Case 4 - Dementia

Question 1

What happens in the first video? What symptoms is the patient presenting?

Answer 1

Grand-daughter brings in Emily Wilkins
E.W. is not worried, thinks her forgetting is due to ‘old-age’ and is normal, thinks her family is making a fuss
But her granddaughter has noticed she is: very forgetful, falling a lot lately, ‘a disaster waiting to happen’, forgotten to pay her bills, left the oven on, saying it’s very unlike E.W. to be like this / present with this
Her granddaughter thinks she changed after her husband died

Question 2

What is the 6-CIT (Six item cognitive impairment test) - what are the questions in it, and how does the patient score on it?

Answer 2

1. What year is it? : 0 [0=correct, 4=incorrect]
2. What month is it? : 0 [0=correct, 3=incorrect]
   Give the patient an address to remember e.g. ‘John, Smith, 42, West St, Bedford’
3. About what time is it (within 1hr)=0 [0=correct, 3=incorrect]
4. Count backwards from 20-1 : 2 [0=correct, 2=1 error, 4=more than 1 error] - missed out ‘5’
5. Say the months of the year in reverse : 2 [0=correct, 2=1 error, 4=more than 1 error] - missed out ‘April’
6. Repeat the address previously stated : 4 [0=correct, 2=1 error, 4=2 errors, 6=3 errors, 8= 4 errors, 10=all wrong]
   =8

Question 3

What are the ranges?

Answer 3

Ranges -
0-7 = normal
8-9 = mild cognitive impairment
10-28 = significant cognitive impairment

Question 4

Why is this system (6-CIT) better than previous tests to look for cognitive impairments?

Answer 4

Scaled - shows level of impairment
Some things more important than others so scaled / given points accordingly
Previous assessments were more culture biased e.g. ‘Who is the queen?’ - assumes everyone knows british history, politics, etc.
This system is less culturally biased, more useful as the UK is increasingly diverse and this tests cognitive funciton rather than knowledge

Question 5

Who to and why refer?

Answer 5

Specialist
To see if it is mild or more significant
Find the root cause - normal aging process, mild cognitive impairment or dementia?

Question 6

How does dementia present at an early stage?

Answer 6

Forgetting small things

Difficulty thinking

Question 7

Dementia Vs mild cognitive impairment (MCI)?

Answer 7

Dementia is progressive, gets much worse overtime - beyond what is normal for aging, deterioration in cognitive function - memory, thinking etc. However, consciousness is not affected!
MCI is more cognitive impairment than the usual healthy person of the same age, however, not as severe and so does not disrupt daily life as badly, therefore not considered to be dementia
Many dementia patients present with MCI initially, and then go on to develop dementia, however, not all MCI patients will develop dementia

Question 8

What can the dementia solcial worker do?

Answer 8

Look at safety in her home - is patient okay living alone in her house?

Question 9

What can a dietician do?

Answer 9

Help look at the diet and how it affects the patient’s neurology etc.
Sort out diet plan for her meals if they cannot think for themsleves

Question 10

What can carers provide?

Answer 10

Help her at home with daily tasks

Question 11

What can voluntary services provide?

Answer 11

Support - give them company

Spend time with them - improves their mood and perhaps helps reduce the speed of the progression

Question 12

What can dementia be co-morbid with?

Answer 12

Depression - may feel very lonely

Question 13

What can a specialist nurse provide?

Answer 13

Administering medication

Docit box / blister packs - preloaded medications

Question 14

What can occupational therapists do?

Answer 14

Assess their home + environment

Help the patient adapt their home to make it more suitable / safe - e.g. railings, lift chairs, etc.

Question 15

What can a physiotherapist help her with?

Answer 15

Rehabilitation - issues with mobility = strengthen them through exercises

Question 16

Can these patients potentially presenting with cognitive impairment make their own decisions?

Answer 16

Perhaps, though there will be a point where the family and MDT together decide the patient lacks capacity

Question 17

How can capacity be assessed?

