Case 4: Dementia

Question 1

which form of dementia is the most common and what percentage is it?

Answer 1

60-70%, alzheimers

Question 2

definition of dementia

Answer 2

Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing.

Question 3

hallmarks of dementia

Answer 3

It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation.

Question 4

symptoms of early stage of dementia

Answer 4

forgetfulness
losing track of the time
becoming lost in familiar places.

Question 5

symptoms of middle stage of dementia

Answer 5

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 6

symptoms of late stage dementia

Answer 6

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 7

what are the major forms of dementia

Answer 7

Alzheimers. Other major forms include vascular dementia, dementia with Lewy bodies (abnormal aggregates of protein that develop inside nerve cells), and a group of diseases that contribute to frontotemporal dementia (degeneration of the frontal lobe of the brain). The boundaries between different forms of dementia are indistinct and mixed forms often co-exist.

Question 8

how many people have dementia worldwide?

Answer 8

50 million

Question 9

what percentage of people with dementia live in middle and low class countries?

Answer 9

60%

Question 10

every year, how many new cases of dementia are there?

Answer 10

Every year, there are nearly 10 million new cases.

Question 11

Estimated proportion of general population aged 60 and over

Answer 11

The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%.

Question 12

How many people are projected to have dementia in 2030 and 2050?

Answer 12

The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050.

Question 13

principle goals for dementia care

Answer 13

early diagnosis in order to promote early and optimal management
optimizing physical health, cognition, activity and well-being
identifying and treating accompanying physical illness
detecting and treating challenging behavioural and psychological symptoms
providing information and long-term support to carers.

Question 14

risk factors for dementia

Answer 14

age
exercise
smoking
depression
alcohol
weight 
diet
blood cholesterol
blood sugar
blood pressure
low educational attainment
social isolation
cognitive inactivity

Question 15

global societal cost of dementia

Answer 15

1.1% of global gross domestic product (GDP)

Question 16

what are the negative ways of treating dementia in some countries?

Answer 16

In many countries, physical and chemical restraints are used extensively in care homes for older people and in acute-care settings, even when regulations are in place to uphold the rights of people to freedom and choice.

Question 17

what is mild cognitive impairment?

Answer 17

Mild cognitive impairment (MCI) is a condition in which someone has minor problems with cognition - their mental abilities such as memory or thinking. In MCI these 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. In some people, MCI is a pre-dementia condition.

Question 18

what percentage of people over the age of 65 have MCI?

Answer 18

It is estimated that between 5 and 20% of people aged over 65 have MCI. It is not a type of dementia, but a person with MCI is more likely to go on to develop dementia.

Question 19

symptoms of MCI?

Answer 19

memory - for example, forgetting recent events or repeating the same question
reasoning, planning or problem-solving - for example, struggling with thinking things through
attention - for example, being very easily distracted
language - for example, taking much longer than usual to find the right word for something
visual depth perception - for example, struggling to interpret an object in three dimensions, judge distances or navigate stairs.

Question 20

Differences between MCI and normal ageing?

Answer 20

Most healthy people experience a gradual decline in mental abilities as part of ageing. In someone with MCI, however, the decline in mental abilities is greater than in normal ageing. For example, it’s common in normal ageing to have to pause to remember directions or to forget words occasionally, but it’s not normal to become lost in familiar places or to forget the names of close family members.

Question 21

What can sometimes be causing symptoms of MCI?

Answer 21

Some people with MCI will turn out to have a different, often treatable, cause following assessment by a doctor. This could include depression, anxiety or stress. The same symptoms could also be caused by a physical illness (such as constipation, infection), poor eyesight or hearing, vitamin or thyroid deficiencies, or the side effects of medication. Where this is the case, the person will be diagnosed with this condition – a thyroid deficiency or depression, for example – rather than MCI.

