Dementia Flashcards
what is dementia
severe loss of memory and other cognitive abilities which leads to impaired daily function
chronic neurodegenerative disease with progressive (slow cognitive decline) and an insidious onset
Heterogenous course
Multiple comorbidities in old age
Younger patients more typical
See Causes for detail
No current cure: acetyl cholinesterase inhibitors
what are risk factors for dementia
aging oral health brain trauma infections or systemic inflammation genetic factors midlife obesity reduced physical activity
what are the most prevalent causes for the 2 types of dementia
1) Young onset
2) late
fAD= frontal alzheimer’s disease
AD = Alzhiermer’s disease
VaD= vascular dementia
FtD= frontal lobe dementia
DLD/PD = lewy body dementia
Dementia can be young onset ( <65 yrs) or late onset ( > 65yrs)
Causes of young onset : Familial autosomal dominant alzheimer’s disease caused by AVP and Presnell mutations, More caused by frontal lobe damage
Causes of late onset : Alzheimer’s most prevalent
what are symptoms of dementia
Symptoms of dementia Head turning sign Forgetfulness / episodic memory ( memory for particular periods of their life ) Get lost easily Disinhibition Changes in personality Poor personal hygiene
what is progression of dementia
Cognitive function decreases with age
In dementia you have a preclinical period : deterioration in cellular function w/o clinical manifestation ie forgetfulness
In Preclinical : increases in amyloid, increases in tau protein inflammation → leads to mild cognitive impairment and dementia
Cognitive function fluctuates up and down - it is not a smooth curve and is dependant on sleep, diet, stress etc
Amyloid tau protein may increase if cause in Alzheimer’s
why is dementia hard to diagnose?
Generally hard to diagnose as :
Disease follow heterogenous course
Old age means disease presentation is of multiple comorbidities ( ie hypertension , diabetes, CVD)
Can have mixed pathologies ( ie can be a lot of molecules causing dementia
Younger present with more typical symptoms
V important to look at clinical history and how the patient changes over time
what is the clinical diagnosis pathway for dementia
1) referral
2) History
3) examination
4) investigation
5) diagnosis
6) management
7 ) repeat
what happens in referal
From GP , therapist , geriatrics doctor ect
what must you ask in the history of dementia
Interview( ask about) :
Must ask about chronology of each ( aka how it’s changed over time ie improve/ deteriorate)
Large deterioration = usually vascular causes of dementia . Small deterioration = alzheimers
( should ask family members = collateral history )
V important to ask about memory esp short term memories Ie what did you have for breakfast today
Delusion : firmly held fixed ideas that can’t be changed
Hallucinations can be auditory , visual, somatic
Confirm with a relative
Look for “head-turning” sign
Vague about recent news events and sports results
Queen square green book
Luria three stage sequence with alternating hand task
See google docs for more ie - memory language maths skills visuospatial skills etc
what examinations of dementia should be conducted
Neurological - Cranial nerve tests . Lower + upper limb tests. Focus tests ie frontal lobe function tests etc
Mental state → appearance , perception , insight ( all the physciologial stuff etc)
what investigations of dementia should be conducted
Neuropsychology : profound impairment of episodic memory esp in relation to recently learned material
MMSE test : +/- ACE III (15 minutes, more memory focussed) Can also do the Cambridge cognitive examination which is more memory focused Or ACE ( addenbrooke's cognitive assessment)
Bloods Full blood count Inflammatory markers Thyroid function Biochemistry and renal function Glucose B12 and folate Clotting Other causes Syphilis serology HIV Caeruloplasmin: wilson’s disease, copper deficiency (at intervals when monitoring a copper related disease or its treatment)
Basic Imagining ie MRI / PET
CSF ( microbiology)
Taken via lumbar puncture + assess for B amyloid and tau protein
what types of MRT/PET should be done for dementia
MRI scan/ structural imaging Left = cognitive normal Middle = mild cognitive impairment Right = alzheimer's disease In AD : Ventricles are dilated and enlarged, hippocampal volume loss - replaced with CSF ( appears black on MRI)
Amyloid PET scans
Cannulate patient
Inject patient with contrast ( ATF) which travels to the brain
Contrast lights up amyloid in the brain
Negative: low likelihood of alzheimer’s (low amyloid, low tau)
what can be possible diagnosis of dementia
See types + causes below Differential list ie : Alxheimers Vascular Lewy body FTD Depression Delirium None ?
what are the management strategies of dementia
See below !
ACHase inhibitors
Watch and wat ( should see deterioration of patient > 6 months)
Treat behaviour and physiological symptoms
OT / social services
Specialist therapy
what are the different types of dementia
In order to diagnose dementia must rule out other conditions
First rule out other conditions: delirium vs dementia vs depression
1) Alzheimer’s
2) vascular dementia
3) dementia with Lewy bodies
4) frontal temporal dementia
5) rapidly progressing dementias
how is delirium different to dementia and depression
see google docs
what is Alzheimer’s and how does it present on an MRI
Subtle, insidious amnestic/non amnestic presentations
(most prevalent)
dysfunction of medial temporal lobe structures (entorhinal cortex and hippocampus)
hippocampal atrophy (replaced by CSF)
→ dilated lateral ventricles
→ widened
symptoms of Alzheimer’s
gradual onset
Often patients lack insight of their problems
memory loss (names, recent events)
E.g. can still drive but can’t remember the way , forget to take medications/ takes too much
Episodic memory impaired
language deficits
rapid forgetting
impaired visuospatial skills
normal gait and neuro exam early
later affective disturbances; behavioural symptoms such as aggression - increasingly irritable
what causes Alzheimer’s
(medial temporal atrophy esp in entorhinal cortex + hippocampus)
This causes memory loss
beta amyloid plaques
→ aberrant cleavage of amyloid precursor protein by beta and gamma secretase instead of alpha resulting in surplus of amyloid beta which aggregates and accumulates in amygdala, hippocampus and cerebral cortex as amyloid plaques (interferes with neuron communication and contributes to inflammation)
neurofibrillary tangles
→ plaques trigger tau hyperphosphorylation which aggregates into NFTs in cortex, hippocampus and substantia nigra - leads to reduced neuronal function and atrophy (degeneration of cholinergic nuclei, reduced acetylcholine)
what is vascular dementia ? symptoms ? causes?
Vascular dementia
→ Related to cerebrovascular diseases with a classical stepwise deterioration +- multiple infarcts
symptoms: abrupt or gradual onset
focal neurological signs
signs of vascular disease
causes: strokes, lacunar infarcts, white matter lesions, vulnerable to cerebrovascular events
what is dementia with lewy bodies ? symptoms ? causes
→ Cognitive impairment before/within 1 year of parkinsonian symptoms, visual hallucinations and fluctuating cognition
Preserved hippocampal and medial temporal volume, DAT scan: fewer dopamine transporters
symptoms: insidious onset, progressive with fluctuations fluctuating cognition visual hallucinations REM sleep disorder neuroleptic sensitivity shuffling gait increased tone tremors falls
causes
generalised atrophy
lewy bodies in cortex and midbrain
(LB= deposits of alpha-synuclein protein)
what is frontotemporal dementia ? symptoms? causes ?
Frontotemporal dementia
→ Behavioural variant FTD, semantic dementia, progressive non-fluent aphasia
symptoms: insidious onset (50s, 60s), rapid progression disinhibition socially inappropraite poor judgemnt apathy decreased motivation poor executive function Limited spontaneous communication Can’t find the right words
causes:
frontal and temporal atrophy due to hyperphosphorylated tau
pick cells and pick bodies in cortex
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