Clinical Aspects of Dementia Flashcards
What is dementia?
Progressive global cognitive decline
Irreversible
Associated decline in functioning
Dementia diagnosis rates have increased in Scotland in recent years. TRUE/FALSE?
TRUE
- national push for more patients to get their diagnosis (targets)
- Diagnosis of Dementia will continue to increase due to ageing population
Prevalence of dementia increases after what age?
65 years (this then counts as “older adults”
Why is it important to know how may patients suffer from dementia in Scotland?
Helps budget for their care
Larger push towards developing new treatment if more patients suffering
Why is post diagnostic support important after a diagnosis of dementia?
- often a time of uncertainty
- Advance planning should be encouraged while patients have the capacity
- counselling may be required
What advance planning mechanisms should be considered when patients are given a dementia diagnosis?
- practical and legal advice (i.e Powers of Attorney, guardianship (if lacking capacity)
- driving - inform DVLA
Explain why dementia causes strain on the NHS in terms of finances and hospital beds.
- using up to ¼ of hospital beds
- stay longer in hospital than other
- 1/3 go into hospital from own homes but are discharged to a care home
- Supporting people with dementia to leave hospital one week sooner would save least £80 million a year
How is dementia clinically diagnosed?
- Hx consistent with global cognitive decline over months/years
- Cognitive testing consistent with Hx
- Decline in level of function
- No evidence of reversible cause
What cognitive testing is usually offered for patients who present with memory loss?
Addenbrookes Cognitive Assessment (ACE-III)
Montreal Cognitive Assessment
Frontal Assessment Battery (FAB)
Detailed neuropsychological testing
How do patients with memory loss usually present to the GP?
- rarely present themself
- usually brought by a spouse OR an older child
What symptoms are first noticed by patients themselves in relation to memory loss?
Short term memory loss
Word finding difficulties
What do patients often blame their memory loss symptoms on?
Sensory impairments - e.g. poor eyesight, poor hearing
What can potentially affect a patient’s performance in an Addenbrooke’s assessment?
Low IQ
Sensory impairment
depression
Anxiety when in clinic
When is the Montreal Cognitive Assessment used?
Smaller than addenbrooke’s
=> often used if patient may not be able to tolerate full addenbrooke’s test
- available in other languages => useful if patient does not use English as first language and requires an interpreter
When would a Frontal Assessment Battery be used?
If suspicious of FTD or to test for decline in executive function (as Addenbrooke’s and MoCA dont test these well)
What questionnaire is used to provide a collateral history and compare the patients function NOW to their function 10 years ago?
Short IQCODE
16 Qs
What is involved in an OT assessment for Dementia and where is it carried out?
Observation of activities- washing, dressing, using a phone, shopping, making toast, travelling.
Carried out in assessment “kitchen” i.e. an unfamiliar environment
Estimates cognitive level and level of supervision required for daily living
Give examples of the reversible causes of cognitive impairment?
Delirium Alcohol Thyroid/metabolic disorders Depression Brain lesion Neuro infections/inflammation
What is mild cognitive impairment?
- Noticeable cognitive impairment
- Little deterioration of function
How much do patients with a Mild Cognitive Impairment usually score on the ACE-III or MoCA?
ACE-III usually 75-90
MoCA usually 24-26
If a patient is found to have mild cognitive impairment, how often should cognitive testing be repeated?
Yearly
What is meant by subjective cognitive impairment?
- Patient thinks they are cognitively impaired
- cognitive testing and function = NORMAL
- associated with anxiety/depression/stress
- often have a relative or friend with dementia
- Vicious cycle of increasing anxiety about memory =>
causing more memory lapses
Who usually refers patients with dementia to old age psychiatry?
GP
Medicine for the elderly
Neurology
Other general hospital clinic
What should be involved in giving a dementia diagnosis?
- Ask patient if they want to bring relative/friend to appointment
- Allow adequate time
- What do they already know? Do they remember cognitive testing?
- What do they want to know?
- Clear explanation of condition
- How do they feel?
- Address specific concerns - e.g. admission/ nursing home etc
What are the main clinical features of Alzheimer’s Dementia?
