Dementia

Question 1

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.

Answer 1

Dementia

Question 2

What is dementia?

Answer 2

A neurodegenerative syndrome with progressive decline in several cognitive domains. Initial presentation is usually of memory loss over months or years.

Question 3

What are the risk factors for developing dementia?

Answer 3

Increasing age, female, family history, ApoE4, low educational attainment, traumatic brain injury, hypertension, diabetes, Down’s syndrome.

Question 4

What are the causes of dementia?

Answer 4

1. Traumatic - head injury
2. Vascular -post-stroke, small vessel disease
3. Infections - herpes simplex, HIV, syphilis, Lyme
4. Toxic - alcohol, heavy metals
5. Metabolic - B12 deficiency, hypothyroidism
6. Genetic - Huntington’s
7. Neurodegenerative - Alzheimer’s, frontotemporal
8. Inflammatory - autoimmune, MS

Question 5

What should you ask about in a history taking for suspected dementia?

Answer 5

1. What symptoms have they been experiencing?
2. How long has it been going on for?
3. Any other features? (to suggest depression, SoL, temporal lobe seizures, obstructive sleep apnoea, alcohol)
4. Memory of recent vs distant events
5. Change in personality
6. Difficulty with comprehension/expression

Question 6

How does memory loss in dementia normally present initially?

Answer 6

Starts with forgetfulness of recent events. The disorientation for time, then place, then person.

Question 7

What are the four A’s of Alzheimer’s?

Answer 7

1. Amnesia - recent memories lost first, disorientation early on
2. Aphasia - word-finding problems, muddled speech
3. Agnosia - recognition problems
4. Apraxia - cannot carry out skilled tasks (e.g. dressing)

Question 8

What is it called when there is a dementia-like presentation, but only one global domain is affected?

Answer 8

Mild cognitive impairment (MCI)

Question 9

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.

Answer 9

Alzheimer’s dementia

Anosognosia - lack of insight into condition

Question 10

Which area of the brain is affected in Alzheimer’s dementia?

Answer 10

Medial temporal lobe (hippocampus) atrophy

Question 11

What is the pathophysiology of Alzheimer’s dementia?

Answer 11

Extracellular B-amyloid plaques and intracellular neurofibrillary tangles

Question 12

What are the risk factors for developing Alzheimer’s dementia?

Answer 12

Female, 1st degree relative, age, Down’s syndrome, ApoE4, HTN, DM, dyslipidaemia, depression, loneliness, decreased physical/cognitive activity.

Question 13

What is the cause of familial early onset Alzheimer’s dementia?

Answer 13

Rare autosomal dominant mutation increasing B-amyloid

Question 14

What is this a presentation of?

Many small strokes, HTN. Sudden onset stepwise deterioration of memory. May be focal neurology.

Answer 14

Vascular dementia

Question 15

What conditions increase the risk of vascular dementia?

Answer 15

HTN, stroke, hypercholesterolaemia, DM, AF, MI, TIAs

Question 16

How is vascular dementia specifically managed?

Answer 16

Control vascular risk factors, not for AChEi/memantine.

Question 17

What is this a presentation of?

Fluctuating confusion with marked variation in levels of alertness, detailed visual hallucinations. Later, parkinsonism.

Answer 17

Lew body dementia

Question 18

What is this a presentation of?

Parkinsonism. Later, fluctuating confusion with marked variation in levels of alertness, detailed visual hallucinations.

Answer 18

Parkinson’s disease dementia

Question 19

What should you not prescribe in Lewy body dementia for the hallucinations?

Answer 19

Anti-psychotics (worsen dementia)

Question 20

What is this a presentation of?
Under 65 years old, executive impairment, behavioural/personality change, inappropriate behaviour, disinhibition, rigid thinking, loss of insight.

Answer 20

Fronto-temporal dementia

Question 21

What is a very late sign of fronto-temporal dementia?

Answer 21

Episodic memory loss and lack of spatial orientation

Question 22

How is dementia diagnosed?

Answer 22

1. History from patient and collateral from relative.
2. Cognitive testing - MMSE and Addenbrooke’s ACE III
3. Medication review
4. Rule out delirium, reversible/organic cause - full bloods
5. Septic screen - MSU, CXR, blood culture
6. Consider CT/MRI to rule our structural pathology
7. Consider LP for low A-beta/tau ratio of unsure

Question 23

What is pseudodementia?

Answer 23

Memory problems in severe depression, low mood precedes cognitive problems.

Question 24

What is the social management for dementia?

Answer 24

1. Carry personal info, blister pack, change gas to electric, visible clocks and calendars
2. Personal care, meal prep, Alzheimer’s society/cafes, day centres, DWP, council tax reduction, blue badge.
3. Emotional support, education, training, respite care.
4. Suggest an advanced directive/appoint lasting power of attorney

Question 25

What is the physical and psychological management for dementia? (non-pharmaceutical)

Answer 25

1. Hearing aids, glasses, exclude superimposed delirium, treat underlying risk factors, review meds.
2. Reminiscence therapy (talk about old days), multisensory therapy, cognitive stimulation therapy.
3. PT/OT assessment

Question 26

What is the pharmaceutical management of dementia?

Answer 26

1. AChEi - donepezil, rivastigmine
2. Antiglutamatergic - memantine (late stage AD and BPSD)
3. SSRI for depression

Question 27

What are the side effects of acetylcholinesterase inhibitors?

Answer 27

Bradycardia (stop ACEi), GI upset, nausea and vomiting.

Question 28

What are the principles of prescribing in dementia?

Answer 28

1. Start low go slow

2. Not curative and do not slow disease progress, may slow decline in memory.