Alzheimer's, Dementia, Delirium Flashcards
what are predisposing factors to acute confusional state
- age > 65
- background of dementia
- significant injury e.g. hip fracutre
- fraility
- polypharmacy
what are precipitating events of acute confusional state
- infection esp UTI
- metabolic: hyperglycaemia, hypercalcemia, dehydration
- change of environment
- severe pain
- alcohol withdrawal
- constipation
what are features of acute confusional state
wide variety of presentations!
- memory disturbances
- agitated or withdrawn
- disorientated
- mood change
- visual hallucinations
- poor attention
how is acute confusional state managed
- treat underlying cause
- modification of environment
- haloperidol 0.5mg as first line sedative
- NICE delirium: haloperidol or olanzapine
why is treating delirium in parkinson’s patient particularly difficult
antipsychotics can often worsen parkinsonian symptoms
if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred
what are risk factors for alzheimer’s
- inc age
- FHX
- apoprotein E allele 24
- caucasian
- down’s syndrome
what macroscopic pathological changes are seen in alzheimer’s
widespread cerebral atrophy involving the cortex and hippocampus
what microscopic pathological changes are seen in alzheimer’s
- cortical plaques due to depositio of type A-B-amyloid protein
- intraneuronal neurofibrillary tangles caused by abnormal aggregation of tau protein
- hyperphosphoryaltion of tau protein
what biochemical change occurs in alzheimer’s
deficit of ACh from damage to an ascending forebrain projection
what is the normal function of the tau protein and how are neurofibrillary tangles formed
tau: interacts w tuberculin to stabilise microtubules and promote tubulin assembly into microtubules
- in AD, tau proteins are excessively phosphorylated which impair its function
what do NICE recommend as non-pharmacological treatment of alzheimer’s
- offering ‘a range of activities to promote wellbeing that are tailored to the person’s preference’
- offering group cognitive stimulation therapy for patients with mild and moderate dementia
- consider including group reminiscence therapy and cognitive rehabilitation
give 3 examples of first line drugs used to manage mild to moderate alzheimer’s
acetylcholinesterase inhibitors
1. donepezil
2. galantamine
3. rivastigmine
give an example of second line alzheimer’s treatment
memantine
what class of drug is memantine
NMDA receptor antagonist
which patients is memantine reserved for
- moderate Alzheimer’s who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors
- as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
- monotherapy in severe Alzheimer’s
name one contraindication of donepezil
bradycardia
give 3 adverse effects of donepezil
- aggression
- agitation
- insomnia
what are 3 common causes of dementia
- alzheimer’s
- cerebrovascular disease
- lewy body dementia
give 4 rare causes of dementia
- huntingdon’s
- CJD
- pick’s disease
- HIV
what are important, potentially treatable differentials of dementia
- hypothyroidism
- vitamin deficiencies
- syph
- brain tumour
- normal pressure hydrocephalus
- depression
- chronic drug use e.g. alcohol
give examples of medications that can cause cognitive impairment/present similarly to dementia
- anticholinergic urological drugs: oxybutynin, solifenacin
- antihistamines e.g. chlorphenamine
- tricyclic antidepressants e.g. amitriptyline
what nutritional/vitamin deficiencies can cause dementia like symptoms
- B12
- thiamine (wernicke-korsakoff)
give some examples of modifiable risk factors of dementia
- Exercise
- Mental stimulation (e.g., a more mentally challenging job)
- Maintaining a healthy weight (obesity increases the risk)
- Blood pressure control (hypertension increases the risk)
- Blood glucose control (diabetes increase the risk)
what are early symptoms of dementia
- Forgetting events
- Forgetting names
- Difficult remembering words
- Repeatedly asking the same questions
- Impaired decision making
- Reduced flexibility
what are features of advanced dementia
- Inability to speak or understand speech (aphasia)
- Swallowing difficulties (dysphagia), which can lead to aspiration and pneumonia
- Appetite and weight loss
- Incontinence
give examples of memory screening tests
- Six Item Cognitive Impairment Test (6CIT)
- 10-point Cognitive Screener (10-CS)
- Mini-Cog
- General Practitioner Assessment of Cognition (GPCOG)
- Montreal Cognition Assessment (MoCA)
what is ACE-III
Addenbrooke’s Cognitive Examination-III (ACE-III) is a detailed and comprehensive assessment tool for memory impairment, typically used by specialist memory services
what are the 5 domains tested in ACE-III
- Attention
- Memory
- Language
- Visuospatial function
- Verbal fluency
<88 indicates possible dementia
as dementia is a progressive condition that is not curable, what does mainstay of management involve (3)
- Lasting power of attorney (nominating a person to make decisions on their behalf when they are no longer able)
- Advanced decisions (around treatments they would want or not want)
- Planning future care, including places and end-of-life care
what factors favour a diagnosis of delirium over dementia
- acute onset
- impairment of consciousness
- fluctuation of symptoms: worse at night
- abnormal perceptio
- agitation, fear
- delusion
how is dementia investiagted in a primary care setting
- blood screen sent to exclude reversible causes e.g. hypothyroidism
- NICE recommends: FBC, U&Es, LFTs, calcium, glucose, B12 & folate
how is dementia further investigated in a secondary care setting
neuroimaging to exclude subdural haematoma or normal pressure hydrocephalus
- provide info on aetiology to guide prognosis and managment
what are the 3 types of FTLD
- Frontotemporal dementia (Pick’s disease)
- Progressive non fluent aphasia (chronic progressive aphasia, CPA)
- Semantic dementia
what are the common features of frontotemporal lobar dementia
- Onset before 65
- Insidious onset
- Relatively preserved memory and visuospatial skills
- Personality change and social conduct problems
what is the most common type of FTLD
pick’s disease
what is pick’s disease characterised by
personality change and impaired social conduct
- other: hyperorality, disinhibition, increased appetite, and perseveration behaviours
what is the characteristic investigation finding of pick’s disease
focal gyral atrophy with a knife-blade appearance
what are macroscopic changes of pick’s disease
atrophy of frontal and temporal lobes
what are microscopic changes of pick’s disease
- Pick bodies - spherical aggregations of tau protein (silver-staining)
- Gliosis
- Neurofibrillary tangles
- Senile plaques
what are the characteristics of semantic dementia
fluent progressive aphasia
- speech is fluent but empty and conveys little meaning
- memory is better for recent rather than remote events
what is the characteristics pathological feature of lewy body dementia
alpha-synuclein cytoplasmic inclusions in the substantia nigra, paralimbic and neocortical areas
what are the clinical features of lewy body dementia
- progressive cognitive impairment typically before parkinsonism
- cognition may be fluctuating
- early impairments in attention and executive function
- parkinsonism
- visual hallucinations
how does lewy body dementia differ from parkinson’s
cognitive impairment before motor symptoms
how is lewy body dementia treated
- can use AChEi and memantine
why should neuroleptics be avoided in lewy body dementia
patients are extremely sensitive and may develop irreversible parkinsonism
what is mental capacity
- ability for patient to make informed decision about healthcare
- decision specific
- understand, retain, weigh (pros/cons) and communicate their decision
what is an advance care plan and who completes this
preferences about future healthacare decisions in the case they patient becomes unwell
- not legally binding
- made by patient
what are long term complications of delirium
- increased mortality
- prolonges hospital admission
- higher complications rates
- inc risk of developing dementia
