Clinical Aspects of Dementia Flashcards
what is dementia
Progressive, global, irreversible cognitive decline
associated decline in functioning
what is involved in post diagnostic support for those with a dementia diagnosis
Planning for future decision making Supporting community connections Peer support Planning for future care Understanding the illness and managing symptoms
diagnostic criteria for demential
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 tests are used to diagnose dementia
Addenbrookes cognitive assessment (ACE III)
Montreal cognitive assessment (MoCA) - shorter, several versions
Frontal Assessment Battery
Detailed neuropsychological testing
how do you get a collateral history
speak to family members/partners/ friends with a structured history
Short informant questionnaire on cognitive decline in the elderly ( short IQCODE)
what do occupational therapy asses for those with dementia
Cognitive performance tests
- observations of activities eg. dressing, washing, using a phone etc
- estimates level of supervision required for daily living
what are some reversible causes of cognitive impairment
DELERIUM Depression Alcohol Brain lesions Medications Metabolic disorder Neuro infection/inflammation
what’s the criteria for a MILD cognitive impairment
Noticeable impairment with little deterioration of function
ACE-III - 75-90
MoCA 24-26
repeat testing regularly
may benefit from home based memory rehabilitation
what is a SUBJECTIVE cognitive impairment
patient feels they are cognitively impaired but cognitive testing and day-day function are normal
associated with anxiety, depression or stress
often those with a relative or friend with dementia
difficult to convince patient they dont have dementia
cycle of increasing anxiety about memory causing more memory lapses
normal lapses interpreted as sinister
what are the most common type of dementia
Alzheimers Vascular dementia Frontotemporal dementia Dementia with lewy bodies Dementia in Parkinsons disease
what are the characteristics of Alzheimer’s dementia
Memory loss (particularly short term)
Dysphasia (difficulty using language)
Dyspraxia (difficulty with physical co-ordination)
Agnosia (loss of ability to recognise people/objects)
what is seen on imaging of Alzheimer’s dementia
CT/MRI - normal, medial temporal lobe atrophy or temporoparaital atrophy
what are the characteristics of vascular dementia
Dysphasia Dyscalculia (difficulty understanding numbers) Frontal lobe symptoms Affective symptoms Focal neurological signs Vascular risk factors
Step wise decline
what is seen on imagine in vascular dementia
moderate - severe small vessel disease or multiple lacunar infarcts
SPECT - patchy reduction in tracer uptake throughout brain
What are the 3 syndromes of frontotemporal dementia
Behavioural
Primary progressive aphasia
Semantic dementia
what is the behavioural syndrome of frontotemporal dementia
behavioural chances executive dysfunction disinhibition impulsivity loss of social skills apathy obsessions change of diet
what is the primary progressive aphasia syndrome of frontotemporal dementia
effortful, non-fluent speech
speech sound/articulatory errors
lack of grammar
lack of words
what is the semantic dementia syndrome of frontotemporal dementia
impaired understanding of meaning of words, empty speech, difficulty retrieving names
what is seen in imaging for frontotemporal dementia
CT/MRI - frontotemporal atrophy
SPECT- frontotemporal reduction in tracer uptake
what are the characteristics of dementia with Lewy bodies
really involvement of reduced attention,
executive function an visuospacial skills
Two of: -visual hallucinations -fluctuating cognition (delerium like) - REM sleep behaviour disorder -Parkinsonism (not more than 1 year prior to onset of dementia) Positive DAT scan
what are the characteristics of dementia in parkinsons disease
80% after 15-20 years of Parkinson’s disease
Must have Parkinsonism for at least 1 year prior to dementia
Similar to DLB but different pathology
positive DAT scan
what imaging is used in dementia
CT Single photon emission CT DaT scan (dopamine active transporter) Magnetic resonance imaging SPECT
when do you use MRI
young
fast progression
other atypical features
when do you use SPECT
most useful in suspicion of frontotemporal dementia
when do you use DAT scans
suspicion of DLB/DPD is patient doesn’t have enough supporting features to be sure of diagnosis
when do you use CT
currently standard
dont use for patient over 80 with typical Alzheimers presentation
what drugs are used for Alzheimers
Cholinesterase inhibitors
Memantine
what cholinesterase inhibitors are used in Alzheimers
Donepezil
Revastigmine
Galantamine
what cholinesterase inhibitors are used in DLB and DPD
Rivastigmine
Donepezil
what do cholinesterase inhibitors do in dementia
Slow cognitive decline
more effective in DLB/DPD than Alzheimers
side effects of cholinesterase inhibitors
GI (nausea and diarrhoea) Headache Muscle cramps Bradycardias Worsen COPD/Asthma
do not prescribe if peptic ulcer or severe asthma/COPD
what does memantine do for dementia
slows cognitive decline
prevents behavioural and psychological symptoms of dementia
start in moderate dementia
side effects of memantine
well tolerated may cause hypertension sedation dizziness headache constipation
what post-diagnostic care is provided for dementia
support for patient and family
assistance with practicalities as well as counselling
lasts for 1 year
provided by Alzheimer Scotland dementia link worker or community mental health nurse
how does dementia impact driving
Must be discussed at diagnosis
Must be reported to DVLA
Doctor decides if patient can drive while investigations are ongoing
on road test
Rookwood driving battery - gives simple tests to see if someones road safe
what tends to happen in the late stages of dementia
behavioural and psych symptoms become more prominent
physical co-morbidity increases
reduced ability to carry out activities of daily living
loss of independence
what are behavioural and psychological symptoms of dementia
Delusions Insomnia Anxiety Disinhibition Agitation Depression Hallucinations
how do you initially manage BPSD
review physical symptoms further investigation consider medication side effects comfort - thirsty, hungry, uncomfortable give sensory aids environment activities exercise sleep hygiene
what pharmacological interventions can be used for agitation
Antipsychotics
- citalopram
- memantine
- analgesia
- dextromethorphan
trazodone for frontotemporal dementia
