Clinical Aspects and Management of Memory Problems

Question 1

What is dementia?

Answer 1

Irreversible and progressive global cognitive decline

Question 2

What are some features of the post diagnostic support for dementia?

Answer 2

Management should start as soon as possible
Time of uncertainty = tailored info and support needed
Should include practical and legal advice
May need postdiagnostic counselling

Question 3

Why is advanced planning needed in patients with dementia?

Answer 3

To allow patients to make decisions while they still have capacity

Question 4

What are some features of dementia in general hospital?

Answer 4

People with dementia aged >65 currently take up 1/4 of hospital beds at any given time
47% of carers said that being in hospital had a significant negative impact on physical health

Question 5

How common is it for patients with dementia to be discharged into care after hospital admittance?

Answer 5

Over 1/3 of people with dementia who go into hospital from living in their own homes are discharged to a care home

Question 6

What is needed to diagnose dementia?

Answer 6

History consistent with global cognitive decline over months-years
Cognitive testing consistent with history
Decline in level of function
No evidence of reversible cause

Question 7

What are some methods of cognitive testing?

Answer 7

Addenbrookes Cognitive Assessment III = standard test
Montreal Cognitive Assessment = shorter test
Frontal Assessment Battery
Detailed neuropsychiatry testing = standardised according to premorbid testing

Question 8

What is the short IQCODE?

Answer 8

Collateral history = 16 questions scored from 1-5, compares patient to how they were 10 years ago

Question 9

How does occupational therapists assess patients with memory problems?

Answer 9

By doing a cognitive performance test = observations of activities like washing, estimates cognitive level and level of supervision needed for daily living

Question 10

What are some reversible causes of cognitive impairment?

Answer 10

Delirium, alcohol, brain lesions, depression, medication, thyroid/metabolic disorders, brain infection

Question 11

What are some features of mild cognitive impairment?

Answer 11

Noticeable cognitive impairment with little deterioration of function = ACE III usually 75-90 ad MoCA usually 24-26

Question 12

What is the management of mild cognitive impairment?

Answer 12

Annual conversion of 10-15% so repeat cognitive testing yearly
May benefit from home based memory rehabillitation

Question 13

What is subjective cognitive testing?

Answer 13

Patient feels they are cognitively impaired but testing and everyday function are normal

Question 14

What are some features of subjective cognitive testing?

Answer 14

Often associated with anxiety, depression or stress
Usually have relative or friend with dementia
Normal memory lapses are interpreted as sinister

Question 15

What are the symptoms and signs of Alzheimer’s disease?

Answer 15

Memory loss (especially short term), dysphagia, dyspraxia and agnosia
CT/MRI normal
Medial temporal lobe or temporoparietal atrophy

Question 16

What are the variants of Alzheimer’s disease?

Answer 16

Frontal, posterior cortical atrophy

Question 17

What are the symptoms of vascular dementia?

Answer 17

Dysphagia, dyscalculia, frontal lobe symptoms, affective symptoms, focal neurological signs

Question 18

What are some features of vascular dementia?

Answer 18

May have vascular risk factors or step wise decline
CT/MRI = moderate-severe small vessel disease, multiple lacunar infarcts
SPECT = patchy reduction in tracer uptake

Question 19

What are the three types of frontotemporal dementia?

Answer 19

Behavioural type, primary progressive aphasia and semantic dementia

Question 20

What are the features of behavioural type frontotemporal dementia?

Answer 20

Behavioural changes, executive dysfunction, disinhibition, impulsivity, loss of social skills, apathy, obsessions

Question 21

What are the features of primary progressive aphasia?

Answer 21

Effortful non-fluent speech, articulatory errors, lack of grammar and words

Question 22

What are the features of semantic dementia?

Answer 22

Impaired understanding of word meaning, fluent but empty speech, difficulty retrieving names

Question 23

What are the imaging results of frontotemporal dementia?

Answer 23

CT/MRI = frontotemporal atrophy
SPECT = frontotemporal reduction in tracer uptake

Question 24

What is the dementia of lewy body dementia like?

Answer 24

Common early involvement of reduced attention, executive function and visuospatial skills

Question 25

What is needed to diagnose lewy body dementia?

Answer 25

Two of = visual hallucinations, fluctuating cognition, REM sleep behaviour disorder, positive DAT scan, parkinsonism (not >1 year prior to dementia onset)

Question 26

What are some features of the dementia that occurs in Parkinson's disease?

