CASC Stations 2 Flashcards
Characteristic of vascular dementia
ü Emotional and personality changes are typically early, followed by
cognitive deficits (including memory deficits) that are often fluctuating in
severity.
ü Cognitive impairment may be patchy compared to the more uniform
impairments seen in Alzheimer’s disease.
ü Depression and anxiety with episodes of affective lability and confusion
are common, especially at night.
ü Urinary incontinence and falls without other explanation are often early
features.
What differentiates vascular from alzheimers in neuroimaging
Presence of periventricular white matter changes
Most common form of vascular pathology in vascular dementia
SVD
Which infarctions cause prominent cognitive problems
Lacunar infarcts in thalamus
Prognosis of vascular dementia
5-7 years from diagnosis
Non-pharmacological interventions for BPSD
Aromathreapy, massage therapy, music therapy, multisensory stimulation
Meaningful activities, structured day time routine, encourage visits from family
Interventions for specific behavioural problems can replace the
structure of the ABC analysis of behaviour. Analysis
is made to identify antecedents, problem behaviour and consequences
of each problem behaviour and clear management plan is tailored
according to the needs of the patient.
How many patients with dementia experience BPSD
66%
Assessment of BPSD
The assessment process involves identifying any concurrent physical
health problems such as urinary tract infection, chest infection and
sources of physical discomfort like pain, constipation, urinary retention
etc or due to the effects of drug treatments, example use of
anticholinergics should be considered.
• It is also important to consider possible concurrent psychological
contributory factors such as depression, fear, anxiety or paranoia.
• The availability and quality of relationships with others (care-givers)
as well as the current ability to cope with the needs of the person with
dementia will shape behavioural patterns.
• The characteristics of the environment should also be considered for
example physical space, comfort and adaptation to promote
independence. The environment should be homelike, familiar and
interesting. Using artefacts, painting, which are designed to create a
natural or homelike setting may be tried to reduce agitation, aggression
and wandering into others rooms.
• Activities may reduce boredom, wandering and aggression. Activity
programmes with trained volunteers may reduce aggressive incidents
in patients whose wandering occurs in the context of boredom and
inactivity.
• Effective therapies like
ü Music
ü Bathing
ü Exercise
ü Pets
ü Aromatherapy
ü Massage
ü Multisensory stimulation
ü Life storybooks,
ü Short conversations are helpful.
Non-pharmacological management of dementia
- Create a safe, caring environment usually in the patient’s own home and a
predictable routine is extremely helpful. - Suggest simple memory enhancement techniques and interventions to
improve coping (example calendars, lists, alarms). Involve psychologist
wherever needed. - Encourage both physical and mental activity including social activities
like attending social clubs and day centres. - Occupational therapy home assessment should be performed routinely to
identify hazards, minimise risks and maximise safety of the patient. - Simplify medication and provide dossett box or similar to aid compliance.
- Organise carers to assist with activities of daily living and prompt
medication etc. - Educate patient and families about the disease and how to cope with the
manifestations at different stages of the illness. - Offer support to care givers and consider counselling and support care
givers by encouraging them to attend the support groups organised by
voluntary agencies like. Offer support in the form of respite care, sitting
services etc - Try to identify and modify reversible factors such as sepsis in the form of
UTI, chest infection, cellulitis, constipation or drug side effects. Periodical
Review by GPs would be extremely helpful. It is important to treat any co-
morbid medical or psychiatric illness.
- In addition, vascular risk factors should be addressed.