Question 22

medications for MCI

Answer 22

MCI is more likely to progress to dementia if the person has a poorly controlled heart condition or diabetes, or has strokes. Therefore, treatment for MCI will often include medication for any heart condition a person may have, or tablets to reduce high blood pressure, prevent clots or lower cholesterol. If depression is diagnosed this will also be treated, with medication, talking therapies or both.

Question 23

ways to reduce risk of MCI

Answer 23

A person with MCI will also be encouraged to lower their risk of developing dementia by adopting a healthy lifestyle. People who smoke should try to stop and people who drink alcohol should keep to recommended levels. Regular physical exercise also seems to reduce the risk of dementia. Eating a healthy diet and keeping to a healthy weight may also help. Ask the GP or primary care team for advice on all of these.

It is strongly recommended that someone with MCI keeps active, both mentally (for example by doing puzzles, or reading) and socially (for example by seeing friends).

Question 24

What is the assessment process for MCI?

Answer 24

The assessment is the same as for suspected dementia. The GP will talk to the person about their symptoms, when they started and how they are affecting their daily life now. The person will have their physical health and any medication they are taking reviewed, and take tests to assess depression and mental abilities.

The GP may be able to make a clear diagnosis at this stage, or they might need to refer the person for more specialist assessment, often at a memory service. Diagnosis may require more than one appointment and may include more detailed assessment by a psychologist. A brain scan may be done, particularly if other potential causes (for example a brain bleed or tumour) are suspected.

Question 25

What are the conditions of diagnosis for MCI?

Answer 25

A doctor will use their own judgement to make the diagnosis. Research guidelines state that MCI should be diagnosed if the person:

has worsening symptoms which can not be otherwise explained
scores poorly for their age on a test of mental abilities
has minor or no problems with more complex daily activities.

Question 26

What is the process after diagnosis of MCI?

Answer 26

If a person is diagnosed with MCI by a specialist, they will usually be discharged back to their GP. What happens next will vary. In some parts of the country, the person will be invited back to the GP or memory service after a set time (often 6 or 12 months) to see whether things have changed. In other parts of the country, they are asked to arrange an appointment themselves, at any time, if they feel their symptoms have got worse.

Question 27

Do people with MCI need to tell the DVLA?

Answer 27

not necessarily

Question 28

Tips for MCI

Answer 28

There is a lot you can do to help reduce your chances of MCI progressing to dementia. There are also many ways to deal with memory problems that will allow you to live well with MCI.

Take medication (for example for blood pressure) as prescribed by the doctor, even if you feel fine. It will help keep underlying health conditions in check.
If you do smoke, now is a good time to stop. If you drink, check you are well within the recommended limits. Ask the GP for advice on both of these.
Try not to become stressed or anxious as this can make memory or thinking problems worse.
Having a regular routine can help to minimise memory problems, though make sure to have some variety in your days or you may get bored. Similarly, try to always keep things in the same place as it will make them easier to find.
Use calendars and diaries, or reminders on electronic devices, to help you remember appointments and important events.
Get regular physical exercise - you could go for a brisk walk or a swim, or do some more energetic tasks in the garden or around the house. Try to do this for at least 30 minutes, five times a week.
Try to break tasks down into small steps if you are struggling, then focus on just one step at a time. For example, while cooking focus on one step of the recipe in turn.
Eat a healthy balanced diet with plenty of fruit and vegetables, lots of starchy foods (like potatoes and rice), regular fish and some meat, but not too much saturated fat or dairy products (like butter and cheese).
Keep your brain active with puzzles, quizzes, reading or anything else you enjoy that stimulates your mind.
Make time to relax - you might enjoying listening to music or sitting in the garden. You could also find out about how to practise breathing exercises by taking out a book about relaxation and breathing at your local library or looking online for tips.
Try to sleep well - avoid stimulants like tea or coffee, or having alcohol, before bed.
Stay socially active - make an effort to keep going out to see friends and family. If you attend a place of worship, continue to go regularly.
Ask your doctor about memory support groups for people with MCI in your area.

