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