Third most common cause of dementia
LBD
How many cases of dementia are due to LBD
20%
How many patients with LBD can antipsychotics precipitate a parkinsonianism crisis
80%
First line treatment for psychotic sx in LBD
Acetylcholinesterase inhibitors
M:F ratio of LBD
1:1
What would EPSE examination include
- Akathisia (Motor restlessness)
- Dystonia (uncontrolled muscular contraction)
- Pseudoparkinsonsim-Tremor, Rigidity, Bradykinesia, mask-like
facies and festinant gait - Tardive dyskinesia (abnormal movements)
Risk factors for akithesia
• Use of high – dose antipsychotics
• Use of high-potency antipsychotics such as haloperidol,
pipothiazine, prochlorperazine, Trifluoperazine,
Zuclopenthixol, promazine, risperidone etc
• Use of depot antipsychotics
• Long term use of antipsychotics
• Rapid increase of antipsychotics
• Sudden withdrawal of antipsychotics
• History of organic brain disease like dementia, alcoholism etc
• History of previous akathisia
• Concomitant use of predisposing drugs (e.g. lithium, SSRIs).
Treatment of akithesia
If antipsychotic related, then reduce the dose of antipsychotics.
• Consider switch to second generation antipsychotics
(Aripiprazole, Olanzapine, quetiapine and Clozapine) as these
drugs are less likely to be associated with it.
• A reduction in symptoms is seen with Propranolol, initially
30mg-80 mg/day
• Other possible useful agents include Cyproheptadine,
Mirtazapine, Mianserin, Trazadone.
• Consider adding or changing to a benzodiazepine e.g.
Clonazepam (0.5-3 mg/day), Diazepam upto 15 mg/day
• For unresponsive, predominantly anxious/agitated patient
(without hypotension) consider Clonidine 0.2-0.8 mg/day
• Anticholinergics are generally unhelpful
Which tuning fork is used to test sensation for neuro exam
128Hz
What sensations are transmitted by dorsal column
Superficial - touch
Vibration
Positional
What sensations are transmitted by lateral column
Pain
Temp
Sections of MMSE
Education Hearing or visual impairments Orientation to time and place Registration Recall Attention and calculation Naming Repetition Three stage command Reading Writing Drawing Working memory Frontal lobe
Questions for MMSE orientation to time and place
- What is the year we are in?
- What month are we in?
- What season is it?
- What day of the week is it today?
- What is today’s date?
- Can you tell me the name of this place?
- What floor of the building are we on?
- What town are we in?
- What county are we in?
- What country are we in?
Questions for MMSE for registration
Say names of three unrelated objects ‘apple, table, penny’ and ask patient to repeat.
Tell them you will ask again after a few minutes
Question for MMSE for attention and calculation
100 - 7 and keep going or
spell WORLD forwards and then backwards
Question for naming part of MMSE
Show your watch and pencil and ask to name it
Question for repetition part of MMSE
Ask patient to repeat the phrase ‘no ifs, ands or buts’
Question for 3-stage command of MMSE
Take paper in your hand, fold it in half and put it on the table
Question for reading part of MMSE
On paper write close your eyes and tell them to read the sentence and do what it says
Question for writing part of MMSE
Can you write a short sentence for me - should contain subject and verb
Question for drawing part of MMSE
Draw intersecting pentagons and ask person to copy - all 10 angles must be present and intersect
Frontal lobe aspects of MMSE
v Can you generate as many words as possible, beginning with a letter F,
but not names of people or places? You have got a minute’. (Testing for
one letter should suffice) OR
v ‘Can you name as many animals as possible, beginning with any letter.
You have got a minute’.
v Normal subjects can generate 15 letter/animals in one minute.
Test for semantic memory for MMSE
Name of current UK PM
Test for working memory
v I am going to say some numbers and when I am through, please repeat
them to me exactly as I said them
Now read the five number sequence at a rate of one digit per second-
3 1 9 6 4
v I am going to say some more numbers and when I am through, please
repeat them to me in the backwards order
Now read the three number sequence at a rate of one digit per second-
2 4 7
Normal person should be able to repeat all five numbers in forward sequence
and all 3 digits in backward sequence.
Aspects of frontal lobe testing
Ask hearing/visual difficulties Verbal fluency Cognitive estimates Similarities, proverbs First-edge Palm test Go-no-go test Alternating sequences, primitive reflexes
Describe verbal fluency aspect of frontal lobe testing
Ask to name as many words as possible with letters F, A or S in one minute - normal subjects produce at least 15.