Question 29

protective (education and occupation) factors of dementia

Answer 29

It has been found that people with higher IQ, level of education, occupational
complexity, or participation in leisure activities with social networks tend to show less
severe symptoms in the presence of the disease of dementia.

Question 30

post-diagnostic interventions of dementia

Answer 30

Social isolation
 Cognitive stimulation
 Prompt treatment of infection
 Prompt treatment of depression

Question 31

suggested drugs that don’t work

Answer 31

Other suggested medications include non-steroidal inflammatory inhibitors (NSAIDs),
oestrogen replacement therapy, and ginko biloba. There is no robust evidence that
any of these therapies work to reduce risk or progression of cognitive decline, and
even some evidence that oestrogen could increase risk.86 Various vitamin and other
supplements have also not shown to improve cognitive risk or decline.87

Question 32

Commonly, people with dementia exhibit what is termed
26
Dementia and Cognitive Decline Evidence Review Oct 2014 Sujata Ray and Dr Susan Davidson
‘challenging behaviour’ (such as aggression), which drugs can be used to combat this?

Answer 32

antipsychotics

Question 33

It could well be that being diagnosed with MCI or dementia, or even prediagnostically noticing the signs, can be distressing and result in depression in some
people. Which drugs combat this?

Answer 33

antidepressants

Question 34

Name and describe the 3 categories of cognitive intervention

Answer 34

Cognitive stimulation - comprises involvement in group activities that are
designed to increase cognitive and social functioning in a nonspecific manner.
Cognitive training - is a more specific approach, which teaches theoretically
supported strategies and skills to optimize specific cognitive functions.
Cognitive rehabilitation - involves an individualised approach using tailored
programs centred on specific activities of daily life. Personally relevant goals
are identified, and the therapist, patient and family work together to achieve
these goals (e.g., joining a social group).

Question 35

What are the effects of exercise on dementia and MCI?

Answer 35

It is important to note that in all of the studies mentioned here, the benefits of
physical exercise only last for at most a few months after exercise interventions have
ceased. Therefore, physical exercise in the case of cognitive function is the same as
it is in the case of cardiovascular function, ie. it needs to become a lifestyle change
rather than a one-off, time-limited intervention.

Question 36

Effects of exercise on MCI specifically

Answer 36

One study reported modest improvements in cognitive function after six
months.
93 Other studies have shown that physical activity benefits memory,
94 95 96
attention,97 executive functions98 99 and cognition in general.
100 10

Question 37

Why do researchers think that physical exercise improves cognitive function in people with dementia?

Answer 37

The reasons why physical
exercise might improve brain function (whereas ‘brain training’ does not), has been
explored by researchers. Studies have shown that in people diagnosed with
Alzheimer’s patients, cardiorespiratory fitness has been associated with brain
volume, in terms of the overall amount of brain tissue and the volume of white
matter.
104 Perhaps importantly, the parts of the brain most associated with memory
are notably affected.
105

Question 38

What other cognitively stimulating activities are used in dementia? These may not necessarily have been proven effective.

