessment involve?

Answer 46

Photic stimulation and hyperventilation.

Question 47

What is the initial management of seizures?

Answer 47

ABCDE, if >5 minutes then need medical assistance.

Question 48

What are the rules surrounding driving and epilepsy?

Answer 48

If when awake - no license for a year seizure-free. If due to medication change - no license for 6 months seizure-free. If whilst asleep - assessed by DVLA. If one-off seizure - 6 months seizure-free + DVLA assessment.