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Cognitive impairment Flashcards

1
Q

Definition of dementia

A

Acquired progressive generalised impairment in cognition that interferes with social functioning but without clouding of consciousness

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2
Q

Cardinal clinical features of dementia

A
  • Memory impairment (short term > long term)
  • Behaviour: Restless, repetitive/purposeless, rigid routine
  • Speech: Dysphasia, mutism
  • Mood: Irritable, depressed
  • Peronsality: Disinhibition, aggression
  • Lack of insight
  • Psychosis (esp visual hallucinations) in 50% of cases
  • Progressive
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3
Q

Differentials for dementia

A
  • Deafness/dysphasia: Check they can hear
  • Depression: Important and reversible
  • Delirium: Associated with organic pathology
  • Drugs: esp anticholinergics
  • Epilepsy: Post-ictal state, ongoing complex partial seizures (temporal lobe epilepsy)
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4
Q

Distinguishing dementia from depression (pseudodementia)

A
  • Did low mood (or other features of old age depression) precede memory impairment
  • Is failure to answer Qs due to lack of ability or lack of motivation? (I don’t know/it’s too hard vs incorrect answer)
  • Neurological deficits suggest organic cause (e.g. dementia)
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5
Q

Prominent features of depression in older adults (> than low mood)

A

Apathy

Anxiety

Forgetfulness

Irritability

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6
Q

Broad categories of dementia aetiologies

A

Common dementias

Degenerative disorders

Metabolic disorders

Infections

Neurological disorders

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7
Q

Most common causes of dementia

A

Alzheimer’s: 50-60% of cases

Vascular dementia: 20-25%

Dementia with Lewy bodies: 10-15%

Everything else: 10%

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8
Q

Degenerative disorders causing dementias (in the 10%)

A

Frontotemporal degeneration

Huntington’s

Parkinson’s plus syndromes

Prion disease (e.g. CJD)

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9
Q

Metabolic/endocrine abnormalities causing cognitive impairment

A

Hypothyroidism

Hyperparathyroidism

Hypercalcaemia

B12/folate deficiency

Alcohol-associated dementia

Cushing’s

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10
Q

Infections causing dementia

A

HIV

Syphilis

Meningitis/encephalitis may present as cognitive impairment (more commonly delirium)

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11
Q

Neurological causes of dementia

A

Head injury

Subdural haematoma

Intracranial tumour/mets

Normal pressure hydrocephalus

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12
Q

Dementia suggested by past history of fall

A

Subdural haematoma

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13
Q

Dementia suggested by repeated falls

A

Lewy body dementia

Progressive supranuclear palsy

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14
Q

Dementia suggested by carotid bruits/hypertension

A

Vascular dementia

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15
Q

Dementia suggested by incontinence

A

Normal pressure hydrocephalus

Delirium

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16
Q

Dementia suggested by prominent behavioural change/apathy early in illness

A

Vascular dementia

FTD

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17
Q

Dementia suggested by prominent aphasia early in illness

A

Vascular dementia

FTD

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18
Q

Dementia suggested by progressive gait disorder

A

PD-assoc dementia

normal pressure hydrocephalus

Vascular dementia

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19
Q

Dementia suggested by prominent fluctuations

A

Lewy body

Delirium

Medication SEs

Obstructive sleep apnoea syndrome

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20
Q

Dementia suggested by hallucinations or delusions

A

Delirium

Medication SEs

Late-onset schizophrenia (paraphrenia)

Dementia with Lewy bodies

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21
Q

Dementia suggested by eye movement abnormalities

A

PD-assoc dementia

Wernicke’s encephalopathy

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22
Q

Formal assessment tools for cognition

A

MMSE

MOCA

CLOX

Addenbrookes Cognitive Examination

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23
Q

Prominent symptoms and signs of Alzheimer’s dementia

A

Memory loss

Dyspraxia

Dysphasia

Apathy

Psychosis

Loss of executive f(x): disorganisation, disorientation, lack of reasoning

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24
Q

Prominent symptoms and signs of vascular dementia

A

Gait disturbance (Parkinsonian, small-step)

Urinary urgency/frequency appears early

Preserved insight

Labile mood, personality changes (occur earlier than AD, before memory)

Sudden-onset, step-wise progression

Hx/risk factors for vascular disease

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25
Q

Prominent signs and symptoms of LB/Parkinsonian dementia

A

Parkinsonism

Visual hallucinations (usually not scary)

Flucctuating dementia

Delirium-like phases

Poor REM sleep

Visuospatial impairment

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26
Q

Prominent signs and symptoms of frontotemporal dementia

A

Early onset (40-60)

Insidious, gradual progression (lacks insight)

Memory initially preserved

Early primitive reflexes + stereotyped behaviours

Peronsality change

Emotional blunting

Expressive dysphasia: echolalia, perseveration, reduced speech

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27
Q

Prominent features of Huntington’s disease

A

Family Hx

Early onset (20s-40s)

Choreiform movements

Irritability/depression

Schizophrenia-like psychosis

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28
Q

Prominent features of normal pressure hydrocephalus

A

Urinary incontinence

Gait apraxia

Mental slowing, apathy, inattention

Onset 50-70s

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29
Q

Clinical features of prion disease

A

Onset <50

Myoclonic jerks

Seizures

Cerebellar ataxia

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30
Q

Problems with antipsychotics in dementia

A

More rapid cognitive decline (esp LBD)

Increased risk of stroke

Increased risk of sudden death

31
Q

Poor prognostic factors for dementia

A

Prion disease (<1y)