Answer 38

speaking a second language, reading, reminiscence therapy - There is no ‘standard’ model for providing this therapy, but
in general the idea is to enable or encourage people to think or talk about personally
significant events that occurred in the past, However, meta-analysis has
found evidence that reminiscence therapy can improve well-being and reduce
depression, even if improvements in cognitive function are not well-evidenced. For a couple of decades, art therapies (art, music and dance) have also been used
as an appropriate intervention for people with dementia, to provide cognitively
stimulating activities and to improve well-being.
115 As in the case for reminiscence
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Dementia and Cognitive Decline Evidence Review Oct 2014 Sujata Ray and Dr Susan Davidson
therapy, there is no definitive model for any of the arts therapies and therefore the
same difficulties apply in terms of providing empirical evidence of their effectiveness.
Recent literature reviews of art therapy for people with dementia have found that it
has not been studied robustly or systematically enough to say whether or not it is
effective in improving cognition, well-being, or anything else. Music therapy has been used to improve symptoms of dementia such as apathy,
depression, irritability, agitation and anxiety, euphoria, hallucinations, and
disinhibition. However, as with the other therapies discussed above, high-quality
evidence for the efficacy is lacking. Two recent meta-analyses found the effects of
music therapy on anxiety symptoms were moderate, the effects on depression and
behaviour were small, and there was not enough evidence to support any beneficial
effect of music therapy on cognitive function or activities of daily living.
118 119
Important factors for success seem to be a long intervention period (greater than 3
months)120 and the effectiveness of the therapist in engaging with the clients.
121

Question 39

Improving living environment examples

Answer 39

Other types of interventions that have been found to be important to help people with
cognitive decline and dementia live at home as long as possible are safety adaptions
in the home, such as grab rails and dealing with tripping and falling hazards.

Question 40

What is an MDT?

Answer 40

combination of professionals from different clinical

disciplines and with specific expertise, that work together to optimise a patient’s care

Question 41

what is a multi-disciplinary team meeting?

Answer 41

refers to a meeting between individuals, or

representatives of these different groups/specialties, to plan the best care for a patient.

Question 42

Who is a care of the elderly ward MDT likely to contain?

Answer 42

likely to include representatives from the following groups:
care of the elderly doctors, nursing staff, physiotherapists, occupational therapists, social
workers, speech and language therapists, dietitians. An MDM might be held weekly to discuss
complex inpatients in order to make plans about how to optimise their discharge process and
destination environment, to discuss patients with complicated personal or family factors and
how to proceed, to discuss best interests for patients who may lack capacity or many other
scenarios requiring joint discussion.

Question 43

Oxleas Advanced Dementia Engagement Service

Answer 43

This is a Consultant-led community-based home care service for patients with advanced dementia. The
service caters for people with a diagnosis of moderate to severe advanced dementia, complicated by complex
mental and physical comorbidities requiring social care input, who are being supported to live at home (by
family or paid carers). These patients tend to be in the last year of their lives with an average age of 75. The
core team works with GPs, secondary care and social services to support carers in providing ongoing and
palliative care. Staff respond to crises at home to prevent unnecessary hospital admissions where possible,
reducing the likelihood that patients are placed in residential care. Care coordination is by the specialist nurse
and care is tailored to each person based on their primary need and the range of services available locally.
MDT Composition
Core: consultant in old-age psychiatry, several specialist nurses (CPNs and/or Community Matrons) Advanced
Practice Nurse, dementia social worker, carer
Additional Team: GPs, social workers, OTs, Physiotherapist, voluntary services.

Question 44

Examples of people who lack mental capacity

Answer 44

People with:
dementia
a severe learning difficulty
brain injury
mental health injury
stroke
unconsciousness caused by anaesthetic or sudden accident

Question 45

What does the mental health act say?

Answer 45

assume a person has the capacity to make a decision themselves, unless it’s proved otherwise
wherever possible, help people to make their own decisions
don’t treat a person as lacking the capacity to make a decision just because they make an unwise decision
if you make a decision for someone who doesn’t have capacity, it must be in their best interests
treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms

Question 46

How is mental capacity assessed?

Answer 46

The MCA sets out a 2-stage test of capacity:

1) Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
2) Does the impairment mean the person is unable to make a specific decision when they need to? People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time – someone may lack capacity at one point in time, but may be able to make the same decision at a later point in time.

Where appropriate, people should be allowed the time to make a decision themselves.

The MCA says a person is unable to make a decision if they can’t:

understand the information relevant to the decision
retain that information
use or weigh up that information as part of the process of making the decision

Question 47

Who should you consult if a patient does not have capacity?