Answer 17

The test looks for the patient to:
Understand, retain, use the information to come to a decision, and recall / communicate their decision
Use MCA guidelines - if they can’t do any 1 of these, they may not have capacity

Question 18

What are the 5 principles of the Mental Capacity Act (MCA)?

Answer 18

1. Assume everyone has capacity - can make their own decisions. Also must have some sort of diagnosis that could potentially affect their capacity (not just saying they don’t have capacity because you don’t agree with their decision)
2. Do not treat people as incapable of making a decision unless all practicable steps have been tried to help them
3. A person should not be treated as incapable of making a decision because their decision may seem unwise
4. Always do things or take decisions for people without capacity in their best interests
5. Before doing something to someone or making a decision on their behalf, consider whether the outcome could be achieved in a less restrictive way.

Question 19

What are some issues with assessing capacity and how is this issue targetted / improved?

Answer 19

Subjective - 2 doctors sign the form assessing capacity independently
Sometimes need to make decisions v. quickly, so 1 doctor makes the decision, and lack of capacity is in place for 24hrs, and then another doctor must come and assess.
Might change - Must be assessed many times over time e.g. deterioration over time, or mental capacity comes back after an event etc.

Question 20

For an adult who has no capacity, who has the say for their care?

Answer 20

Medical team

Question 21

For a child, who has the say for their care?

Answer 21

Partly the parents / family, partly the medical team

Question 22

What are the 4 common types of dementia?

Answer 22

Alzheimer’s
Vascular
Lewy Body
Fronto-temporal Dementia

Question 23

What is Alzheimer’s and what are its symptoms?

How does it progress?

Answer 23

50% of dementia patients have this

Memory loss, confusion, gradual onset (deterioration), more likely to retain LTM than STM

Question 24

What is vascular dementia and what are the symptoms?
What can it stem from?
How does it progress?

Answer 24

25% of dementia patients have this
Often stems from multiple mini strokes affecting different areas of the brain - atherosclerosis, problems with speech / motor function, stroke-like symptoms e.g. paralysis of the limb, numbness of face etc., traced to cardio-vascular problems as process of atherosclerosis affects the whole body including the heart, carotid arteries, peripheripheral vascular disease e.g. issues with circulation in the arteriole system in their limbs; hypertension, high cholestrol, smoking, obesity, diabetes, family history of athersclorosis etc.
Progression is step wise, deteriorate, stabilise, deteriorate etc.
Medications can help with atherosclerosis to delay / stabilise for longer

Question 25

What is lewy body dementia and what are its symptoms?

Answer 25

Build up of proteins in the cortex in the brain stem, important for movement, can cause hallucinations, sleep disorders, some confusion, Parkinsonian symptoms e.g. shuffling of the feet, tremor, poor posture etc.

Question 26

What is fronto-temporal dementia and what are its symptoms?

Answer 26

Become different as people, don’t have a filter on what is inappropriate to say, personality almost fully changes

Question 27

What are the key pathological findings in Alzheimer’s disease?

Answer 27

1. Extra-cellular amyloid (abnormal protein) plaques - Beta-amyloid peptide production and deposition in the brain’s grey matter (avoid saying lumps / growths - may make them think its cancer)
2. Intracellular neurofibrillary tangles - abnormal tau proteins causing malformed microtubules = tangling of these fibres inside the neurons preventing proper functioning / causing reduction in function
3. Synaptic deterioration and neuronal death - connections between the nerve cells are not functioning, and some of the neurons are damaged / dying
4. Gross cerebro-cortical atrophy - brain tissue is reducing in volume because of cell death

Question 28

What are the 3 common areas of the brain that are affected majorly by Alzheimers?

Answer 28

Posterior cingulate cortex, anterior thalamus and hippocampus

Question 29

Label the posterior cingulate cortex, anterior thalamus and hippocampus?

Answer 29

PCC - located above the hypothalamus in the brain matter
AT - Big round red thing in the middle
H - located just above the brain stem, under the AT

Question 30

What are 3 major functions affected by the involvement of these areas?

Answer 30

Attention
STM
Orientation

Question 31

Which brain region corresponds to which impairment and which questions of the 6-CIT tests this function?