Alternative is as many animals in a minute etc
Describe abstraction aspect of frontal lobe testing
Proverb interpretation: ask patient meaning of two common proverbs such as too many cooks spoil the broth and a stitch in time saves nine.
Describe similarities aspect of frontal lobe testing
The patient is asked to explain the similarities between things (use
things that are routinely used).
Tell me how an apple and a banana are alike. If the subject answers in
a concrete manner, then say only one additional time. Tell me
another way in which these items are alike. If the subject does not
give the appropriate answer which is fruit, say yes and they are also
both fruit’. Do not give any additional instructions. After the practice
trial, say ‘Now tell me how a train and a bicycle are alike’. Following
the response administer the 2nd trial saying ‘Now tell me how a ruler
and a watch are alike’
Example:
a. Train and a bicycle (means of transportation, means of
travelling are acceptable. ‘They have wheels’ is not an
acceptable response)
b. Ruler and a watch (used to measure, measuring instruments
are acceptable. ‘They have numbers’ is not an acceptable
response)
Explain cognitive estimation aspect of frontal lobe examination
- What is the height of an average English man?
* How many camels are there in England?
Explain coordinated movements aspect of frontal lobe examination
Go-no-go test: Ask the patient to place a hand on the table and to
raise one finger in response to a single tap, while holding still in
response to two taps. You tap on the under surface of the table to
avoid giving visual cues.
Luria three-step task: A sequence of hand positions is
demonstrated which would be placing a fist, then edge of the palm
and then a flat palm onto the palm of the opposite hand and
repeating the sequence (fist-edge-palm)
It can be demonstrated up to five times.
Describe some frontal lobe signs
Glabellar tap
Primitive reflex
Describe the glabellar tap
Tap between the patients’ eyebrows, which causes
repeated blinking even after five or more taps, if it is positive.
Describe primitive reflex
This would include Grasp reflex in which you
stroke the patient’s palm while distracting the patient, watch for
involuntary grasping and pouting reflex in which you tap on a
spatula on patient’s lips, resulting in spouting and both reflexes can
be subtle.
What are you looking for in luria motor test
Motor planning
Execution
Error correction
Tests for parietal lobe testing
Alexia and agraphia Anosognosia Calculation Constructional apraxia Finger agnosia R-L orientation Stereognosis Two point discrimination Visual field defects
Tests for working memory
Forward digit span
Backward digit span
Tests for anterograde memory
Registration and recall of three items
Registration and recall of an address
John Brown,
42, West street, Luton
Bedfordshire
Testing aspects of language
Comprehension Repetition Naming Word fluency Reading Writing
Describe comprehension testing
Simple commands e.g close your eyes
Describe repetition tests
Repeat ‘No Ifs and or buts’
Describe naming tests
Point to two or three objects and ask patient to name.
How to test ideomotor praxis
Show me how you brush your teeth?
Show me how you comb your hair?
Show me how you cut paper with scissors?
How to test ideational praxis
The subject should be asked to perform a complex task with
multiple steps for example, placing a letter in an envelope, sealing it, addressing
it, stamping it and then posting it.
How to test orobuccal praxis
Here the subject is asked to carry out specific movements on
command like stick out your tongue, lick your lips etc.
Tests for temporal lobe
v Short-term memory & anterograde amnesia- name and an address test
v Long term memory- Personal and semantic memory
v Language comprehension- word and sentence comprehension
Memory- Short-term & Anterograde memory (new learning)
Registration and recall of a seven-item name and address
Tests for parietal lobe
v Praxis- Constructional praxis/visuospatial- drawing a wire cube/clock drawing task v Ideomotor praxis v Orobuccal praxis Acalculia (100-7) Finger agnosia R-L orientation
Describe finger agnosia
Ask the patient to move on command or point to individual fingers- his own and
the examiners
Describe R-L orientation
Test the integrity of volitional movements and at the
same time of right-left orientation by asking the patient to point to various parts
of the body.