Answer 47

In particular, try to consult:

anyone previously named by the individual
anyone engaged in caring for them
close relatives and friends
any attorney appointed under a Lasting Power of Attorney or Enduring Power of Attorney
any deputy appointed by the Court of Protection to make decisions for the person

Question 48

What does the mental capacity act say?

Answer 48

assume a person has the capacity to make a decision themselves, unless it’s proved otherwise
wherever possible, help people to make their own decisions
don’t treat a person as lacking the capacity to make a decision just because they make an unwise decision
if you make a decision for someone who doesn’t have capacity, it must be in their best interests
treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms

Question 49

What is an advanced statement?

Answer 49

An advance statement is a written statement that sets down a person’s preferences, wishes, beliefs and values regarding their future care. It’s not legally binding.

The aim is to provide a guide for anyone who might have to make decisions in a person’s best interests if that person has lost the capacity to make decisions or communicate their decision.

An advance statement can cover any aspect of a person’s future health or social care.

This could include:

how they want any religious or spiritual beliefs they hold to be reflected in their care
where they would like to be cared for – for example, at home or in a hospital, nursing home or hospice
how they like to do things – for example, if they prefer a shower instead of a bath, or like to sleep with the light on
concerns about practical issues – for example, who will look after their pet if they become ill

Question 50

What is an advanced decision?

Answer 50

An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a legally binding decision that allows someone aged 18 or over, while still capable, to refuse specified medical treatment for a time in the future when they may lack capacity to consent to or refuse that treatment.

An advance decision must be valid and applicable to current circumstances. If it is, it has the same effect as a decision made by a person with capacity – healthcare professionals must follow the decision.

If the advance decision refuses life-sustaining treatment, it must:

be in writing, signed and witnessed
state clearly that the decision applies even if life is at risk
People who make an advance decision may wish to consider letting their family, friends and carers know about it.

Question 51

What is a lasting power of attorney?

Answer 51

You can grant a Lasting Power of Attorney (LPA) to another person (or people) to enable them to make decisions about your health and welfare, or decisions about your property and financial affairs.

Question 52

What should the attorney do in the conditions of an LPA?

Answer 52

make sure the MCA’s statutory principles are followed
check whether the person has the capacity to make that particular decision for themselves – if they do, a personal welfare LPA can’t be used and the person must make the decision

Question 53

Which court deals with the mental capacity act?

Answer 53

court of protection

Question 54

Under which age is classed as early onset alzheimer’s

Answer 54

under 65

Question 55

which proteins lead to the onset of alzheimer’s

Answer 55

amyloid and tau

Question 56

as alzheimer’s progresses, what happens to the nerve cells of the brain?

Answer 56

they are damaged, proteins build up in the brain and lead to nerve damage

Question 57

early specific symptoms of alzheimer’s

Answer 57

Regularly forgetting recent events, names and faces.
Becoming increasingly repetitive, e.g. repeating questions after a very short interval.
Regularly misplacing items or putting them in odd places.
Uncertainty about the date or time of day.
People may be unsure of their whereabouts or get lost, particularly in unfamiliar places.
Problems finding the right words.
Some people become low in mood, anxious or irritable. Others may lose self-confidence or show less interest in what’s happening around them.

Question 58

symptoms of alzheimer’s as the disease develops

Answer 58

People will find that their ability to remember, think and make decisions worsens.
Communication and language become more difficult.
People may have difficulty recognising household objects or familiar faces.
These become harder, for example using a TV remote control, phone or kitchen appliance. People may also have difficulty locating objects in front of them.
Changes in sleep patterns often occur.
Some people become sad, depressed or frustrated about the challenges they face. Anxieties are also common and people may seek extra reassurance or become fearful or suspicious.
People may experience hallucinations, where they see or hear things that aren’t there. Others may believe things to be true that haven’t actually happened, known as ‘delusions’.
People may have problems walking, be unsteady on their feet, find swallowing food more difficult or have seizures.
People gradually require more help with daily activities like dressing, eating and using the toilet.

