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Mental Health > Case 4 - Dementia > Flashcards

Case 4 - Dementia Flashcards

1
Q

What is the most comprehensive test of cognitive function?

A

Addenbrooke’s Cognitive Examination

(ACE-iii or ACE-R for revised)

  • Tests 5 basic executive functions
  • Score out of 100
  • < 82 = considered abnormal (NOT a diagnostic test)
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2
Q

What 5 aspects of cognition does an ACE-iii examine?

A
  • Memory
  • Attention
  • Fluency
  • Visuospatial skills
  • Language

N.B. informally it also tests your higher executive function i.e. task planning / management - which requires the above basic executive functions.

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3
Q

Name 2 short/simple cognitive assessments?

A

MOCA (Montreal Cognitive Assessment)

  • Score out of 30
  • < 26 = suggests MCI (mild cognitive impairment)
  • < 17 = suggests dementia)

MMSE (mini mental state examination) - less used due to copyright issues

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4
Q

What assessment tool can be used to discriminate between dementias with impact on frontal executive function and Alzheimer’s dementia?

A

Frontal Assessment Battery (FAB)

  • Can be used in mildly demented pts or better (MMSE > 24)
  • Total score is out of 18 (higher score = better performance)
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5
Q

Dementia syndromes can be divided into cortical and subcortical.

To what do these regions refer to?

How are cortical and subcortical dementia characterised?

A

Cortical = outer layer i.e. cerebral cortex

Subcortical = areas beneath cortex e.g. basal ganglia, limbic system (amygdala, hippocampus), diencephalon (thalamus, hypothalamus)

DEMENTIA:
- Cortical dementia = early symptoms include higher function difficulty e.g. memory, language, dyspraxia (visuospatial), lack extra-pyramidal features

  • Subcortical dementia = early symptoms don’t tend to involve higher function, but do include; behaviour, mood/affect, motor slowing, extra-pyramidal features
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6
Q

Dementia syndromes can be divided into cortical and subcortical.

Give examples of each cortical and subcortical dementia.

A

CORTICAL:

  • Alzheimer’s dementia
  • Lewy-body dementia (memory before motor)
  • Fronto-temporal dementia (Pick’s disease)

SUBCORTICAL:

  • Vascular dementia
  • Parkinson’s dementia (motor before memory)
  • Wilson’s dementia
  • Huntington’s
  • HIV/AIDS dementia
  • MND / MS dementia
  • Alcohol related dementias
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7
Q

Which parts of the brain does Alzheimer’s disease characteristically affect?

A

Medial temporal lobe i.e. hippocampus - impacts episodic memory (anterograde amnesia)

Lateral temporal lobe i.e. Wernicke’s area - can cause receptive dysphasia (difficulty understnading written or spoken language but have fluent speech without meaning i.e. word salad)

Anterior + inferior temporal lobe - impacts semantic memory (general knowledge e.g. facts, ideas, concepts)

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8
Q

What are the four most common types of dementia?

A
  • Alzheimer’s disease (2/3rds of dementia)
  • Vascular dementia
  • Lewy Body dementia (~15% of dementia)
  • Fronto temporal dementia
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9
Q

What investigations are reccomended for someone with suspected dementia?

A

Bloods:

  • Done to exclude reversible causes
  • FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels

MRI / CT:
- Done to exclude reversible causes e.g. subdural haematoma, normal pressure hydrocephalus

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10
Q

What are the recommended pharmacological management steps for Alzheimer’s disease?

A
  1. One of the 3 acetylcholinesterase (AChE) inhibitors - mild-moderate AD
    - Donepezil
    • ​once daily, long-half life, start 5mg and ↑ to 10mg after 1 month
      - Galantamine​
    • Oral solution, tab and modified release cap
      - Rivastigmine (also a butyrylcholinesterase inhibitor)
      - short half life (1hr), BD, daily patch more common
  2. Memantine (NMDA receptor antagonist) recommended:
    - Monotherapy in severe AD OR
    • Moderate AD + intolerant / contraindication to AChE inhibitors OR
    • In addition to AChE inhibitors for moderate-severe AD
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11
Q

What are the recommended pharmacological management steps for NON- Alzheimer’s disease?

A

LEWY-BODY:

  1. Offer donepezil or rivastigmine
  2. Consider galantamine (only if donepezil or rivastigmine not tolerated)
  3. Consider memantine (if AChE inhibitors not tolerated/contraindicated)
  4. Some parkinson’s medication (e.g. levodopa) can help with movement impairment

VASCULAR:
1. Only consider AChE inhibitors or memantine for vascular IF they have suspected comorbid AD, PD dementia or Lewy-body

FRONTO-TEMPORAL DEMENTIA OR MS COGNITIVE IMPAIRMENT:
1. DO NOT offer AChE inhibitor OR memantine

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12
Q

What investigations need to be done prior to starting a AChE inhibitor or NMDA receptor antagonist (memantine)?

