Clinical Aspects of Dementia Flashcards
what is dementia?
progressive global decline
irreversible
associated decline in functioning
syndrome not a disease - can be caused by many things
describe the immediate post diagnosis support in dementia?
management of the dementia should start immediately
advanced planning should be encouraged while patients have the capacity to decide about future needs
should include practical and legal advice (powers of attorney, driving etc)
post diagnostic counselling
normally provided by alzheimer scotland dementia link worker, CMHT band 4 practitioner or community mental health nurse
assistance with practicalities as well as advice and counselling
lasts 1 year
what is the impact of hospitalization of people with dementia?
often stay longer than others for the same procedure
over 1/3 are discharged to a care home
most say it has a negative effect on physical and mental health
financial effects and use a lot of beds
how is dementia diagnosed?
history consistent with global cognitive decline over months-years
cognitive testing consistent with history
decline in level of function
no evidence of reversible cause
what cognitive testing is used in dementia diagnosis?
addenbrookes cognitive assessment (ACE-III) = standard test in most POA departments
MoCA
Frontal assessment battery (FAB)
detailed neuropsychological testing
what questionnaire is used when getting a collateral history from a relative?
short informant questionnnaire on cognitive decline in the elderly (short IQCODE)
how is occupational therapy used at dementia diagnosis?
cognitive performance test
- observation of activities like washing, dressing, using phone, shopping, cooking etc
- estimates cognitive level and level of supervision required for daily living
reversible causes of cognitive impairment?
delirium alcohol medication thyroid depression brain lesions neuro infections/inflammation
features of mild cognitive impairment?
noticeable cognitive impairment with little deterioration of function
ACE-III = 75-90
MoCA = 24-26
how is mild cognitive impairment managed?
repeat cognitive testing yearly
may benefit from home based memory rehabilitation
what is subjective cognitive impairment?
patient feels that they are cognitively impaired but testing and day to day function are normal
often associated with anxiety, depression or stress
patients often have a friend or relative with dementia and can be difficult to convince that they dont have it
main features of alzheimers?
memory loss particularly short term
dysphasia
dyspraxia
agnosia
what is seen on imaging in alzheiemrs?
CT/MRI = normal
medial temporal lobe atrophy or temporoparietal atrophy
2 variants of alzheimers?
frontal
posterior cortical atrophy
main features of vascular dementia?
dysphasia dyscalculia frontal lobe symptoms and affective symptoms more common than in alzheimers may have focal neurological signs may have vascular risk factors may have step wise decline
what is seen on imaging in vascular dementia?
CT/MRI = moderate-severe small vessel disease or multiple lacunar infarcts SPECT = patchy reduction in tracer uptake throughout brain
what are the 3 syndromes in frontotemporal dementia?
behavioural variant
primary progressive aphasia
semantic dementia
describe behavioural variant of frontotemporal dementia?
behavioural changes executive dysfunction disinhibition impulsivity loss of social skills apathy obessions change in diet
describe primary progressive aphasia variant of frontotemporal dementia?
effortful non-fluent speech
speech sound/articulatory errors
lack of grammar
lack of words
describe semantic dementia variant of frontotemporal dementia?
impaired understanding of meaning of words
fluent but empty speech
difficulty retrieving names
what is seen on imaging in frontotemporal dementia?
CT/MRI = frontotemporal atrophy SPECT = frontotemporal reduction in tracer uptake
criteria for lewy body dementia?
two of
- visual hallucinations
- fluctuating cognition (delirium-like)
- REM sleep behaviour disorder
- parkinsonism (not more than 1 year prior to onset of dementia)
- positive DAT scan
how does dementia develop in parkinson’s disease?
80% develop dementia after 15-20 years of disease
must have parkinsonism for at least 1 year prior to onset of dementia
main features of parkinson’s dementia?
similar to lewy body but different pathology
positive DAT scan
what features would suggest a non-dementia cause for reduced cognition?
fast progression young patient neurological signs family history of rare or young dementia clues in PMH (e.g HIV) something just doesnt fit
what types of imaging are used in dementia?
CT
single photon emission CT
DaT (dopamine active transporter) scan
MRI
who needs a scan and what scan should be used?
CT is standard
- dont always need to do one of patient is over 80 with typical history of alzheimers unless to rule out tumour/bleed/stroke etc
MRI = if young with past progression or other atypical features
SPECT = most useful for frontotemporal dementia, can clarify alzheimers
DAT = for suspected lewy body/parkinsons when patient doesnt have enough supporting features to be sure of diagnosis
what cholinesterase inhibitors are used in alzheimers?
donepezil
rivastigmine
galantamine
what cholinesterase inhibitors are used in lewy body and parkinson’s dementia?
rivastigmine
donepezil
side effects of cholinestrease inhibitors?
GI - nausea and diarrhoea headache muscle cramps bradycardia worsens COPD/asthma
special considerations in cholinesterase inhibitors?
check pulse before prescribing/before pulse increase
not used in active peptic ulcer or severe asthma/COPD
what is memantine and when is it used?
NMDA receptor antagonist
licensed for alzheimers and preventing BPSD
side effects of memantine?
well tolerated in most might cause hypertension (so check BP before starting) sedation dizziness headache constipation
how is driving managed in dementia?
discuss driving at diagnosis
must be reported to DVLA
patient must fill in CG1 form
DVLA request report from the doctor, then doctor decides if patient is safe to drive while investigations ongoing
how is safety to drive measured?
rookwood driving battery
on road test
what can be used for agitation in dementia?
antipsychotics citalopram memantine analgesia dextromethorphan trazodone for frontotemporal cholinesterase inhibitors pregabalin
what can be used for anxiety in dementia?
antidepressants
benzodiazepines
pregabalin
what can be used for visual hallucinations in dementia?
cholinesterase inhibitors
antipsychotics
how can insomnia be managed in dementia?
melatonin
Z drugs
benzodiazepines
sedating antidepressants