Question 59

What are the main types of vascular dementia?

Answer 59

stroke related and subcortical vascular dementia - small vessel disease

Question 60

vascular dementia symptoms

Answer 60

Slower thinking – taking more time to process information and to form thoughts and sentences.
Personality changes – people may become low in mood, more emotional or lose interest in what’s happening around them.
Movement problems – difficulty walking or changes in the way a person walks.
Stability – unsteadiness and falls.
Bladder problems – frequent urge to urinate or other bladder symptoms. This can be common in older age, but can be a feature of vascular dementia when seen with other symptoms.

Question 61

dementia with lewy bodies occurence

Answer 61

Dementia with Lewy bodies (DLB) is the third most common type of dementia. For every 100 people with dementia, around 10-15 will have DLB. This means roughly 100,000 people in the UK are likely to have this form of dementia. DLB can also occur with other types of dementia such as Alzheimer’s disease; this is called ‘mixed dementia’.

Question 62

What causes lewy body dementia?

Answer 62

DLB is caused by small round clumps of protein that build up inside nerve cells in the brain. One of these proteins is called alpha-synuclein and the clumps it forms are called Lewy bodies. Lewy bodies damage the nerve cells and affect the way they communicate.

In DLB, the nerve cells that are affected by Lewy bodies are in areas of the brain that control thinking, memory and movement.

Question 63

symptoms of lewy body dementia

Answer 63

There are also some more specific symptoms associated with the disease. Some of these symptoms are also seen in Parkinson’s dementia.

These symptoms include:

Changes in alertness and attention, and periods of confusion, that may be unpredictable and change from hour-to-hour or day-to-day.
Movement problems – Parkinson’s-type symptoms such as slower movements, stiffness in the arms and legs, and shaking or trembling.
Visual hallucinations – Seeing things that are not really there, e.g. people or animals. These often happen repeatedly and are realistic and well-formed.
Sleep disturbances – Vivid dreams, shouting out or moving while sleeping which can disrupt sleep, and may cause injury.
Fainting, unsteadiness and falls.
Sense of smell – Problems with detecting smells.
DLB is a progressive condition which means symptoms get worse over time. As the disease progresses, people will need increasing help with eating, moving, dressing and using the toilet. DLB can progress slowly over several years but the speed of change and type of symptoms can vary from person to person.

Question 64

describe fronto-temporal dementia?

Answer 64

Frontotemporal dementia (FTD) is a relatively rare form of dementia. It is thought to account for fewer than one in 20 of all dementia cases. It commonly affects people between the ages of 45 and 64. However, FTD can affect people younger and older than this.

Originally called Pick’s disease after the scientist who first observed the symptoms, FTD is now known to be made up of several different conditions. Your doctor may refer to these conditions by their specific names or may describe them all as ‘frontotemporal dementia’, as we will in this booklet.

Frontotemporal dementia includes the following conditions:

Behavioural variant FTD (bvFTD)
Semantic dementia (the word semantic means the meaning of language)
Progressive non-fluent aphasia – aphasia is a language disorder where people have problems speaking and writing
FTD associated with motor neurone disease
Semantic dementia and progressive non-fluent aphasia are types of primary progressive aphasia. You can find out more about these conditions on the primary progressive aphasia pages.

FTD is caused by damage to cells in areas of the brain called the frontal and temporal lobes. These areas regulate our personality, emotions and behaviour, as well our speech and understanding of language.

