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Mental Health > Dementia > Flashcards

Dementia Flashcards

1
Q

What are the types of dementia?

A
  • Alzheimer’s dementia
  • Vascular dementia
  • Lewy Body Dementia (+ Parkinson’s dementia)
  • Fronto-temporal dementia
  • Pseudo-dementia - secondary to depression
  • Other types: Korsakoff’s, Huntington’s
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2
Q

What are differentials of dementia?

A
  • Traumatic brain injury - acute onset of deficits, more focal, well defined and less progressive
  • Huntington’s - progressive cognitive deficits, choreic movements, FH + early onset
  • Normal pressure hydrocephalus - additional signs such as magnetic gait and incontinence
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3
Q

How is mild dementia classified?

A
  • A degree of memory loss interfering with everyday activities
  • Difficulty learning of new material
  • Difficulty in registering new information
  • MMSE 20-24
  • Able to manage independent life
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4
Q

How is moderate dementia classified?

A
  • A degree of memory loss which represents a serious handicap to independent living
  • Only very familiar material is retained
  • New information is retained only occasionally and very briefly
  • MMSE 10-20
  • Need help with ADLs
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5
Q

How is severe dementia classified?

A
  • A degree of memory loss characterised by complete inability to retain information
  • Only fragments of previously learned info remain
  • Unable to learn new information
  • MMSE <10
  • Completely dependent for ADLs
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6
Q

What are the additional symptoms for dementia?

A
  • Decline in emotional control or motivation - emotional lability, irritability
  • Apathy
  • Coarsening of social behaviour
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7
Q

What is the exclusion criteria for dementia?

A
  • Absence of delirium
  • Symptoms present for at least 6 months
  • No clouding of consciousness
  • Should be irreversible
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8
Q

What are the investigations for dementia?

A
  • Urinalysis: no WBC, proteins or blood (check for UTI which could be causing delirium and contributing to confusion)
  • Bloods (part of confusion screen to check for inflammatory markers - delirium)
  • CT or MRI brain scan (help detect haemorrhages/clots, space-occupying lesions, areas of lobar atrophy)
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9
Q

What test is used when other differentials have been ruled out for dementia?

A

ACE III (Addenbrook’s Cognitive Examination) which allows a comprehensive assessment of various aspects of cognition:
- Memory
- Attention
- Fluency
- Visuospatial skills
- Language
A score below 82 is highly suggestive of dementia

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10
Q

What are some other cognitive tests for dementia and depression in dementia?

A
  • MOCA
  • MMSE
  • Frontal assessment battery

Depression:

  • Hospital Anxiety and Depression Score
  • Beck’s Depression Inventory
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11
Q

What are the instruments to assess functional and psychological symptoms of dementia?

A
  • Functional assessment: functional activities questionnaire, activities of daily living questionnaire, Bristol functional assessment
  • Psychological assessment: neuropsychiatric inventory (NPI)
  • Care giver strain: MBRC caregiver strain instrument
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12
Q

What is the clinical presentation of dementia?

A
  • Aphasia (language impairment)
  • Agnosia (inability to interpret sensations/recognise things)
  • Apraxia (difficulty performing motor functions)
  • Lexical anomia (knowing how to use an object but unable to name it)
  • Decrease of motivation and drive - apathy and lack of spontaneity
  • Rate of progression - slow
  • Investigation: CT/MRI brain - cerebral atrophy, particularly if shown to increase over time
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13
Q

Describe the features of Alzheimer’s Dementia

A
  • Difficulty focusing
  • Poor memory
  • Visual hallucinations
  • Disorganised speech
  • Depression
  • Early onset - autosomal dominant (50% chance), Down’s syndrome patients are at increased risk
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14
Q

Describe the features of vascular dementia

A
  • Single infarct dementia - dependent on area
  • Multi-infarct dementia
  • Subcortical dementia - small vessel disease: personality changes, slowness of thought, affective symptoms, executive skills (planning or organising, making decisions or solving problems)
  • Stepwise progression
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15
Q

What are the symptoms of temporal lobe impairment?

A
  • Difficulty understanding words
  • Short term memory
  • Semantic memory (factual knowledge)
  • Inability to categorise object
  • Identification and verbalisation
  • Visuo-spatial neglect
  • Agnosia
  • Dysphasia
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16
Q

What are the symptoms of parietal lobe impairment?