A

ECG - to assess HR, arrhythmias and QTc interval

  • AChE inhibitors are contraindicated for pts with; bradykinesia, Left Bundle Branch Block or a ↑ QTc interval
  • AChE inhibitors also contraindicated if Hx of; gastric ulcers or seizures

U+Es:
- Memantine can cause acute renal failure

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13
Q

What are some common side effects of AChE inhibitors?

A
  • Nausea / vomiting
  • Diarrhoea
  • Urinary incontinence
  • Headache / dizziness
  • Insomnia
  • Muscle cramps
  • ↓ Appetite –> weight loss
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14
Q

In addition to cognitive symptoms of dementia, what other categories of symptoms are there?

A

Non-cognitive i.e.

Behavioural and Psychological symptoms of dementia (BPSDs) e.g.

  • Hallucinations
  • Delusions
  • Anxiety
  • Behaviour: marked agitation, aggression, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity such as shouting
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15
Q

What psychological treatments are available for the management of cognitive + BPSDs in dementia?

A
  • Cognitive stimulation therapy (CST)
  • CBT
  • Reminiscence therapy
  • Aromatherapy
  • Sensory stimulation
  • Music therapy
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16
Q

What pathological changes occur to a brain with Alzheimer’s?

A

MACROSCOPIC:

  • Widespread cerebral cortical atrophy
  • Medial temporal lobe atrophy (particularly hippocampus)
  • Enlarged ventricles (due to cerebral atrophy)

MICROSCOPIC:

  • Beta-amyloid plaques (cortex)
  • Neurofibrillary tangles (intraneuronal aggregation of tau protein)

BIOCHEMICAL:
- Acetylcholine deficit (due to factors above) - loss of cholinergic neurons and ↓ ACh

17
Q

Describe dementia in layman’s terms.

A

-

18
Q

What are some risk factors for dementia?

A

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19
Q

How does Alzheimer’s present clinically?

A

-

20
Q

What pattern of inheritance does early onset Alzheimer’s follow?

What genes are involved?

A

-

21
Q

What genetic disorder conveys a high risk of also developing Alzheimer’s?

A

-

22
Q

What are the features of dementia with Lewy-bodies?

A

-

23
Q

Which of the following are mandatory parts of a standard dementia screening of an individual with memory loss which are essential for dementia diagnosis? (Select TWO)

  • Neuropsychological assessment
  • Cognitive testing
  • History-taking
  • SPECT scan
  • Brain imaging - MRI/CT
A

-

24
Q

How would you summarise the treatment available for Alzheimer’s?

(think conservative and pharmacological/medical)

A

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25
Q

Vascular Dementia:

  • What are the risk factors?
  • What is the pathophysiology?
  • How would you summarise the treatment?
A

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26
Q

What investigations would you do as part of a confusion screen?

(think: bedside, bloods, imaging)

A

-

27
Q

Anticholinergic drugs DECREASE the effect of AChE inhibitors.

Name some anti-cholingeric drugs.

A

-

28
Q

Separate the following statements by whether they are true of Alzheimers or DLB.

  • More common in men
  • Gradual decline in cognitive impairment
  • Fluctuating cognitive impairment
  • More common in women
  • Physical deterioration usually at a late stage
  • Decrease in facial expression develops later in disease
  • Visual hallucinations occur early
  • Hallucinations may occur, but in late stages
  • Early problems with balance
  • Face shows very little emotion from early in the disease
A

-

29
Q

What do the BMJ list as core clinical features of dementia with Lewy-bodies?

(supportive clinical features or biomarkers are less important but can add to picture)

A

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30
Q

What is the pathology underpinning DLB?

A

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31
Q

What medication can be given to manage REM sleep behaviour disorder (RBD - can be a feature of dementia with lewy-bodies)?

A

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32
Q

In patients with DLB and who have psychotic symptoms which are making the patient challenging (e.g. shouting, hitting etc) - if you choose to give an anti-psychotic, what are the best choices?

A

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33
Q

How can you differentiate between DLB and Parkinson’s disease with dementia?

A

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34
Q

What are common features of Fronto-temporal dementia

also called Pick’s disease?

A

-

35
Q

What are the features (symptoms and radiological) of normal pressure hydrocephalus?

A

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Mental Health (5 decks)

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