Answer 31

Posterior cingulate cortex - orientation - Year? Month? Time?
Hippocampus - STM (associated with amnesia) - address?
Anterior thalamus - Attention - counting backwards, saying months in reverse

Question 32

What does E.W.’s 6-CIT point to?

Answer 32

Hippocampus and Anterior Thalamus deterioration

Question 33

What is the limbitic system?

Answer 33

Supports memory, emotion and behaviour

Includes the cingulate gyrus, hippocampus, anterior thalamus and entorhinal cortex (as well as some other structures)

Question 34

What were the key findings from the MCI paper?

Answer 34

Reduced posterior cingulate cortex volume
Reduced entorhinal cortex volume (part of the temporal lobe)
Decreased fractional anistrophy in the parahippocampal cingulum

Question 35

What does the patient’s profile say about her?

Answer 35

She likes spending time with her grandchildren
Emily suffers from hypertension and is on amlodipine
She likes embroidery
Emily’s husband died suddenly of a heart attack three years ago
She was a shopkeeper, she ran the shop with her husband, but sold it after her husband’s death
Emily plays bridge with friends once a week at her local bridge club

Question 36

What is dementia?

Answer 36

A chronic and progressive syndrome - deterioration in cognitive functions i.e. memory, thinking, behaviour and the ability to perform everyday activities
Not a normal part of ageing

Question 37

How does dementia impact people / society?

Answer 37

Psychological impacts on not only the patients, but their families and carers too
Huge economic implication
One of the biggests causes of dependency
Conflicts with human rights i.e. dementia patients often denied basic human rights / freedom due to the extentive restraints in care homes etc.

Question 38

What are the early stage dementia signs and symptoms?

Answer 38

Forgetfulness
Losing track of the time
Becoming lost in familiar places

Question 39

Why is it difficult to catch dementia early and why is this an issue?

Answer 39

Often overlooked as the onset of symtoms are gradual and associated with ‘old-age’ forgetting
Issues with early prevention strategies as less likelyto catch dementia early

Question 40

What causes / triggers dementia?

Answer 40

Often as a result of a variety of diseases / injuries such as:
Alzheimers, strokes, etc.

Question 41

What are the middle stage dementia signs and symptoms?

Answer 41

Becoming forgetful of recent events and people’s names
Becoming lost at home
Having increasing difficulty with communication
Needing help with personal care
Experiencing behaviour changes, including wandering and repeated questioning

Question 42

What are the late stage dementia signs and symptoms?

Answer 42

Near total dependence and inactivity
Serious memory disturbances
Becoming unaware of the time and place
Having difficulty recognizing relatives and friends
Having an increasing need for assisted self-care
Having difficulty walking
Experiencing behaviour changes that may escalate and include aggression

Question 43

What is MCI?

Answer 43

Mild cognitive impairment (NOT a type of dementia)
Minor problems with cognition - difficulties are worse than would normally be expected for a healthy person of their age
However, the symptoms are not severe enough to interfere significantly with daily life, and so are not defined as dementia

Question 44

What are some symptoms of MCI?

Answer 44

Forgetting events / repeating the same question
struggling with thinking things through
Very easily distracted (lack of attention)
Longer than usual to find the right word to describe
Struggling with visual depth perception

Question 45

What are some inteventions / strategies for cognitive decline and dementia?

Answer 45

Prevent dementia or delay its onset by reducing associated risk factors through:
Public health approaches and lifestyle modification
Slow down the progression of dementia or MCI, through drug treatments and / or lifestyle changes
Focus on quality of life, enabling those with a diagnosis to live as well as possible with the condition
Strong link between cognitive function and physical function (found by many studies)

Question 46

What lifestyle factors are believed to benefit cognitive function in later life?

Answer 46

Physical activity
Mediterranean diet
Not smoking
Not drinking to excess

Question 47

What are some post-diagnostic interventions?

Answer 47

Reduce social isolation
Cognitive stimulation
Prompt treatment of infection
Prompt treatment of depression

Question 48

What are the 3 categories of cognitive interventions and are they useful?