A
  • Anomia (object identification)
  • Dysgraphia (difficulty writing/drawing)
  • Agnosia
  • L-R disorientation
  • Dyscalculia
  • Apraxia
  • Visuo-spatial neglect e.g. clock, cube
  • Tactile perception
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17
Q

What are the symptoms of frontal lobe impairment?

A
  • Loss of spontaneity
  • Loss of cognitive flexibility
  • Conceptualisation
  • Poor concentration/sensitivity to interference
  • Poor impulse control
  • Difficulty with problem solving
  • Expressed language
  • Behaviour
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18
Q

What are the features of Lewy Body Dementia?

A
  • Sleep disturbances - nightmares, aggressive, movements, disturbed sleep cycle, REM sleep behaviour disorder
  • Cognitive fluctuations - hallucinations, delirium etc that comes and goes
  • Features of PD
  • Autonomic dysregulation
  • Variable cognition
  • Psychotropic medication hypersensitivity
  • Urinary incontinence
  • Cognition (visuo-spatial difficulties, language impairment, dyspraxia)
  • Hyposmia (reduced smell)
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19
Q

What is REM sleep behaviour disorder?

A
  • Not confused upon waking up
  • Exhibit dream enacted behaviours
  • Does not cause excessive daytime sleepiness
  • Clonazepam is effective for this
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20
Q

What is the difference between LBD and PDD?

A
  • LBD - memory difficulties and psychotic symptoms develop 1 year before motor difficulties (initially similar to AD, then develop motor symptoms)
  • PDD - memory difficulties and psychotic symptoms develop 1 year after motor difficulties
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21
Q

How do you diagnose LBD?

A
  • Progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions or with usual daily activities
  • Prominent or persistent memory impairment may not occur in the early stages but it usually evident with progression
  • Deficits on tests of attention, executive function and visuoperceptual ability may be especially prominent and occur early
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22
Q

What are the 3 types of Fronto-Temporal dementia?

A
  • Pick’s disease
  • Primary progressive aphasia - non-fluent aphasia
  • Semantic dementia - loss of semantic memory, most often in verbal domain e.g. loss of word meaning
23
Q

What are the symptoms of the behavioural variant of FTD?

A
  • Disinhibition
  • Apathy (but not sad)
  • Lose empathy
  • Repetitive, compulsive or ritualised behaviours
  • Changes in eating habits
  • Executive function difficulties
24
Q

What is dysexecutive function?

A
  • Dysfunction in frontal part of the brain - can present with cognitive, behavioural or emotional symptoms
  • Causes: brain tumour, stroke, head injury, FTD, AD, vascular dementia, schizophrenia, personality disorder and ADHD
  • Assess with FAB
25
Q

Describe acetylcholinesterase inhibitors for dementia

A
  • Cholinesterase inhibitors - donezapil, galantamine
  • Butyryl-cholinesterase inhibitors - rivastigmine
  • Rivastigmine better choice for LBD + PD (oral or patch)
  • If moderate to severe dementia use galantamine
  • No medication can help with vascular dementia
26
Q

Describe glutamate receptor antagonists for dementia

A
  • NMDA receptor blockers - memantine (generally used only if AChE doesn’t work)
  • Glutamate thought to cause toxicity due to hyperexcitation of neurones
  • Memantine inhibits neutron excitation by inhibiting glutamate receptors
27
Q

What is the pharmacological treatment for vascular dementia?

A
  • Vascular risk prevention
  • Aspirin
  • Statins
28
Q

What is the pharmacological treatment for LBD?

A

Rivastigmine

  • If there is swallowing difficulties are present, can give a patch
  • Increased risk of neuroleptic sensitivity - if necessary quetiapine is best
29
Q

What are the interactions of dementia medications?

A
  • Memantine renally excreted so avoid in renal impairment or if taking medications that are renally excreted
  • Donezapil and galantamine metabolised by liver enzymes (CD26 + C3A4). Enzyme inducers e.g. carbamazepine may reduce levels of these.
  • ACh drugs decrease effect of AChE-I
  • Cholinomimetrics and AChE-I increase each other’s effects
  • Beta blockers and AChE-I increase each other’s effects
  • Memantine and glutamate receptor antagonists (ketamine, amantadine, dextromethorphan) increase each other’s effects and risk of pharmacotoxic psychosis
30
Q

What are the side effects of AChE-I?

