Dementia Flashcards
Define Dementia
Chronic or progressive syndrome of brain disease leading to disturbance of multiple higher cortical functions
- including memory, orientation, comprehension, calculation, learning capacity, language and judgement
- sufficient to impair personal ADLs
Risk factors for dementia
Age
Female
Genetics
Lifestyle - smoking, alcohol, obesity, cholesterol, hypertension, cerebrovascular disease
Psychosocial - no physical activity, depression
Features of dementia
Timeline - who noticed decline, when, what differences
Collateral hx
Symptoms - memory, decision making, language, degree of insight
Current family support
Any recent changes or bereavement
Risks - wandering, cooking, driving, neglect, alcohol, smoking
Significant co-morbidities
Self care ability - managing finances
Clinical cognitive assessment
Attention and orientation
o Alertness and cooperation
o Time, place, person
o Spell world backwards, months of the year backwards
Memory
Language
o Naming objects, comprehension, repetition, reading, writing
Executive and frontal lobe function
o Letter and category fluency (name as many words starting with P)
o Impulsivity
o Personality change
o Primitive reflexes 0 e.g. palmar-mental reflex
Apraxia
o Mimicking tasks (brush teeth, comb hair), hand gestures
Visuospatial ability
o Topographic disorientation, neglect
o Copy drawing of cube, clock face
Ix for dementia
Physical exam - other causes - infection - focal neurology - vascular dementia Bloods - U+Es, B12, folate, TFTs ECG, CXR, EEG, MSU Neuro-imaging - CT/MRI - cerebral atrophy in late stages
Mx of dementia
MDT – psychiatrist, GP, occupational therapist, support worker etc
Support – Alzheimer’s society, age UK
Psychological interventions – cognitive stimulation therapy, cognitive rehab
Comorbidities
o Vascular risk modification
o Avoid polypharmacy (anticholinergics, TCAs, antihistamines, opiates)
o Depression screen
Risk assessment - driving, carer strain
Future planning – follow up, power of attorney, will
Social care involvement
Legal framework – capacity, DOLS
Define mild cognitive imapriment
Evidence of objective cognitive decline
Not an official diagnosis
10-10% conversion to dementia per year
Pathophysiology of Alzheimer’s
Deposition of amyloid plaques and neurofibrillary tangles (tau proteins)
Symptoms of Alzheimer’s
Short term memory loss Problems with language - shrinking vocab Disorientation Mood swings Apraxia with fine motor tasks
Mx of Alzheimer’s
Diagnosed on hx, cognitive assessment and ruling out other disease
Mediations - acetylcholinesterase inhibitors, memantine
Features of vascular dementia
Stepwise cognitive decline with progressive vascular occlusions
Symptoms mainly include cognitive decline and memory impairment
Some focal neurology maybe present
Brain imaging shows cerebrovascular disease
Features of Lewy body dementia
Abnormal deposits of alpha-synuclein (Lewy bodies) in the brain
Symptoms of parkinsonism, impaired cognition, sleep disorders, visual hallucinations, fluctuations in attention, slowness of movement, mood changes
REM sleep behaviour disorder – acting out dreams due to loss of normal muscle paralysis during REM sleep
DLB – cognitive symptoms arise before or with Parkinson’s symptoms
PDD – Parkinson’s is well established before cognitive symptoms
Features of frontotemporal dementia
Changes in behaviour, social conduct, impulsivity, loss of comprehension
MRI shows frontal and/or temporal lobe atrophy in later disease
Core features of delirium
Cognitive impairment
Rapid onset
Fluctuating severity
Risk factors for delirium
Over 65s Dementia Polypharmacy Functional/sensory impairment Malnutrition
Precipitating factors for delirium
Acute illness Drugs Electrolyte disturbance New environment Constipation Dehydration Post-op period
Types of delirium
o Hyperactive – increased fall risk, may require antipsychotic (avoid if possible)
o Hypoactive – often mistaken for depression or missed
o Mixed – fluctuating
Diagnosis of delirium
Confusion Assessment
- delirium should be suspected with the presence of Features 1 and 2 and 3/4
1) Acute Onset and Fluctuating Course – collateral history required for baseline
2) Inattention
3) Disorganized Thinking
4) Altered Level of Consciousness
4AT tool – score out of 12
o Alertness – normal (0) abnormal, markedly drowsy, agitated, hyperactive (4)
o AMT – age, D.O.B., place, current year (0 – no mistakes, 1 – 1 mistake, 2 – 2 or more mistakes)
o Attention – months of the year backwards (0 – 7 or more months, 1 – doesn’t reach 7 months, 2 – untestable)
o Acute change/fluctuating course (0 – no, 4 – yes)
Prevention and mx of delirum
Minimise environmental disruption
Good nursing care
Medication review
Ensure availability of glasses and hearing aid if needed
Orientation clock
Side room
Medication last resort – low dose lorazepam/haloperidol
Complications of dementia
Increased mortality at 6 months
Risk of accelerated cognitive decline
Define cognitive impairment
Disturbance of higher cortical functions including memory, thinking, judgement, language, perception and awareness
Confusion Assessment Method for Delirium
Acute onset and fluctuating course
Inattention
Disorganised thinking
Altered level of consioucsless