Answer 26

80% have dementia after 15-20 years of Parkinson's Similar presentation to lewy body dementia Positive DAT scan Must have had parkinsonism for at least 1 year prior to dementia onset

Question 27

What imaging can be done for dementia?

Answer 27

CT, single photon emission CT, DAT scan, MRI

Question 28

What patients get a CT scan?

Answer 28

Standard investigation = useful for excluding tumour or bleed, quantifying vascular changes or identifying structural changes

Question 29

What patients get MRI scans?

Answer 29

Young patients, fast progression or other atypical features

Question 30

What type of dementia are SPECT scans best for?

Answer 30

Frontotemporal dementia

Question 31

When are DAT scans done?

Answer 31

Suspected lewy body or Parkinson's dementia when patient doesn't have enough supporting features to be sure of diagnosis

Question 32

What effect do cholinesterase inhibitors have?

Answer 32

Slow cognitive decline

Question 33

What types of dementia are cholinesterase inhibitors used for?

Answer 33

Alzheimer's disease, lewy body dementia and dementia in Parkinson's disease = less effective in treating Alzheimer's

Question 34

What are the side effects of cholinesterase inhibitors?

Answer 34

Nausea and vomiting, headache, muscle cramps, worsen COPD and asthma Bradycardia = check pulse before prescribing or increasing dose

Question 35

What are the contraindications of cholinesterase inhibitors?

Answer 35

Active peptic ulcer | Severe COPD or asthma

Question 36

What is memantine used for?

Answer 36

Licensed for Alzheimer's disease = slows cognitive decline and prevents BPSD, start for moderate dementia

Question 37

What are the side effects of memantine?

Answer 37

Generally well tolerated = hypertension, sedation, dizziness, headache, constipation

Question 38

What professions make up the dementia MDT?

Answer 38

Doctors, nurses, PDS workers, support workers, OT, physiotherapists, dietician, speech and language therapy, psychology, social workers

Question 39

What role doe medical staff have in dementia?

Answer 39

Diagnosis, medical management, medication, mental health/capacity law

Question 40

What role do nursing staff have in dementia?

Answer 40

Mental health assessment and therapies

Question 41

What role do social workers have in dementia?

Answer 41

Care management, housing, adult protection, mental health/capacity law

Question 42

What people tend to become informal carers?

Answer 42

60% are spouses and 30% are adult children = provide 70% or more of total home care costs

Question 43

Why does dementia impose an objective burden on carers?

Answer 43

Leads to high levels of dependency and problematic behaviours

Question 44

What effect does being a carer have on people?

Answer 44

Increased psychological and physical morbidity, social isolation and financial burden

Question 45

What effect do psychological interventions for dementia have?

Answer 45

Have capacity to reduce carer distress and delay nursing home admission

Question 46

What implications does dementia have on driving?

Answer 46

Must be reported to DVLA = doctor decides if patient can drive while investigations are ongoing

Question 47

What paperwork must be filled in for a patient with dementia who drives?

Answer 47

Patient must fill in CGI form | Doctor fills out DVLA request form

Question 48

What happens as dementia progresses?

Answer 48

Behavioural and psychiatric aspects of dementia become more prominent = reduced ability to carry out normal activities independently

Question 49

What tends to cause the requirement of institutional care in dementia?

Answer 49

Loss of independence and BPSD

Question 50

What are some behavioural and psychological symptoms of dementia?

Answer 50

Hallucinations, delusions, insomnia, anxiety, disinhibition, agitation, aggression, depression

Question 51

What is the initial management of dementia?

Answer 51

Antecedents, behaviours and consequences = can use chart Review physical symptoms and consider medication side effects Consider comfort, environment and sleep hygiene

Question 52

What are some treatments for aggression?

Answer 52

Alzheimer's = antipsychotics, citalopram, memantine, analgesia Frontotemporal dementia = trazodone

Question 53

How are comorbid depression and anxiety treated?

Answer 53

``` Depression = antidepressant +/- adjuncts Anxiety = antidepressants, benzodiazepines, pregabalin ```

Question 54

How are visual hallucinations and insomnia treated?

Answer 54

``` Hallucinations = cholinesterase inhibitors, antipsychotics Insomnia = melatonin, Z drugs, benzodiazepines, sedating antidepressants ```

Question 55

How is aggression treated?

Answer 55

Benzodiazepines, antipsychotics, sedating antidepressants, cholinesterase inhibitors, memantine, pregabalin