Ask them for example- Touch your left ear with your left hand,
Touch your left knee with your right hand etc
Testing of ideational praxis
- Wave goodbye
- Salute, like a soldier
- Keeping scissors in the sagittal plane
How can vascular dementia lead to frontal dysfuction
Involvement of subcortical structures leading to dysexecutive syndrome (apathy, impaired planning and judgement, declining ability to pay attention)
Incidence of serotonin syndrome
15% of people who have too much meds with 5HT
What is serotonin syndrome?
Serotonin syndrome is the constellation of symptoms caused by excess
serotonin in the central nervous system, typically caused by use of two or
more SSRI medication or following an overdose of SSRI medication.
Sx of serotonin syndrome
Autonomic - sweating, hyperthermia, tachy, GI sx
Cognitive sx - confusion, agitation, hallucinations, headache, coma
Somatic sx - hyperreflexia, myoclonus, tremor
Rx of serotonin syndrome
• Remove the precipitant medications
• Control hyperthermia (reduce muscle hyperactivity with
benzodiazepine); may require paralysis and artificial
ventilation
• Provision of cardiovascular and respiratory support to manage
autonomic instability
• An overdose can be treated with activated charcoal
• Benzodiazepines can be used to manage myoclonus
Prognosis of serotonin syndrome
• Serotonin syndrome will resolve 24 hours after the drugs clear
the system (which can be days if medication with long half-life
has been ingested)
• Prognosis is favourable with quick and appropriate medical
management
Relevant info to check when assessing financial capacity
• The person’s income, savings and expenditure
• Their financial needs and responsibilities
• Whether there are likely to be any changes in the person’s financial
circumstances.
• Does the person have basic skills to manage money- identifying
currency, adding notes/coins by value?
• Can the person correctly state what change they would expect for
one or more items of differing value?
• Can they understand what a bank account, a chequebook, a cash
card and a credit card are?
• Can they understand the parts of a cheque and its stub and
complete a dummy transaction?
• Can they explain the parts of their bank statement?
• Can they identify solicitation by advert (post/email) for legitimate
and bogus (spam) financial transactions?
Things to explore when assessing someones capacity to refuse treatment
- The nature of the problem and proposed treatment
- Why someone has said that he/she needs it
- The treatment’s principle risks and benefits
- Patient’s ability to retain this information and make a reasoned
decision - The consequences of not receiving the proposed treatment.
- Whether he or he has an impairment or disturbance in the
functioning of the mind or brain (especially delusional ideas) - Patient’s reasons for refusing treatment.
What are first rank sx?
• Auditory Hallucinations- Third person auditory hallucinations, Running
commentary hallucinations
• Thought-Alienation Phenomena- Thought withdrawal, Thought
insertion and Thought broadcasting
• Passivity phenomena-Made feelings, made impulses and made volition
or acts, somatic passivity
• Delusional perception
Core features of mania
Elated mood
Irritable
Increased energy resulting in insomnia
Principal sx of PTSD
Hyperarousal
Intrusions
Avoidance
Sx of hyperarousal in PTSD
- Persistent anxiety and Irritability or outbursts of anger
- Insomnia
- Poor concentration and exaggerated startle response
Sx of intrusions in PTDS
- Intensive intrusive imagery (flashbacks)
- Vivid memories
- Recurrent distressing dreams and nightmares
Sx of avoidance in PTSD
- Actual or preferred avoidance of circumstances resembling or associated
with the stressor - Emotional detachment and inability to feel emotions
- Diminished interest in activities.
Questions for intrusions in PTSD
- How often do you think about the accident?
- Do you sometimes feel as if the accident is happening again?
- Do you get flashbacks?
- Have you revisited the scene?
- Do you get any distressing dreams/nightmares of the event?
- What would happen if you hear about an accident?
- Do you have any difficulties remembering parts of the accident?
Questions for hyperarousal in PTSD
- Have you had the feeling that you are always on the edge?
- Do you tend to worry a lot about things going wrong? (Feeling anxious)
- Do you startle easily? (Enhanced startle response)
- Tell me about your sleep please. (Explore for sleep disturbance)
- Are you sometimes afraid to go to sleep?
