Alzheimer's Dementia

Question 1

Who does Alzheimer’s affect?

Answer 1

-Most common form of dementia, accounts for 50% of cases
-Prevalence increases with age

Question 2

What causes Alzheimer’s?

Answer 2

-Progressive degeneration of the cerebral cortex
-Widespread cortical atrophy, notably in the medial temporal lobes
-Affected neurons develop amyloid plaques, neurofibrillary tangles and produce less ACh
-Neurodegeneration occurs at least a decade before clinical onset
-OVERALL patients experience irreversible global, progressive impairment of brain function –> reduced intellectual ability

Question 3

What risk factors are there for Alzheimer’s?

Answer 3

-Ageing
-Caucasian ethnicity
-FH
-Slightly more common in women
-Head injury
-RF associated with vascular disease
-?Wine is protective

Question 4

How does Alzheimer’s present?

Answer 4

Insidious onset, slow progression
Early stages: memory lapses, forgetting names, difficulty finding words, inability to remember recent events, forgetting appointments
Progression: apraxia, language difficulty, confusion, difficulty planning and decision making
Late stages: wandering, disorientation, apathy, psych (depression, hallucination, delusion) and behavioural (disinhibition, aggression, agitation) symptoms, altered eating, incontinence

Question 5

What are the 5 A’s of Alzheimer’s?

Answer 5

Aphasia
Amnesia
Apraxia
Agnosia
Associated behaviours

Question 6

What signs might the patient have on examination?

Answer 6

Core features:
-Dementia established by clinical exam and neuropsychological tests
-Deficits in 2+ areas of cognition
-Insidious onset, progressive, between 40-90yrs
-Absence of systemic disorder
-No disturbance of consciousness
Mild cognitive impairment presentation:
-Pt shows concern regarding change in cognition
-Impairment of 1+ cognitive domains
-Preservation of independence

Question 7

What are the differential diagnoses for Alzheimer’s?

Answer 7

-Normal ageing
-Other forms of dementia
-Normal pressure hydrocephalus
-Parkinson’s
-Hypothyroidism
-Drug-induced cognitive impairment
-Vit B12 deficiency
-Depression, schizophrenia
-Acute confusional state
-Neurosyphilis

Question 8

How would you investigate a patient with suspected Alzheimer’s?

Answer 8

Rule out treatable cause:
-FBC, CRP, MSU, U+E, LFT, glucose, TFT, Ca2+, B12, folate
-Specialist assessment to determine type of dementia
-MRI / CT to exclude cerebral pathology - observe for atrophy

Question 9

What treatment would you discuss with an Alzheimer’s patient?

Answer 9

Biological (pharmacological)
-AChE Inhibitors must be used only have discussion with pt and family - cholinergic side effects (donepezil, galantamine, rivastigmine)
-NMDA antagonists only to be used in moderate/severe dementia and if AChEI is contraindicated / not tolerated (Memantine)
Psycho-social
-Pt centered care, memory assessments, support group guidance, memory enhancement strategies, CBT, physio, carer support