9a.) Confusion in the Elderly Flashcards
State some possible causes of confusion in the elderly
- Dementia
- Depression
- Drugs
- Delirium
- Metabolic
4 D’s and the M
What is delirium?
Acute onset of altered mental status with a flucutating course, often involves:
- Inattention
- Disorgnaised thinking/confusion
- Altered level of consciousness
What is depression?
Change in mood and feeling of self-worth
Broadly speaking, what is dementia?
Cognitive decline due to disease of brain; it is chronic, progessive and has an insidious (graudual) onset
What is cognition?
The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses
State some drugs which can cause confusion
- Morphine
- Cocaine
- Alcohol
- Zopiclone (sleeping tablet)
State some metabolic causes of confusion
- Hypothyroidism
- Hypercalcaemia
- Vit B12 deficiency
- Normal pressure hydrocephalus
Describe dementia, include:
- It is a decline in…
- What impairments it leads to?
- Impact on everyday life
- Decline in higher cortical function
- Impairment of memory, intellect and personality
- Individual fails to cope with everyday life
Dementia can be broadly divided into two categories (NOTE: this is not referring to the different types of dementia); what are the 2 categories and what determines which category you are in
- Early onset: symptoms manifest before 65
- Late onset: symptoms manifest after 65
State the 5 types of dementia
- Alzheimer’s dementia
- Dementia with Lewy body
- Vascualr dementia
- Fronto-Temporal dementia
- AIDS-Dementia complex
An 80 year old man is brought into GP by his daugher who is concerned that there has been a steady decline of his cognitive function over the last year; state 3 tests you could do to test his cognition?
- MMSE: mni mental state examination (ACUTE)
- MOCA: Montreal cognitive assessment (NEUROLOGY CLINIC)
- Ask to draw a clock and a specific time on that clock
*The top two test things such as memory, calculation, laguage, orientation, visuospatial
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Describe the macroscopic changes in Alzheimer’s disease
- Global atrophy of brain lobes, mostly: frontal, parietal & temporal (not so much in occipital)
- Sulcus widening (due to brain atrophy)
- Enlarged 3rd & 4th ventricle spaces (due to brain atrophy)
Describe microscopic changes in Alzheimer’s dementia
- Amyloid beta plaques
- Neurofibrillary tau tangles
These plaques and tangles kill neurones; since neurogoenesis in limited in CNS the neurones that die are unlikely to be replaced
Describe the pathophysiology of Alzhemier’s dementia
(3 main points)
Plaques
- Amyloid precursor protein in usually found in membrane; it is thought to have a role in growth & repair after injury
- When it’s broken down & recycled, if wrong enzymes do this the degradation products are insoluble amyloid beta
- Amyloid beta aggregates to form plaques outside neuron which can:
- Interrput neurone signalling
- Cause inflammation and hence damage to other neurones
- Deposit aroudn blood vessels weakening walls and increasing risk of haemorrhage
Neurofibrillary tangles
- TAU protein usually binds & stabilises microtubles
- Kinase phosphorylates TAU
- TAU changes shape
- Aggregtes with othehr TAU proteins to form neurofibrillary tangles WITHIN the neuron
Increase in ACh esterase enzyme leading to decreased ACh neurotransmitter
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What are teh 4 groups of neurones predominatly affected in Alzheimer’s dementia?
- Cholingergic (treatment targets this)
- Noradrenergic
- Serotonergic
- Those expressing somatostatin
There have been genes identified for both early onset and late onset Alzheimer’s disease:
- State the 3 genes for early onset
- State the 1 gene for late onset
Early onset:
- Beta-amyloid precursor protein (beta-APP)
- Presenilin 1
- Presenilin 2
Late onset
- Apolipoprotein E gene
- **All genes affect beta amyloid*
Describe the typical presentation of someone with Alzheimer’s disease
- Deterioration in memory
- Deterioration in spatial navigation
- Difficulty in executive functions:
- Language
- Visuospatial functioning
- Calculation
- Daily life activities affected
Drugs used to treat Alzheimer’s can be broadly categorised into two categories based on their target/mechanism of action; state the two mechanisms of action
*ALSO, for each include what they are good for treating
- Acetylcholine esterase inhibitors (mild to moderate Alzheimer’s)
- NMDA (glutamate receptor) antagonists (useful for agitation and severe Alzheimer’s)
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Give an example of a drug that is an:
- ACh esterase inhibitor
- NMDA antagonist
- AChE= donepezil, galantamine, rivastigmine
- NMDA antagonist= memantine
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Describe the pathophysiology of Demetia with Lewy Bodies, include:
- What Lewy bodies are
- Where they are found in the neurones
- Where Lewy Bodies are found in the brain
- Brainstem changes
- Lewy bodies are spherical aggregations of alpha-synuclein protein which are found in cytoplasm of neurones?
- Lewy bodies are found in substantia nigra, temporal lobe, frontal lobe and cingulate gyrus
- Branstem changes mirror those in Parkinson’s (degeneration of dopaminergic neurones in substantia nigra compacta)
State the 3 core clinical features of Dementia with Lewy Bodies
- Fluctuating cognition with variations in attention and alertness
- Visual hallucinations
- Features of parkinsonism (which may lead to frequent falls): shuffling gait & flexed posture (ONLY)
*** As you can see, dementia with Lewy bodies has some quite distinct features
Discuss how you could distinguish between Dementia with Lewy bodies and Parkinsons dementia
- Dementia with Lewy bodies: if dementia precedes movement disorder we call it dementia with Lewy bodies
- Parkinson’s disease: if movement disorder appears before dementia then we call it Parkinson’s