- How has your concentration been recently?
- How has your memory been lately?
- Do you loose your temper more often that you used to? (Irritability)
Questions for avoidance in PTSD
• How hard is it for you to talk about the accident?
• Do you deliberately try to avoid thinking about accidents?
• Have you been to the place where the accident happened?
• Do you make any effort to avoid the thoughts or conversations associated
with the trauma? How would you do that?
• Do you make any effort to avoid activities, places or people that arouse
recollection of the trauma?
Examples of social impairment in autism
Marked impairment in the use of multiple nonverbal behaviors such as
eye-to eye gaze, facial expression, body postures, and gestures to
regulate social interaction
Failure to develop peer relationships appropriate to developmental
level
Lack of spontaneous seeking to share enjoyment, interests, or
achievements with other people
Lack of social or emotional reciprocity
Examples of restricted interests in autism
Encompassing preoccupation with one or more stereotyped and
restricted patterns of interest that is abnormal either in intensity
or focus
Apparently inflexible adherence to specific, nonfunctional routines or
rituals
Stereotyped and repetitive motor mannerisms
Persistent preoccupation with parts of objects
Risk factors for Alzheimers
- Age
- Presence of Apolipoprotein e4 allele
- Female sex
- Down’s syndrome
- H/O of Head injury
- Postmenopausal oestrogen decline
- Education <8 years
- HTN, Coronary artery disease, diabetes, high cholesterol.
Prevalence of Alzheimers in those >65
10%
Prevalence of Alzheimers in those >85
50%
How many people develop Alzheimers in their 40s and 50s
1%
How many people with early onset Alzheimers in 40s and 50s have inherited genetic mutations?
50%
Risk of developing Alzheimers of children of patients with early onset Alzheimers
50%
What is apraxia
Inability to carry out purposeful movements without sensory or motor impairment
What is agnosia
Failure of recognition, especially people
What is aphasia
Problems with language
Cognitive sx to explore in dementia
Short and longterm memory Orientation Attention & concentration Visuospatial abilities Temporal and spatial disorientation Naming and recognition ADLs Judgement and decision making
Questions for temporal and spatial disorientation
Losing the way at home or neighbourhood
Getting lost in familiar routes
Questions for visuospatial difficulties
- Does he have difficulty recognising things, places or people?
- Does he have difficulty in recognising familiar faces?
Questions for language difficulties
- How about the way he speaks?
- Does he have any word-finding problems?
- Can he understand when someone speaks to him?
Questions for judgement and decision making
What about planning, making decisions etc?
Has he got difficulty in solving everyday problems that he used to solve?
Questions for behavioural sx in dementia
• Has there been any change in his behaviour like being more irritable than usual?
• Have you noticed any change in personality that seems to have occurred recently?
• Ask about becoming aggressive frequently, episodes of violent and anger outbursts
• Also enquire about behaving inappropriately, socially withdrawn, wandering at
nighttime, disinhibited behaviour, repetitive behaviours etc.
Risk assessment in dementia
Self neglect Self harm Falls Wandering Fire risk - home safety, using cooker safely, smoking Financial management Risk of driving
Non-pharma treatment for dementia
Safe environment with predictable routine
Memory enhancement techniques - calendars, lists, alarms
Encourage physical and mental activity including social activities
OT - home assessment to identify hazards
Simply meds into dosette box
Carers for ADLs
Psychoeducation to patient and family
Carer support
Any medical factors like infection, drug SEs
Address vascular risk factors
Efficacy of antidementia drugs
40-50% of people show some improvement or stabilisation of their condition over a 6 month period
How often do you do MMSE when patient is on antidementia drugs
Baseline
Every 6 months - suggested to stop drugs once MMSE goes <10/30
Causes of wandering behaviour in Dementia
Boredom Energy - need for exercise Short term memory loss Confusion about time Feeling lost in new environment Pain - arthritic pain Response to anxiety Searching for the past - searching for someone or something relating to the past or a task to perform e.g. related to a previous occupation
Early sx in vascular dementia
Emotional and personality changes
ü Depression and anxiety with episodes of affective lability and
confusion are common, especially at night.