Answer 48

Cognitive stimulation - group activities that are
designed to increase cognitive and social functioning in a nonspecific manner
Cognitive training - more scientific approach, teaches supported strategies and skills to optimize specific cognitive functions
Cognitive rehabilitation - individualised approach, focused on daily activities, personal goals identified and therapist, family and the patient work collectively towards the goal
Still being explored - generally objectively show no difference compared to the control group, however, people subjectively (i.e. patients feel) think their cognitive function is improving

Question 49

What is the favoured hypothesis for the amyloid plaques and what are some issues with this hypothesis?

Answer 49

Amyloid cascade hypothesis
Amyloid precursor protein that is normally cleaved by alpha secretases, instead gets cleaved by beta and gamma secretases
Abnormal beta-amyloid proteins produced instead, which deposit as insoluble plaques
However, these plaques are found in people without dementia, and the amount of plaque does not correlate with the severity of dementia

Question 50

What are NFTs and how do they contribute to Alzheimer’s?

How do NFTs link to beta-amyloids?

Answer 50

Neuro-fibrillary tangles - formed when the tau protein normally involved in the microtubule productio is hyper-phosphorylated and so aggregates into NFTs
Disrupts the microtubule system resulting in impaired neuronal growth, transport and communication
Deposit in the hippocampus and medial temporal lobe
There is a positive correlation between disease severity and the location and density of NFTs
Suggestions that Beta-amyloid promotes tau hyperpolarisation, and presence of of beta-mayloid only toxic if NFTs are also present

Question 51

How does cerebro-cortical atrophy contribute to Alzheimer’s?

Answer 51

Loss of synapses
Particular loss of neurons in the nucleus basalis of MeynertThese neurones are particularly rich in Acetylcholine and supply the hippocampus, amygdala and neocortex and so neuronal loss in this region results in a relative deficiency Acetylcholine
Acetylcholine is involved in memory function

Question 52

What is a common mechanism for alzheimer’s drugs currently present?

Answer 52

Supply acetylecholine to replace the deficit

Question 53

What causes the sleeping and mood disorders in patient’s with Alzheimer’s?

Answer 53

Loss of neurones in the brainstem’s median raphe and locus ceruleus neurones results in reduction in serotonin and noradrenaline levels, respectively, which contributes to the mood and sleep effects of the disease

Question 54

What is the ethical framework (6 components) to address the ethical issues associated with dementia?

Answer 54

Component 1: A ‘case-based’ approach to ethical decisions: Ethical decisions can be approached in a three-stage
process - identifying the relevant facts; interpreting and applying appropriate ethical values to those facts; and comparing the situation with other similar situations to find ethically relevant similarities or differences
Component 2: A belief about the nature of dementia: Dementia arises as a result of a brain disorder, and is harmful to the individual
Component 3: A belief about quality of life with dementia: With good care and support, people with dementia can
expect to have a good quality of life throughout the course of their illness.
Component 4: The importance of promoting the interests both of the person with dementia and of those who care
for them: People with dementia have interests, both in their autonomy and their well-being. Autonomy is not simply
to be equated with the ability to make rational decisions. A person’s well-being includes both their moment-to-moment experiences of contentment or pleasure, and more objective factors such as their level of cognitive functioning. The separate interests of carers must be recognised and promoted.
Component 5: The requirement to act in accordance with solidarity: The need to recognise the citizenship of people with dementia, and to acknowledge our mutual interdependence and responsibility to support people
with dementia, both within families and in society as a whole.
Component 6: Recognising personhood, identity and value: The person with dementia remains the same, equally valued, person throughout the course of their illness, regardless of the extent of the changes in their cognitive and other functions.

Question 55

What is an ethical approach to a care pathway for people with dementia?

Answer 55

People should have access to good quality assessment and support from the time they, or their families, become concerned about symptoms that relate to a possible diagnosis of dementia
Professionals responsible for communicating a diagnosis of dementia should actively encourage the person with dementia to share this information with their family, making clear that the diagnosis is of importance to those providing informal care and support
Welcome the increasing emphasis on services which are flexible and appropriate to the individual