Cognition + Dementias

Question 1

4 areas of cognition to assess

Answer 1

Recent memory Language Visuospatial ability Executive function

Question 2

Tests for cognition

Answer 2

ACE-III = complex but best AMTS = shorter

Question 3

Physical tests to order when there is cognitive decline

Answer 3

Bloods: U+E, LFTs, B12 + folate, TFTs, calcium CT head

Question 4

Frontal lobe deficit symptoms

Answer 4

Behaviour + personality changes

Question 5

Temporal lobe deficit symptoms

Answer 5

Agnosia, aphasia, hallucinations, visuospatial difficulties, inability to recognise faces (prosopagnosia)

Question 6

Parietal lobe deficit symptoms

Answer 6

Aphasia, agnosia, visuospatial difficulties, finger agnosia, dyscalculia, apraxia

Question 7

Occipital lobe deficit symptoms

Answer 7

Visual perception defects: visual agnosia, alexia, prosopagnosia, illusions, hallucinations

Question 8

Primary dementias

Answer 8

Alzheimers, DLB, frontotemporal (Picks), Huntingtons

Question 9

Secondary dementias

Answer 9

Vascular, infective, inflammatory, metabolic, endocrine, trauma

Question 10

Cholinesterase inhibitors: names, action, SE, formulation

Answer 10

Donepezil, galantamine, rivastigmine Increase cholinergic transmission Work for Alzheimers + DLB Side effects: GI, hypersalivation, vivid dreams, HTN, syncope Rivastigmine can come in patches

Question 11

Alzheimers pathology, risk factors, S+S

Answer 11

Pathology: decreased ACh, extracellular senile plaques made of beta-amyloid, intracellular neurofibrillary tangles, symmetrical atrophy (more pronounced in medial temporal + parietal lobes). Glial proliferation, granulovascular degeneration, Hirano inclusion bodies Risk factors: females, Downs, fam hx, dialysis S+S: insidious onset memory loss + personality changes 5 As: amnesia, apraxia, agnosia, aphasia, associated symptoms (behaviour + personality)

Question 12

DLB pathology, diagnosis, S+S

Answer 12

Pathology: Lewy bodies = intracellular eosinophilic inclusions, decreased ACh, senile plaques Lewy bodies more present in cortical areas (temporal lobe, cingulate gyrus, insular cortex) vs Parkinsons - more present in basal ganglia S+S: fluctuating cognition, visual hallucinations, Parkinson like symptoms, frequent faints + falls Formally diagnosed with a DaT scan

Question 13

Vascular dementia pathology, risk factors, S+S

Answer 13

Pathology: multiple infarcts Risk factors: male, CV disease, HTN, high cholesterol, DM, smoking, alcohol S+S: sudden onset, stepwise progression. Commonly mood and behavioural changes Don’t use AChEis

Question 14

Frontotemporal dementia pathology, S+S, management

Answer 14

Picks disease Pathology: asymmetrical knife blade atrophy, neuronal loss + gliosis Ballooned neurons (Pick cells) + tau-positive neuronal inclusions (Pick bodies) No senile plaques or neurofibrillary tangles S+S: early personality + behavioural changes, pacing + disinhibition, executive impairment Stop anticholinergic drugs

Question 15

Huntington’s pathology, inheritance, S+S

Answer 15

Onset in 4th/ 5th decade Pathology: abnormal huntington protein leads to neuronal loss in caudate nucleus and putamen (movement) + cerebral cortex (dementia) Autosomal dominant S+S: choreiform movements, progressive dementia, depression

Question 16

Normal pressure hydrocephalus pathology, S+S, treatment

Answer 16

Pathology: impaired CSF reabsorption, reducing CSF production so ICP isn’t raised. S+S: gait disturbance, ataxia, dementia + urinary incontinence Treat with a shunt

Question 17

Cruetzfeld Jakob disease

Answer 17

Prion disease causing rapidly progressive dementia and myoclonic jerks

EEG changes

Hummingbird sign

Question 18

Organic syndromes causing psych symptoms

Answer 18

Cushings - depression (+ weight gain, thin skin, kidney stones, HTN, loss of periods) Hypothyroidism - depression (+weight gain, lethargy, constipation) Hyperparathyroidism - depression (+N+V, polydipsia/uria, fatigue, bone pain) Acute porphyria - anxiety, confusion, hallucinations (+red urine, abdo pain, vomiting)

Question 19

Treatment of dementias (memory loss, depression, psychosis)

Answer 19

1st line = Cholinesterase inhibitors for Alzheimers + DLB Memantine - NMDA receptor antagonist = 2nd line for Alzheimers + DLB SSRI (citalopram) for depressive symptoms Minimise use of APs Quetiapine for psychosis - don’t use typical APs due to risk of EPSEs

Question 20

Delirium S+S, treatment

Answer 20

Rapid onset, fluctuating, altered consciousness, distubed sleep-wake cycle Hyper or hypoactive Disorientation to time and place, immediate recall impaired Treatment: supportive, use haloperidol to sedate if needed

Question 21

Psychological treatment of dementias

Answer 21

Comfortable environment Visual/ hearing aids Support groups/ respite care Counselling

Question 22

Social treatment of dementias

Answer 22

Patient safety at home Mobility help Restrict driving Legal counsel - power of attorney Monitor meds compliance

Question 23

What to give to someone with dementia + gastric ulcers?

Answer 23

NMDA receptor antagonist eg memantine

Question 24

What scores on MMSE + ACE III indicate dementia?

Answer 24

MMSE: 20-26 = mild cognitive impairment;

10-20 = moderate impairment;

<10 = dementia

ACE III <82 indicates likely dementia

Question 25

What is pseudodementia?

Answer 25

Temporary dementia caused by depression, other mental disorders, psychoactive drugs

Can be reversed with correct management of underlying cause