ü Urinary incontinence and falls without other explanation are
often early features.
Prognosis of vascular dementia
5-7 years
Treatment of psychotic sx in Parkinsons
Reassurance and psychoeducation - possible SE of meds
It is important to acknowledge that medicines that treat
symptoms in one domain (motor symptoms) may worsen
symptoms in other domains (non motor symptoms) and
therefore adopting a balanced approach is very important
• Gradual withdrawal of non-essential drugs such as
anticholinergics, selegeline, amantadine and dopamine
agonists. Monitor for signs of motor deterioration.
• If necessary, core reduction in levodopa therapy. Readjust
dose of L-Dopa, Alter the timing of meds and doses, preferably
giving L-dopa after food. This might slow down the rate of
absorption and minimize the side effects.
• ‘Wait and watch policy’ is often adopted.
• Add an atypical antipsychotic in the hope of attenuating future
psychosis.
• Consider oral atypical antipsychotic medication, preferably
quetiapine (12.5 mg-75 mg but higher doses may be required)
associated with lower incidence of EPSEs and also it dose not
require blood count surveillance. In refractory cases use
clozapine in small doses is preferred as it is the most effective
and only licensed antipsychotic in PD but regular blood tests
and close monitoring for neutropenia and agranulocytosis is
essential.
• Consider ACHEIs inhibitors such as Rivastigmine, particularly
if the patient has dementia and it may be also useful in treating
hallucinosis and psychosis and can help with other
neurobehavioral features such as apathy and anxiety.
Core features of FTD
- Insidious onset and gradual progression.
- Early decline in social interpersonal conduct.
- Early impairment in regulation of personal conduct.
- Early emotional blunting.
- Early loss of insight.
Behavioural features of FTD
o Decline in personal hygiene and grooming.
o Mental rigidity and inflexibility.
o Distractibility and impersistence.
o Hyperorality and dietary changes.
o Perseverative and stereotyped behaviour.
o Utilisation behaviour.
Speech and language features of FTD
o Altered speech output (aspontaneity and economy of speech/ pressured speech). o Stereotypy of speech. o Echolalia. o Perseveration. o Mutism.
Risk of developing dementia in those with MCI
10-15% develop dementia in a year compared to 1-2% of gen pop >65
Predictors of those with MCI developing dementia
- Older age
- Severity and nature of baseline cognitive performance (particularly
impaired episodic recall) - Presence of particular genotype (APOE e-4)
- Presence of functional impairments
Prevalence of depression in >65
10%
How many people >65 with depression show cognitive impairment
70%
Recovery time for depression in >65 being treated with meds
6-8 weeks
Maintenance period on antidepressant for >65 who have had depression
Up to 2 years, may be lifelong
1 year if one episode of depression
When is a will considered legally valid
if the testator is of “Sound disposing
mind” at the time of making it.
Legal criteria for testamentary capacity
ü Whether the testator understands what a will is and what the
consequences are (Is ware of what a will constitutes)
ü Basic understanding of the nature and extent of the property.
(Knows the general extent of their assets)
ü He/she must be aware of the people who might reasonably
expect to benefit from the assets (should know the name of
close relatives and can assess their claims to the property)
ü He/She should be free from an abnormal state of mind and
must be free of delusional beliefs that might affect the
distribution of assets and must not be under the influence of
any drugs that tend to distort the patient’s mental capacity as
far as making a will is concerned.
What must patients who drive do when newly diagnosed with dementia
Notify DVLA and insurance providers
Based on medical reports, decision re fitness to drive is made
What happens to group 1 drivers with dementia
In early dementia when sufficient skills are
retained and progression is slow, a licence may be issued subject to
annual review. A formal driving assessment may be necessary.
What happens to group 2 drivers with dementia
Refuse or revoke licence. Those who have poor
short-term memory, disorientation, lack of insight and judgement are
almost certainly not fit to drive.