Question 65

symptoms of fronto-temporal dementia

Answer 65

Symptoms may include:

Changes in emotions – this may include a change in how people express their feelings towards others or a lack of understanding of other people’s feelings.
Lack of interest – people may become withdrawn or lose interest in looking after themselves, such as failing to maintain their normal level of personal hygiene.
Inappropriate behaviour – this might include making inappropriate jokes or showing a lack of tact. Humour or sexual behaviour may change. Some people become impulsive or easily distracted.
Obsessions – people might develop unusual beliefs, interests or obsessions.
Diet – changes in food preference such as eating more sweet things, over-eating or over-drinking.
Awareness – lack of awareness of any changes in their personality or behaviour.
Decision making – difficulty with simple plans and decisions.
Language – decline in language abilities. This might include difficulty getting words out or understanding them. People may repeat commonly used words and phrases, or forget the meaning of words.
Recognition – difficulty recognising people or knowing what objects are for.
Memory – day-to-day memory may be relatively unaffected in the early stages, but problems with attention and concentration could give the impression of memory problems.
Movement problems – around one in every eight people with behavioural variant FTD also develops movement problems of motor neurone disease. This can include stiff or twitching muscles, muscle weakness and difficulty swallowing.

Question 66

What is the extracellular amyloid plaques hypothesis?

Answer 66

Amyloid precursor is cleaved by alpha secretase into alpha-beta peptides which aggregate to form oligomers and fibrils with beta-sheet pairing, forming insoluble plaques. In alzheimer’s disease, beta and gamma secretases abnormally cleave amyloid precursor, leading to a build up of excess amyloid-beta.

Question 67

What genes are involved in the formation of senile plaques?

Answer 67

amyloid precursor protein, presenilin 1, presinilin 2, ApoE, all of which are involved with the generation, metabolism and movement of amyloid

Question 68

which protein is involved in neurofibrillary tangles?

Answer 68

tau

Question 69

what is tau involved with, intracellularly?

Answer 69

assembly of microtubules - an essential function of neuronal growth and development

Question 70

What happens to tau in alzheimer’s?

Answer 70

hyperphosphorylated, oligomerising and aggregating into filamentous neuro-fibrillary tangles

Question 71

What do neurofibrillary tangles cause?

Answer 71

disrupting the microtubular system, impairing neural growth, transport and communication

Question 72

where do neurofibrillary tangles normally deposit?

Answer 72

hippocampus, medial temporal lobe, frontal cortices, lateral parietotemporal regions

Question 73

what is the correlation between the location and density neurofibrillary tangles and severity of the disease?

Answer 73

positive

Question 74

What is the correlation between the amount of senile plaques and the severity of impairment?

Answer 74

there isn’t one

Question 75

what is caused by mutations of the tau gene?

Answer 75

familiar fronto-temporal dementia

Question 76

What do studies show about the link between AB oligomers and NFTs?

Answer 76

they may promote hyperphosphorylation of tau and some studies suggest that AB oligomers are only toxic if NFTs are also present.

Question 77

What are the consequences of cellular damage in the brain?

Answer 77

loss of synapses and neurons microscopically, and macroscopically, cerebro-cortical atrophy

Question 78

Where in the brain do you find a significant loss of neurones?

Answer 78

nucleus basalis of Meynert

Question 79

What are the consequences of cell death in the nucleus basalis of Meynert

Answer 79

these neurons are particularly rich in acetylcholine, so losing them results in an acetylcholine deficiency

Question 80

where do the neurones from the nucleus basalis of meynert supply?

Answer 80

supply the hippocampus, amygdala and neocortex

Question 81

how does a deficiency in acetylcholine affect cognitive function?

Answer 81

memory

Question 82

what is the mechanism of many of the drugs used for alzheimer’s

Answer 82

replacing lost acetylcholine to help improve memory

Question 83

loss of neurons in which area of the brain causes a reduction in serotonin and noradrenaline levels, and what effects do these have on a person’s health

Answer 83

Loss of neurones in the brainstem’s median raphe and locus ceruleus neurones which contributes to the mood and sleep effects of the disease

Question 84

Name 9 members of a multidisciplinary team that might help treat someone with dementia

Answer 84

carer, social worker, voluntary service, specialist nurse, psychiatrist, neurologist, GP, occupational therapist, physiotherapist

Question 85

How do you make a decision in their best interest, if someone lacks capacity?