Memory loss particularly short term
Dysphasia
Dyspraxia
Agnosia
Scans are not diagnostic, but what may appear on a CT/MRI of a patient with Alzheimer’s?
CT/MRI may be normal,
OR medial temporal lobe atrophy or temporoparietal atrophy
What variants of Alzheimer’s dementia are known to exist?
Frontal
Posterior cortical atrophy
What are the main clinical features of vascular dementia?
Dysphasia
dyscalculia
frontal lobe symptoms
affective symptoms more common than in Alzheimers
May ALSO have:
- focal neurological signs
- vascular risk factors
- step wise decline
What do CT/MRI and SPECT scans usually show 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 main syndromes of Frontotemporal dementia?
Behavioural variant- behavioural changes, executive dysfunction, disinhibition, impulsivity, loss of social skills,
Primary progressive aphasia- effortful non-fluent speech, speech sound/articulatory errors,
Semantic dementia- impaired understanding of words, fluent but empty speech, difficulty retrieving names
How does Frontotemporal dementia appear on CT/MRI or SPECT scans?
CT/MRI- frontotemporal atrophy
SPECT- frontotemporal reduction in tracer uptake
What is the criteria for a diagnosis of Dementia with Lewy Bodies?
Early reduced attention, executive function and visuospatial skills
AND Two of:
- Visual hallucinations
- Fluctuating cognition (delirium-like)
- REM sleep behaviour disorder
- Parkinsonism
- Positive DAT scan
What is the difference between Dementia with Lewy Bodies and a diagnosis of Parkinson’s Disease Dementia?
Must have parkinsonism for at least 1 year prior to onset of dementia
=> Parkinsons dementia NOT Dementia with Lewy Bodies
What imaging may be used in a patient with a suspected dementia?
CT
MRI
Single Photon Emission CT
DaT (Dopamine Active Transporter) Scan
CT is used to exclude what organic causes of cognitive decline?
tumour
bleed
stroke
When is MRI typically used to investigate a dementia?
if <70
Fast progression
Atypical features
What is SPECT useful for?
Differentiating types of dementia
especially Frontotemporal Dementia
A DaT scan is used to indicate what types of dementia?
Dementia with Lewy Bodies
Parkinson’s Dementia
What cholinesterase inhibitor is licensed for the treatment of dementia with Lewy Bodies and Parkinson’s dementia?
Rivastigmine
What are the usual side effects of cholinesterase inhbitors?
Nausea and diarrhoea
these usually subside after 2 weeks
When is memantine used?
Moderate alzheimer’s dementia
can be used earlier to prevent further decline
Why is it important to monitor BP in memantine use?
Can increase blood pressure
Who makes up the informal carers who help dementia patients?
60% spouses
30% older children
What can be used to test if patients with dementia are competent to drive?
- Score >70 on Addenbrookes
- Rockwood driving battery (tests divided attention/ visuospatial function)
- On road driving test
What cholinesterase inhibitors are licensed for use in ALzheimers dementia?
donepezil
Rivastigmine
Galantamine
When are cholinesterase inhibitors contraindicated?
active peptic ulcer
severe asthma/COPD
What other function does memantine have other than slowing dementia decline?
prevents behavioural and psychological symptoms
What household items can be made more dementia-friendly for patients?
Clock - digital, morning/afternoon etc, reminders to take tablets
Phone - large numbers or even photos on phone handset
Signposting - made obvious
Clear kitchen cupboards
GPS
What are the most common behavioural and psychological symptoms associated with dementia?
Hallucinations/Delusions Insomnia Anxiety Disinhibition Agitation Aggression Depression
What non-pharmacological management should be used for patients initially in dementia?
Review physical symptoms Consider medication side effects sensory aids Environment Activities Exercise Sleep hygiene
What short term treatments can be used to restore circadian rhythm in dementia patients suffering from insomnia?
melatonin
Z drugs
benzodiazepines
sedating antidepressants
What drugs can be used for agitation and aggression in patients with dementia?
benzodiazepines antipsychotics sedating antidepressants cholinesterase inhibitors memantine pregabalin
What drugs can be used for visual hallucinations in dementia?
cholinesterase inhibitors
antipsychotics (BE AWARE OF USING THESE IN LEWY BODY)
