236 - Dementia Flashcards
What are differentials of an elderly person with ? dementia?
Physical illness (hypothyroid? infection?)
Delerium
Mild cognitive impairment (decline greater than expected but doesn’t interfere with daily life)
Depression
Sensory impariments
What are the ICD 10 criteria for dementia?
Acquired impairment > 6 months in memory \+ impaired in at least 1 of: - executive function - language - Praxis - Gnosis
What are the 4 domains of impariment seen in dementia?
Cognitive
Activities of daily living
Neuropsychiatric / behavioural
Caregiver burden
What are some cognitive tests used in dementia?
6 item CIT: Kingshill Clockface test Mini mental state exam ACE-III: addenbrookes MoCA: montreal cognitive exam
What key tests should be done when thinking of dementia?
Bloods (inc. TFT, B12/folate)
CXR
EEG
CT brain - for exclusion or other causes, and can see ischaemia or atrophy.
? MRI brain - better white matter detail, but hard to tollerate when confused
SPECT/DAT/PET - specialised tests to look at regional blood flow ect.
What are 5 main types of dementia?
Alzheimers (50%) Vascular Parkinson's Lew-body Fronto-temporal
Describe Alzheimer’s dementia
Insidious onset + gradual decline.
B amyloid plaques and neurofibrillary tangles (caused by Tau protein)
Deficit in Cholinergic (AcH) system - Glutamate overactivation of NMDA - get cerebral atrophy and ventricular dilatation.
What are the risk factors for dementia?
Age >70
F:M is 2:1
Head injury, environment…
Genetics - 40% of
Describe Vascular dementia?
Sudden onset with step wise deterioration.
Mood and behavioural changes occuer
Insight is preserved
Can fluctuate
Neuropathology: atherosclerosis -> single or multiple thrombolic infarcts
On imaging: Large volume infarcts, lacunae (small volume deep grey matter ischaemia. Leukonosis (looks white despite being grey matter)
What are the risk factors for vascular dementia?
Smoking Diabetes High cholesterol High Bp Male
Describe parkinson’s dementia?
Pt has prominent parkinsonian features that are present >6 months before the dementia began,
What is Lewy-body dementia?
Mild parkinsonian motor featires Cognitive and motor onset together Fluctuating cognition Vicid hallucinations act out dreams Repeated falls
Lewy bodies often see in substansia nigra
Describe front-temporal dementia
Pt express apathy, reduced motivation, self-neglect, disinhibited, reduced social awareness.
Have personality changes
Loss of language
Variable memory loss
Ofter
What is delerium?
An acute, sudden onset fluctuating, confusional state.
Abnormal attention and arousal, perceptual abnormalities, impaired conscious level.
Increase risk of death
Usually associated with illness - so treat cause
Review medication
Avoid provocation or over stimulation
What is BPSD in dementia?
Behavioural + psychiatric symptoms of depression
60% of pt have these, espeically in later stages.
eg. agitation, agression, restlessness, depression, anxiety, delusions, disinhibitions.
Management - Antipsychoitics? Only if really needed, study showed they actually increase mortality.
Try alternative therapies - reminiscence, aromatherapy
What medication is available for Alzheimer’s?
Mild/mod: Acetylcholinesterase inhibitors - Donepexil, Rivastigmine, Galantamine.
- not a cure but maintains level for longer, reduces ACh break down, so more in cleft, and also reduces formation of B-amyloid plaques.
Mod-severe: NMDA receptor antagonist - Memantine
Blocks effects of pathologically elevated/toxic levels of glutamate that cause dysfunction
What side effects do you get with Rivastigmine (or other Acethylcholinesterase inhibitors)?
When is their use cautioned?
N+V, Diarrhoea, Weight loss, dizziness
Caution: arrhythmia’s, epilepsy, asthma
What side effects can you get with memantine?
Constipation, hibe BP, Dyspnoea, headache, hallucinations
What medication can be used in someone with Vascular dementia?
Nothing specific - reduce vascular risk factors
Aspirin, statins…
? night sedation - Zopidone
Where is LTM stored/processed?
Medial temporal areas
What is declarative memory?
Explicit
Semantic - concepts
episodic - autobiographical
Where is declarative memory processed?
In medial temporal love, hypothalmus and thalmus
What is non-declarative memory?
+ where is each part processed?
Implicit
Procedural memory, skills, habits - Striatum
Motor learning - cerebellum
Emotional conditioning - Amygdala
Describe the information flow as sensory information is processed and memorised..
Sensory info -> cortical association areas -> parahippocampal + thinal cortices -> hippocampus -> mamillary bodies (in hypothalmus) -> Thalmus
What part of the information flow does korsakoff’s syndrome affect?
B1 (thiamine) deficiency
Stops mamillary bodies -> thalamus section
Causes: retrograde + anterograde amnesia
What parts of the information flow does damage to medial temporal lobes affect? What does it cause?
Affects parahippocampal and hippocampal areas
Causes Severe anterograde amnesia
eg. HM or clive wearning
What do different parts of the cortex in the brain do roughly?
Frontal - select and plan appropriate responses + personality
Parietal - Attending to stimuli
Occipital - visual cortex
Temporal - Identifying the nature of the stimuli
Damage to where causes someone to understand language but not be able to construct their own - speaking with halted, badly syntaxed speech?
Broca’s area - frontal lobe
Damage to where causes someone not to be able to understand language, they speak fluent but non-sensical speech with good grammar?
Wernickes area - temporal lobe
When you damage the temporal lobe what can happen to your sensory recognition?
Agnosia - can’t recognise sensory stimuli
Visual agnosia - Can see but not name items
Prosopagnosia - Can’t recognise faces
How do neurones die? Why?
Apoptosis
Necrosis
Autophagy
Often due to misfolded toxic protein eg. B amyloid or Tau
What in too high levels is excitotoxic and can cause neuronal death?
Glutamate
what memantine tries to reduce
What is senescence?
The impact of time on the body
Can you prevent ageing?
Rat studies - chronic undernutrition - lives longer
Reproductive cost - sexual activity reduced lifespan of male fruit flies
What is ageism?
Unjustifiable difference in treatment based solely on age.