A
  • Bradycardia
31
Q

What tests should be done before starting AChE-I and NMDA receptor antagonists?

A
  • ECG - assess HR, presence of conduction abnormalities and QTc interval
  • Cholinesterase inhibitors are contraindicated for patients with bradykinesia, LBBB + prolonged QTc interval
  • U+E - memantine can cause acute renal failure
32
Q

What are the behavioural and psychological symptoms of dementia?

A
  • Hallucinations
  • Delusions
  • Anxiety
  • Marked agitation
  • Associated aggressive behaviour
  • Behaviour changes: aggression, agitation, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity e.g. shouting
33
Q

What are the pharmacological choices of treatment for dementia?

A
  1. AChE-I
  2. Memantine
  3. Mood stabiliser- sodium valproate/pregabalin
  4. Antidepressant - trazodone/mirtazapine/sertraline
  5. Antipsychotics - last resort, preferably quetiapine
34
Q

When would you offer antipsychotics to dementia patients?

A
  • At risk of harming themselves or others OR

- Experiencing agitation, hallucinations or delusion that are causing them severe distress

35
Q

What are the psychological managements for dementia?

A
  • Cognitive stimulation therapy
  • CBT
  • Reminiscence therapy
  • Aromatherapy
  • Sensory stimulation
  • Music therapy
36
Q

What physiotherapy and OT interventions can be done for dementia patients?

A

Therapy staff working with the memory assessment team will complete a community risk assessment, checking for things like:

  • Wandering
  • Falls
  • Fire
  • Self neglect
37
Q

What are the risk reduction strategies for dementia patients?

A
  • Door sensors and locators
  • Telemonitoring
  • Adaptations at entrance + steps inside house
  • Contact fire brigade - assess and install fire retardant equipment and furnishings, can cut off gas to oven
  • Food + fluid charts, weight charts
  • Nutritional supplements via GP
  • Carers
38
Q

What can a health and welfare LPA make decisions about?

A
  • Your daily routine e.g. washing, dressing, earring
  • Medical care
  • Moving into care home
  • Life-sustaining treatment
    Can only be used when unable to make own decisions.
39
Q

What can a property and financial LPA make decisions about?

A
  • Managing a bank or building society account
  • Paying bills
  • Collecting benefits or a pension
  • Selling your home
    Can be used as soon as it’s registered, with your permission
40
Q

What is advanced care planning?

A
  • Should be discussed post diagnosis with patient and carer as would empower them to play a part in their future care should they lose capacity
  • Includes formal documentation of decisions to do with resuscitation, preferred place of care, death
  • The topic of a will should be broached with the patient as it is good practice to arrange for this when so-called testamentary capacity is present
41
Q

What can happen to your attorney to end your LPA?

A
  • Loses mental capacity
  • Divorces you or ends your civil partnership if they’re your husband, wife or partner
  • Becomes bankrupt or they’re subject to Debt Relief Order (DRO) - if they’re property snd financial affairs LPA
  • Is removed by Court of Protection
  • Dies
42
Q

What are the mandatory parts of dementia screening in an individual with memory loss?

A
  • History taking
  • Cognitive testing
  • Neuropsychological assessments can highlight cognitive deficit
  • Imaging is never diagnostic but could help settle the diagnosis and show cerebrovascular issues
  • SPECT to differentiate between AD and FTD
43
Q

Describe the progression of Alzheimer’s Dementia

A
  • Gradual decline in cognitive impairment
  • More common in women
  • Hallucinations may occur, but in late stages
  • Decrease in facial expression develops later in the disease
  • Physical deterioration usually at late stage
44
Q

Describe the progression of LBD

A
  • Face shows very little emotion from early in disease process
  • More common in men
  • Visual hallucinations occur early
  • Fluctuating cognitive impairment
  • Early problems with balance
45
Q

What are the core features of LBD?

A
  • Fluctuating cognition (mimics delirium)
  • Recurrent well-formed visual hallucinations
  • Spontaneous features of Parkinsonism
46
Q

What are the suggestive features of LBD?

A
  • REM sleep behaviour disorder
  • Severe neuroleptic sensitivity
  • Low dopamine transporter uptake in basal ganglia on SPECT/PET
47
Q

What is the pathology of LBD?

A
  • