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MD4001 Week 5 > 7. Clinical aspects of dementia and its management > Flashcards

7. Clinical aspects of dementia and its management Flashcards

1
Q

Dementia is a generic term indicating a loss of…

A

 intellectual functions including memory
 significant deterioration in Activities of Daily Living (ADLs)
 changes in social behaviour

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2
Q

Dementia is a ______, not a specific diagnosis

A

Dementia is a syndrome, not a specific diagnosis

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3
Q

What is the syndrome of dementia:
Neuropsychological deficits?
Neuropsychiatric features?
ADLs?

A 
1. Neuropsychological deficits: 
Amnesia 
Aphasia 
Agnosia 
Apraxia
  1. Neuropsychiatric features:
    (Behavioural and psychological symptoms, BPSD)
    Psychiatric symptoms Behavioural disturbances
  2. Activities of daily living:
    Instrumental
    Basic
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4
Q

Cognitive assessment in dementia of the frontal lobe?

A

Frontal lobe involved in sequencing and fluency. Also is disinhibition

Test:

  1. Luria hand sequencing task
  2. Verbal fluency 1 minute to say as many words beginning with F, A and S or animals.
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5
Q

Cognitive assessment in dementia of the temporal lobe?

A

Temporal lobe: For memory and speech (LHS)

Tests:

  1. Address recall after 5 minutes
  2. Object recall
  3. Serial 7s: Must maintain attention (subcortical test too). Take away 7 from 100 etc etc
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6
Q

Cognitive assessment in dementia of the parietal lobe?

A

Parietal lobe: For spatial awareness (RHS) and language (LHS)

Test:

  1. Clock face
  2. Naming objects
  3. Drawing cube, interlocking infinity
  4. Agnosia (object recognition)
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7
Q

What is the minimental test?

“MMSE”

A

HIghly insensitive
Have to be pretty demented to score poorly. Lack of responsiveness
Max score = 30
Issues over copyright

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8
Q

ACE-III, meaning?

A

Addenbrookes Cognitive Examination (ACE)

82/100 score or less meaning impairment

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9
Q

Features of mild cognitive impairment (MCI) that differentiate it from dementia?
Prognosis of conversion?

A

MCI requires subjective memory impairment and cognitive impairment not meeting dementia diagnostic criteria (in particular with no impairment in core ADLs)

Conversion prognosis:
Conversion to dementia is highest in MCI patient in which their impairment is one of MEMORY
Conversion is by no means inevitable, even for MCI up to 25% in some studies show subsequent recovery of normal cognitive function

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10
Q

Does early diagnosis benefit people with dementia & their carers?

A 
Outcome of early diagnosis..
To patient:
-slower cognitive decline
-better maintained functional status
-decrease in mortality
-delayed institutional care admission
-better mental wellbeing
-aggression, agitation, wandering decrease
-more rights and dignity

For carer:

  • improve QoL
  • Improved mental wellbeing
  • Reduced strain

OVERALL reduced healthcare and societal costs

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11
Q

Detection and treatment to slow rate of disease progression at a ________ stage is likely to have an even greater disease-modifying effect than targeting aMCI patients
2 broad groups of early diagnostic investigations
1. _____________
2. Other biomarkers of AD

A

Detection and treatment to slow rate of disease progression at a preclinical stage is likely to have an even greater disease-modifying effect than targeting aMCI patients
2 broad groups of early diagnostic investigations
1. Neuroimaging
2. Other biomarkers of AD

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12
Q

Neuroimaging used in dementia?

A

CT and MRI

Perfection SPECT (Single Photon Emission Computed Tomography):

  • Looks at which areas of brain are perfused more
  • Not v sensitive and specific
  • Lots of abnormalities

PET: Using Fluoro-DeoxyGlucose

  • Not common and experiments
  • Uptake of FDG proportional to cerebral glucose metabolism, thus thought to be indicator of cerebral metabolism

Amyloid imaging:

  • type of PET Scan
  • able ot visualise amount of amyloid
  • Unknown relationship between amyloid quantity and cognitive degeneration
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13
Q

Amyloid imaging:

  • Use in AD diagnosis?
  • Use of PiB PET?
A

Beta-amyloid (A-beta) is an amino acid metalloprotein, which is a normal product of cell metabolism in the brain.
AD diagnosis: In the disease the is overproduction and impaired clearance of A-beta, leading to accumualtion of extracelluar plaques of amyloid-beta

PiB PET (Pittsburgh compound B Positron Emission Tomography). The PiB cross the BB easily then binds strongly to amyloid-beta allowing quantitative imagining of amyloid-beta burden. Combined with CSF amyloid-beta and tau measurement,

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14
Q

best antecedent biomarkers for AD at the preclinical and prodromal phases?

A

PiB PET
+
Combined with CSF amyloid-beta and tau measurement

Note: However in established dementia Aβ burden on PiB-PET does not correlate well with level of cognitive impairment

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15
Q

What are the main CSF markers for the diagnosis and management of AD?

A 
Amyloid-beta42 (AB42)
Total tau (t-tau)
Phosphorylated tau (p-tau)
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16
Q

Treatment of dementia options?

A
  1. Acetylcholinesterase inhibitors e.g. Donepezil, galantamine, rivastigmine for mild-moderate dementia ( for mild-moderate dementia)
  2. NMDA receptor antagonist e.g. memantine (for moderate to severe DAT)
17
Q

Alzheimers drugs?

A

AChE Inhibitors: Donepezil, galantamine, rivastigmine

Memantine for people in tolerant of AChE inhibitors

18
Q

Diagnostic criteria for Alzheimers disease?

A

Deficits in 2+ areas of cognition
Progressive worsening of memory and other cognitive functions
No disturbance of consciousness
Onset between 40 and 90 yrs
Absence of other disorders that could account for progressive deficits in memory and cognition

19
Q

The Spectrum of Behavioural and Psychological Symptoms of Dementia (BPSD).
Describe psychotic, behavioural and affective symptoms?

A

Psychotic:
Halluciinations
Delusions
Misidentifications

Behavioural:
Sleep disturbance
Aberrant motor behaviour
Agitation
Aggression 
Stereotypes
Hyperorality
Eating change 
Hypersexuality
Affective:
Depression * (treatment available)
Anxiety
Apathy
Elation
Disinhibition
20
Q

features used to diagnose Dementia with Lewy body (DLB)?

A
  1. PROGRESSIVE COGNITIVE DECLINE of sufficient magnitude to interfere with normal social and occupational function. (Memory impairment a feature of progression/decline)
  2. Fluctuating cognition with pronounced variations in attention and alertness
  3. Recurrent visual hallucinations (well formed and detailed)
  4. Spontaneous motor features of parkinsons (but NO TREMOR)
21
Q 
Clinical diagnostic features of fronto-temporal dementia:
Behavioural?
Affective?
Speech?
Spatial orientation?
Physical?
A

Behavioural:

  • Disinhibition
  • Manners that are socially abnormal e.g. clapping, singing, dancing
  • Impulsivity, distractibility

Affective:
-Depression, anxiety, delusion, suicidal

Speech:
-Progressive reduction

Spatial orientation and praxis preserved

Physical:

  • Early: Incontinence and normal reflexes
  • Late: Akinesia, ridigity, tremor
22
Q

Clinical diagnostic features of vascular dementia?

A

Early gait disturbance (small step, or parkinsonism gait)
Early urinary frequency
Unsteadiness and frequent unprovoked falls
Pseudobulbar palsy

Personality and mood changes e.g. abulia, despression, emotional incontinence

23
Q

Depression Diagnosis and Assessment Bundle (DAB) strategies?

Diagnostic Confirmation: Dementia diagnosis made following reference to ICD or DSM
diagnostic schedules (eg p34-40 SIGN86)
A
  1. Patient interview
    - i.e. full history with focus on impact of illness of ADLs
  2. Patient cognitive examination
    - Key to highlight areas hidden during history
    - E.g. MMSE, MOCA, ACE III
  3. Informant interview
    - Asking close relations for details of the patients decline
    - Could use informant questionnaire
  4. Investigations
    - Haematological e.g. FBC, B12, folate. If low could be causative factor
    - Biochemical (U&E, Glucose or HbA1c, LFT, Ca, PO4, Cholesterol, TSH)
    - Radiological (CT or MRI brain scan within the previous 12 months)
  5. Specialist assessments from specialised practitioners

MD4001 Week 5 (11 decks)

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