Clinical Aspects of Dementia

Question 1

what is dementia?

Answer 1

progressive global decline
irreversible
associated decline in functioning
syndrome not a disease - can be caused by many things

Question 2

describe the immediate post diagnosis support in dementia?

Answer 2

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

Question 3

what is the impact of hospitalization of people with dementia?

Answer 3

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

Question 4

how is dementia diagnosed?

Answer 4

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 5

what cognitive testing is used in dementia diagnosis?

Answer 5

addenbrookes cognitive assessment (ACE-III) = standard test in most POA departments
MoCA
Frontal assessment battery (FAB)
detailed neuropsychological testing

Question 6

what questionnaire is used when getting a collateral history from a relative?

Answer 6

short informant questionnnaire on cognitive decline in the elderly (short IQCODE)

Question 7

how is occupational therapy used at dementia diagnosis?

Answer 7

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

Question 8

reversible causes of cognitive impairment?

Answer 8

delirium
alcohol
medication
thyroid
depression
brain lesions
neuro infections/inflammation

Question 9

features of mild cognitive impairment?

Answer 9

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

Question 10

how is mild cognitive impairment managed?

Answer 10

repeat cognitive testing yearly

may benefit from home based memory rehabilitation

Question 11

what is subjective cognitive impairment?

Answer 11

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

Question 12

main features of alzheimers?

Answer 12

memory loss particularly short term
dysphasia
dyspraxia
agnosia

Question 13

what is seen on imaging in alzheiemrs?

Answer 13

CT/MRI = normal

medial temporal lobe atrophy or temporoparietal atrophy

Question 14

2 variants of alzheimers?

Answer 14

frontal

posterior cortical atrophy

Question 15

main features of vascular dementia?

Answer 15

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

Question 16

what is seen on imaging in vascular dementia?

Answer 16

CT/MRI = moderate-severe small vessel disease or multiple lacunar infarcts
SPECT = patchy reduction in tracer uptake throughout brain

Question 17

what are the 3 syndromes in frontotemporal dementia?

Answer 17

behavioural variant
primary progressive aphasia
semantic dementia

Question 18

describe behavioural variant of frontotemporal dementia?

Answer 18

behavioural changes
executive dysfunction
disinhibition
impulsivity
loss of social skills
apathy
obessions
change in diet

Question 19

describe primary progressive aphasia variant of frontotemporal dementia?

Answer 19

effortful non-fluent speech
speech sound/articulatory errors
lack of grammar
lack of words

Question 20

describe semantic dementia variant of frontotemporal dementia?

Answer 20

impaired understanding of meaning of words
fluent but empty speech
difficulty retrieving names

Question 21

what is seen on imaging in frontotemporal dementia?

Answer 21

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

Question 22

criteria for lewy body dementia?

Answer 22

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

Question 23

how does dementia develop in parkinson’s disease?

Answer 23

80% develop dementia after 15-20 years of disease

must have parkinsonism for at least 1 year prior to onset of dementia

Question 24

main features of parkinson’s dementia?

Answer 24

similar to lewy body but different pathology

positive DAT scan

Question 25

what features would suggest a non-dementia cause for reduced cognition?

Answer 25

fast progression
young patient
neurological signs
family history of rare or young dementia
clues in PMH (e.g HIV)
something just doesnt fit

Question 26

what types of imaging are used in dementia?

Answer 26

CT
single photon emission CT
DaT (dopamine active transporter) scan
MRI

Question 27

who needs a scan and what scan should be used?

Answer 27

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

Question 28

what cholinesterase inhibitors are used in alzheimers?

Answer 28

donepezil
rivastigmine
galantamine

Question 29

what cholinesterase inhibitors are used in lewy body and parkinson’s dementia?

Answer 29

rivastigmine

donepezil

Question 30

side effects of cholinestrease inhibitors?

Answer 30

GI - nausea and diarrhoea
headache
muscle cramps
bradycardia
worsens COPD/asthma

Question 31

special considerations in cholinesterase inhibitors?

Answer 31

check pulse before prescribing/before pulse increase

not used in active peptic ulcer or severe asthma/COPD

Question 32

what is memantine and when is it used?

Answer 32

NMDA receptor antagonist

licensed for alzheimers and preventing BPSD

Question 33

side effects of memantine?

Answer 33

well tolerated in most
might cause hypertension (so check BP before starting)
sedation
dizziness
headache
constipation

Question 34

how is driving managed in dementia?

Answer 34

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

Question 35

how is safety to drive measured?

Answer 35

rookwood driving battery

on road test

Question 36

what can be used for agitation in dementia?

Answer 36

antipsychotics
citalopram
memantine
analgesia
dextromethorphan
trazodone for frontotemporal 
cholinesterase inhibitors
pregabalin

Question 37

what can be used for anxiety in dementia?

Answer 37

antidepressants
benzodiazepines
pregabalin

Question 38

what can be used for visual hallucinations in dementia?

Answer 38

cholinesterase inhibitors

antipsychotics

Question 39

how can insomnia be managed in dementia?

Answer 39

melatonin
Z drugs
benzodiazepines
sedating antidepressants