Dementia Flashcards
What is this a presentation of?
Decline in intellectual function, including difficulties with language, simple calculation, planning and judgement, and motor skills as well as loss of memory.
Dementia
What is dementia?
A neurodegenerative syndrome with progressive decline in several cognitive domains. Initial presentation is usually of memory loss over months or years.
What are the risk factors for developing dementia?
Increasing age, female, family history, ApoE4, low educational attainment, traumatic brain injury, hypertension, diabetes, Down’s syndrome.
What are the causes of dementia?
- Traumatic - head injury
- Vascular -post-stroke, small vessel disease
- Infections - herpes simplex, HIV, syphilis, Lyme
- Toxic - alcohol, heavy metals
- Metabolic - B12 deficiency, hypothyroidism
- Genetic - Huntington’s
- Neurodegenerative - Alzheimer’s, frontotemporal
- Inflammatory - autoimmune, MS
What should you ask about in a history taking for suspected dementia?
- What symptoms have they been experiencing?
- How long has it been going on for?
- Any other features? (to suggest depression, SoL, temporal lobe seizures, obstructive sleep apnoea, alcohol)
- Memory of recent vs distant events
- Change in personality
- Difficulty with comprehension/expression
How does memory loss in dementia normally present initially?
Starts with forgetfulness of recent events. The disorientation for time, then place, then person.
What are the four A’s of Alzheimer’s?
- Amnesia - recent memories lost first, disorientation early on
- Aphasia - word-finding problems, muddled speech
- Agnosia - recognition problems
- Apraxia - cannot carry out skilled tasks (e.g. dressing)
What is it called when there is a dementia-like presentation, but only one global domain is affected?
Mild cognitive impairment (MCI)
What is this a presentation of?
Persistent, progressive, global cognitive impairment. Visuo-spatial, memory, verbal abilities, and planning affected. Anosognosia. Irritability, mood disturbance, behavioural change, psychosis.
Alzheimer’s dementia
Anosognosia - lack of insight into condition
Which area of the brain is affected in Alzheimer’s dementia?
Medial temporal lobe (hippocampus) atrophy
What is the pathophysiology of Alzheimer’s dementia?
Extracellular B-amyloid plaques and intracellular neurofibrillary tangles
What are the risk factors for developing Alzheimer’s dementia?
Female, 1st degree relative, age, Down’s syndrome, ApoE4, HTN, DM, dyslipidaemia, depression, loneliness, decreased physical/cognitive activity.
What is the cause of familial early onset Alzheimer’s dementia?
Rare autosomal dominant mutation increasing B-amyloid
What is this a presentation of?
Many small strokes, HTN. Sudden onset stepwise deterioration of memory. May be focal neurology.
Vascular dementia
What conditions increase the risk of vascular dementia?
HTN, stroke, hypercholesterolaemia, DM, AF, MI, TIAs
How is vascular dementia specifically managed?
Control vascular risk factors, not for AChEi/memantine.
What is this a presentation of?
Fluctuating confusion with marked variation in levels of alertness, detailed visual hallucinations. Later, parkinsonism.
Lew body dementia
What is this a presentation of?
Parkinsonism. Later, fluctuating confusion with marked variation in levels of alertness, detailed visual hallucinations.
Parkinson’s disease dementia
What should you not prescribe in Lewy body dementia for the hallucinations?
Anti-psychotics (worsen dementia)
What is this a presentation of?
Under 65 years old, executive impairment, behavioural/personality change, inappropriate behaviour, disinhibition, rigid thinking, loss of insight.
Fronto-temporal dementia
What is a very late sign of fronto-temporal dementia?
Episodic memory loss and lack of spatial orientation
How is dementia diagnosed?
- History from patient and collateral from relative.
- Cognitive testing - MMSE and Addenbrooke’s ACE III
- Medication review
- Rule out delirium, reversible/organic cause - full bloods
- Septic screen - MSU, CXR, blood culture
- Consider CT/MRI to rule our structural pathology
- Consider LP for low A-beta/tau ratio of unsure
What is pseudodementia?
Memory problems in severe depression, low mood precedes cognitive problems.
What is the social management for dementia?
- Carry personal info, blister pack, change gas to electric, visible clocks and calendars
- Personal care, meal prep, Alzheimer’s society/cafes, day centres, DWP, council tax reduction, blue badge.
- Emotional support, education, training, respite care.
- Suggest an advanced directive/appoint lasting power of attorney
What is the physical and psychological management for dementia? (non-pharmaceutical)
- Hearing aids, glasses, exclude superimposed delirium, treat underlying risk factors, review meds.
- Reminiscence therapy (talk about old days), multisensory therapy, cognitive stimulation therapy.
- PT/OT assessment
What is the pharmaceutical management of dementia?
- AChEi - donepezil, rivastigmine
- Antiglutamatergic - memantine (late stage AD and BPSD)
- SSRI for depression
What are the side effects of acetylcholinesterase inhibitors?
Bradycardia (stop ACEi), GI upset, nausea and vomiting.
What are the principles of prescribing in dementia?
- Start low go slow
2. Not curative and do not slow disease progress, may slow decline in memory.
