Dementia

Question 1

Confusion = … until proven otherwise

Answer 1

Due to acute illness

Question 2

When Dx dementia, what do you need to ensure?

Answer 2

➤ No treatable cause

Question 3

What is dementia?

Answer 3

It is a syndrome of many causes of global impairment of cognition without impairment of consciousness.

Question 4

Key to diagnosis dementia

Answer 4

Good Hx

Question 5

Types of dementia

Answer 5

• Alzheimer’s disease.
• Vascular dementias (or multi-infarct dementia).
• Lewy body dementias.
• Frontal lobe dementias (such as Pick’s disease).
• Subcortical dementias (such as Huntington or progressive supranuclear palsy).
• Focal cortical atrophy syndromes (such as primary aphasia).
• Metabolic-toxic dementias (such as chronic hypothyroidism or B12 deficiency).
• Infections (such as syphillis, neuroAIDS or chronic meningitis).

Question 6

Lewy body dementia - Where? Characteristed by? Tx?

Answer 6

o Third commonest type of dementia (15-25%).
o Lewy body in the brainstem (midbrain) and cortex.
o Characterised by fluctuating cognitive loss, alertness. Parkinson manifestation. Visual hallucination.
o Rivastigmine might help (cholinesterase inhibitors).

Question 7

Common causes of dementia

Answer 7

• Alzheimer’s disease.
• Vascular dementia. 25% (multiple small strokes) or also called (multi-infarct dementia). Evidence of vascular pathology (ex: high BP, stroke, stepwise deterioration)
• Lewy body dementia. Characterised by Lewy body in the brainstem and neo-cortex and fluctuating symptoms but persistent cognitive impairment.
• Frontotemporal dementia. Characterized by atrophy of frontal and temporal lobes. Change in personality, emotional unconcern disinhibition, hyperorality, stereotyped behaviour. No features of Alzheimer’s pathology.

Question 8

! Ameliorable causes of dementia

Answer 8

• Decrease T4
• Decrease B12/Folate
• Decrease thiamine
• Parkinson’s disease, Syphilis, Pellagra
• Cerebral tumours (ex: meningiomas)
• Subdural haematoma
• Normal pressure hydrocephalus

Question 9

Rare causes of dementia

Answer 9

• Chronic alcohol or barbiturate abuse.
• Pellagra / Nicotinic acid deficiency.
• CJD.
• Parkinson’s.
• HIV.
• Progressive leukoencephalopathy.

Question 10

Symptoms of dementia

Answer 10

• Normal daily tasks are done with increasing incompetence.
• Increase forgetfulness (progressive impairment of memory and other cognitive functioning).
• Personality changes.

Question 11

Dementia - Tests / Ix

Answer 11

• FBC/ film, U&E, Ca, LFT, TSH, CXR.
• Urine test.
• Syphilis serology.
• Folate/ B12.
• CT.
• EEG & CSF examination.
• HIV test.

Question 12

Dementia - Management

Answer 12

• Deal with treatable conditions.
• Social services.
• Carer support.
• In most people dementia will remains and progress.

Question 13

Dementia - Living with dementia / Ideas

Answer 13

• Support for carers & family members
• Dx
• Practical help
• Local support & services
• Legal planning & dementia
• Money matters
• Getting a break

Question 14

Dementia - Younger people with dementia / ideas

Answer 14

• Local support
• Support online
• Children & family
• Future care options
• Maintaining skills
• Benefits available
• Employment
• Fact sheets

Question 15

Alzheimer’s disease - onset?

Answer 15

• Now includes onset at any age. Onset may be from 40 years old.
• Prevalence: 10% over age 65, 47% over age 84.

Question 16

Most common cause of dementia in the elderly

Answer 16

Alzeihmer’s disease

Question 17

Alzheimer’s disease - Survival?

Answer 17

Survival: 7yr from onset.

Question 18

Alzheimer’s disease - Characteristics

Answer 18

The patient will remember things that happened many years ago very clearly, but events in the recent past are forgotten.

Question 19

Alzheimer’s disease - Pathophysiology

Answer 19

• Two microscopic changes occur in the brain in Alzheimer’s disease: Senile plaques develop between neurons, while neurofibrillary tangles develop within neurons.
• These changes are thought to be related to the cause, development, and course of the disease.
• Involvement of cholinergic neurons causes levels of acetylcholine within synapses to decline.
• Levels of acetylcholine esterase also drop, perhaps to compensate for the loss of acetylcholine.
• Activity of another cholinesterase enzyme increases, and a significant portion of acetylcholine is metabolized by this enzyme as the disease progresses.
• Eventually the neuron is destroyed

Question 20

Alzheimer’s disease - Risk factors

Answer 20

o Defective genes on chromosomes 1, 14, 19 and 21.
o Family history of Alzheimer’s disease.
o Aging and oestrogen deficiency.
o Head injury.

Question 21

Alzheimer’s disease - Presentation

Answer 21

o There is no natural standard history, cognitive impairment is progressive but behavioural and psychotic symptoms may disappear at later course of disease.
o Behavioural changes: aggression, wandering.
o Lack of concentration.
o Confusion about time & place (loss of visual-spatial skill).
o Anosognosia (lack of awareness): disinhibition.
o Sometimes saying or doing outrageous things
o Mood can be depressed, anxious or agitated.
o Reasoning can become slow and muddled.
o Some people may experience hallucinations or delusion.
o Parkinsonism, wasting, incontinence and seizures may occur.

Question 22

Alzheimer’s disease - Dx

Answer 22

o Early diagnosis may help patients to take legal decisions.
o Brain imaging and neuropsychological tests help rule out fronto-temporal, Lewy body and vascular dementias.
o Need thorough physical exam and complete medical history.
o A careful review of the patient’s medicine, and alcohol use is important.
o Medical conditions, including tumours, infection, and dementia caused by mild strokes (multi-infarct dementia) should be excluded. These possibilities must be ruled out as well through appropriate blood and urine tests, brain MRI or CT and EEGs.
o One of the most important parts of the diagnostic process is to evaluate and exclude the patient from depression and delirium.
o The neurological exam is normal in most patients in early stages.

Question 23

Alzheimer’s disease - Management

Answer 23

• Social services, family and Alzheimer society.
• Exclude treatable causes.
• Meticulus control of blood pressure, only 5% of dementia is in pure form, 95% is mixed of AD and vascular component. optimal cerebral perfusion is needed, diastolic should not lowered more than 70 mm.
• Treat concurrent illnesses.
• Avoid drugs that suppress cognition (neuroleptics, sedative, tricyclic).
• Arrange a well-lit cognitively stimulating care setting (eg: multisensory stimulation, massage, music & aromatherapy). Also structured conversation and exercise can help.
• Drugs:
   Oral cholinestrase inhibitors: help embedding new memories more than accessing the old ones. (Eg: Donepezil 4 mg at night doubled after 4 weeks. Other drugs are rivastigmine and galantamine.)
   Antiglutamatergic drugs (Eg: Memantine helps moderate to severe cases of AD (SE, hallucination, confusion, hypertonia, hypersexuality)).