32. Deterioration of intellect

Question 1

what is dementia

Answer 1

An acquired global impairment of intellect memory and personality without impairment of consciousness, that is usually (but not always) progressive and usually irreversible

Presentation: Progressive IMPairment of Intellect, Memory and Personality resulting in impairment in the activities of daily living.

Question 2

approach to ?cognitive decline

Answer 2

1. rule out reversible causes = PINCH ME, mood, agitation, bleed, hearing loss
   - examination: CN, neuro Ul, LL, hearing, cardiovascular (vascular dementia)
   - bloods: confusion screen
   - imaging: CT head ?bleed
2. Assess cognitive decline severity eg MMSE
3. Get imaging during the work up eg CT or MRI

Question 3

What assessment tools for dementia are recommended for the NON-specialist setting

Answer 3

10-point cognitive screener (10-CS),

6-Item cognitive impairment test (6CIT)

Question 4

interpretation of MMSE

Answer 4

<24 = could be dementia

<10 severe dementia

Question 5

presentation alzhimers

Answer 5

insidious onset, Loss of ability to learn, process and retain new info, memory loss especially for names and recent events, language deficits, rapid forgetting, normal gait and neuro exam early

Question 6

imaging results alzhimers

Answer 6

generalised atrophy (esp medial temporal and parietal later), beta amyloid plaques amyloid plaques and neurofibrillary (tangles tau protein tangles within brain cells)

Question 7

management alzhimers

Answer 7

non-pharma
- activities to promote wellbeing

pharma
1. acetylcholinesterase inhibitor eg donepezil, galantamine and rivastigmine)

2. memantine (an NMDA receptor antagonist)

Question 8

what investgation should you do before prescribing acetylcholinesterase inhibitors ?

Answer 8

ECG

Unsafe if have QT prolongation, third degree heart block, sinus bradycardia - always check ECG before prescribing.

Question 9

adverse effects acetylcholinesterase inhibitors

Answer 9

cholinergic side effects such as diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence.

Question 10

SE acetylcholinesterase inhibitors

Answer 10

diarrhoea

donezapil - insomnia

Question 11

SE memantine

Answer 11

constipation

Question 12

presentation vascualr dementia

Answer 12

abrupt or gradual onset, focal neurological signs, signs of vascular disease, stepwise deterioration in someone with previous cardiovascular illness or events.

Question 13

pathology/imaging findings vascualr dementia

Answer 13

strokes, lunacar infarcts, white matter lesions, vulnerable to CVS events

Question 14

what imaging is best for vascualr dementia

Answer 14

MRI

Question 15

what may be used to help make a diagnosis of vascualr dementia

Answer 15

NINDS-AIREN criteria

• presence of cog decline that interferes with ADLs, not due to secondary effects of CVS event
• cerebrovascular disease as shown by neuro signs and/or imaging
• relationship between the above, inferred by
  the onset of dementia within three months following a recognised stroke
  an abrupt deterioration in cognitive functions
  fluctuating, stepwise progression of cognitive deficits

Question 16

management of vascualr dementia

Answer 16

1. manage CVS risk
   eg Antiplatelet therapy (aspirin, clopidogrel), Carotid angioplasty/stenting, BP control, glycaemic control, statins

+ supportive and social prescribing

Question 17

presentation frontotemporal dementia/picks disease

Answer 17

insidious onset, 50-60yo, rapid progression, sibinhibition, socially inappropriate, poor judgement, apathy, poor executive function, impulsivity.

No movement abnormalities

Question 18

pathology/imaging frontotemporal dementia

Answer 18

MRI shows significant atrophy of the frontal and temporal lobes. Pick cells and pick bodies in cortex

Question 19

management of picks disease

Answer 19

supportive care, benzos, antipsychotics

NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia

Question 20

what is Semantic dementia

Answer 20

a type of frontotemporal lobar degeneration

fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.

Question 21

common features of the frontotemporal lobar dementias

Answer 21

Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems

Question 22

triad in pellagra? other fetaures>

Answer 22

Dementia, Dermatitis, Diarrhoea

Other features include hair loss, sunlight sensitivity and glossitis.

Question 23

cause of pellagra? risk factors?

Answer 23

Caused by vitamin B3 (niacin) deficiency.

Alcoholism and crohn’s are risk factors for pellagra due to malnutrition/malabsorption. Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin).

Question 24

tetrad of wernike’s

Answer 24

ataxia, ophthalmoplegia, nystagmus and acute confusional state

Question 25

where are the lesions in wernikes

Answer 25

mamillary bodies and ventricle walls

Question 26

which b vitamin is thiamine

Answer 26

B1

Question 27

what is korsakoffs

Answer 27

irreversible damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus

Question 28

features korsakoffs

Answer 28

anterograde amnesia: inability to acquire new memories
retrograde amnesia
confabulation