Young age of onset

Focal neurological signs

Psychotic symptoms

32
Q

Initial assessment + workup of dementia

A
  • Baseline bloods –> treat reversible causes
  • Corroborative Hx
  • MOCA/MMSE
  • CT scan before referral to 2ry care
  • Treatment of exacerbating factors
    • Infection, dehydration, constipation (esp if sudden deterioration)
  • DVLA + driving advice (alone not ban on driving)
  • Establish formal multidisciplinary care plan
33
Q

Long-term management of dementia components

A
  • Psychoeducation
  • Social support
  • Optimising environment
  • Psychological treatments
  • Pharmacological interventions (employ later)
  • Medico-legal aspects
  • Carer support
34
Q

Social support services in dementia

A

Support for carers and patients

e.g. meals-on-wheels, day care, respite admissions

35
Q

Optimising environment in dementia

A

Calm, familiar, well-lit

Regular toileting schedule to treat incontinence, other routines

Visible clocks

36
Q

Psychological treatments in dementia

A

Aromatherapy

Reminiscence therapy

Music/art therapy

Structured group cognitive stimulation programme

37
Q

Medico-legal aspects in dementia

A

DOLS

MCA

Advance directives

LPA

38
Q

Histopathology of Alzheimer’s

A

Neurofibrillary tangles (Tau protein)

Beta-amyloid plaques

Cerebral atrophy, esp loss of cholinergic neurons in basal forebrain

39
Q

Genetic risk factors for Alzheimer’s

A

ApoE4 allele

APP/PSEN mutations (rare)

Down’s syndrome

40
Q

Environmental protective factors for Alzheimers

A

High educational attainment

Regular physical/mental exercise

41
Q

Medical risk factors for Alzheimer’s

A

Homocysteinemia

Obesity/diabetes in middle age

Hypertension

Hx of depression

Head injury

42
Q

Pharmacological treatment of mild-mod Alzheimer’s

A

Chlolinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine)

43
Q

Contraindications to donepezil

A

Baseline bradycardia

Cardiac conduction abnormalities (e.g. sick sinus)

Peptic ulcer

Hepatic impairment

COPD/asthma

Caution w/ beta blockers/Ca channel blockers

44
Q

Pharmacological treatment of mod-severe Alzheimer’s

A

Memantine (NMDA antagonist)

45
Q

Effect of pharmacological treatments of Alzheimer’s

A

Delay entr into residential care (6-9 months)

46
Q

Risk of developing dementia after stroke

47
Q

Risk of developing dementia after two strokes

48
Q

Management of vascular dementia

A

Manage cardiovascular risk factors

No evidence for aspirin

49
Q

Histopathology of Lewy body dementia

A

Alpha-synuclein intracellular inclusions in cerebral cortex

50
Q

Distinction between Parkinson’s associated dementia and Lewy body dementia

A

PDD occurs >12mo after onset of Parkinsonism

51
Q

Pharmacological treatment of LBD/PDD

A

Cholinesterase inhibitors (rivastigmine)

NOT antipsychotics

52
Q

Risk of PDD after onset of PD

53
Q

Treatment of normal pressure hydrocephalus

A

Ventricular shunting

54
Q

Prognosis of normal pressure hydrocephalus dementia

A

50% respond well to ventricular shunting

55
Q

Management of Huntington’s dementia

A

Symptomatic treatment of depression/psychosis

Genetic counselling for family

56
Q

Neuropathology in normal pressure hydrocephalus

A

Disproportionate enlargement of ventricles on CT/MRI

57
Q

Neuropathology in Huntington’s

A

Accumulation of huntingtin –> neurotoxic

Atrophy of caudate nucleus –> frontal lobe

58
Q

Time criterion for dementia

59
Q

Presentation of neurosyphilis

A
  • Argyll-Robrtson (aka prostitute’s) pupil: accommodate but don’t react
  • Hypomania
  • Memory issues
  • 15-20y post-infection
60
Q

Common misidentifying delusions in Alzheimer’s

A

Capgras

Mirror sign

Phantom boarder

61
Q

Distinction between MCI and dementia

A

MCI: AoDL intact + still possesses insight (complaint of memory loss)

62
Q

Chance of developing dementia from MCI

63
Q

Classical progression of vascular dementia

A

Stepwise deterioration

64
Q

MMSE score for mild-moderate Alzheimer’s

65
Q

MMSE score for severe AD

66
Q

Temporal sequence of symptoms in vascular dementia

A

Labile affect + personality changes often precede cognitive deficitys

67
Q

Distinction between anhedonia and apathy

A

Apathy –> will not seek out enjoyment but will report enjoyment of things if they happen to them

Anhedonia –> reports nothing is enjoyable

68
Q

Side effects of cholinesterase inhibitors

A

Anorexia

Nausea + Vomiting

Diarrhoea

Syncope

Urinary incontinence

69
Q

Side effects of memantine

A

Dizziness

Headache

Ataxia

Dyspnoea

Constipation

Hypertension

70
Q

Managing agitation/behavioural disturbance in dementia

A

Risperidone, haloperidol

Increased stroke risk, use with caution

71
Q

Prognosis of AD

A

Death within 3-10 years

Irreversible

72
Q

Prognosis for LBD

A

Death within 4-10 years

Worse functional impairment due to parkinsonism, more need residential care

73
Q

Prognosis for VD

A

3-5 year life expectancy, death from stroke/IHD

Psychiatry (20 decks)

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