Answer 85

• whether lack of capacity is temporary or permanent
• which options for treatment provide best overall benefit
• which option would be least restrictive of the patient’s future choices
• the patient’s past wishes and feelings, in particular any relevant written statement made when the patient had capacity
• the views of anyone the patient asks you to consult, or has legal authority to make a decision on their behalf eg, lasting power of attorney (however they do not have the power to demand specific forms of treatment if they are not clinically necessary or appropriate)
• what you know about the patient’s beliefs and values

Question 86

How should you assess capacity?

Answer 86

Must have underlying conditions that contribute to lack of capacity.
Can they understand?
Can they retain information?
Can they recall information?
Can they use that information to make decisions?
Can’t just have 1 doctor make the assessment, must be more than 1 and 2 doctors to sign independently. If only one person can sign due to emergency, the lack of capacity only lasts 24 hours. Medical team decide for adults (but do involve family) when someone lacks capacity.

Question 87

What procedure must you use if the person is below 16?

Answer 87

Gillick competence procedure

Question 88

What does gillick competent mean?

Answer 88

For a particular decision, a young person

• understands the problem and implications
• understands the risks & benefits of treatment
• understands the consequences if not treated
• understands the alternative options
• understands the implications on the family
• is able to retain (remember) the information
• is able to weigh the pros and cons
• is able to make and communicate a reasoned and weighed decision regarding their wishes.

Question 89

what are the discriminating features of alzheimer’s?

Answer 89

50% of dementia
weight loss due to forgetting to eat
gradual onset
confusion
better long term memory than short term

Question 90

What are the discriminating features of Fronto-temporal dementia?

Answer 90

difficulty with communication and speech
personality and behaviour changes
disinhibited - no filter
memory problems only occur later on unlike alzheimer’s
struggling with organisation, getting distracted easily

Question 91

What are the discriminating features of Lewy-body dementia?

Answer 91

movement, hunched posture, rigid muscles, shuffling walk, trouble initiating movement, Parkinson’s like symptoms

Question 92

What are the discriminating features of vascular dementia?

Answer 92

25% of dementia, traces of cardiovascular problems, athlerosclerosis (multiple infarcts in tiny blood vessels) can happen all over the body, stroke, numbness/slackness of face, step-wise process rather than gradual, problems with memory and language but not as much as Alzheimer’s

Question 93

What are the three key anatomical areas implicated in Alzheimer’s Disease

Answer 93

posterior cingulate cortex, thalamus, hippocampus

Question 94

which function of the posterior cingulate cortex is implicated in dementia?

Answer 94

orientation

Question 95

which function of the hippocampus is implicated in dementia?

Answer 95

forming new memories and navigating new places

Question 96

which function of the anterior thalamus is implicated in dementia?

Answer 96

attention

Question 97

Which part of the brain is involved in forming new memories and navigating new places?

Answer 97

hippocampus

Question 98

which part of the brain is involved in controlling attention?

Answer 98

A for Anterior thalamus

Question 99

which part of the brain is involved in orientation?

Answer 99

posterior cingulate cortex

Question 100

Label the hippocampus, anterior thalamus and posterior cingulate cortex on a sagittal diagram of the brain

Answer 100

-see notes for answer

Question 101

The questions ‘what year is it?’, ‘what month is it?’ and ‘ what time is it?’ are testing which part of the brain and what for?

Answer 101

posterior cingulate cortex, for orientation

Question 102

Giving a patient an address and then later asking them to repeat it, is a test of which part of the brain and which function?

Answer 102

hippocampus for forming new memories (short term)

Question 103

Asking the patient to say the months backward and count back from 20 to 1 in reverse is a test of which part of the brain and which function?

Answer 103

anterior thalamus for attention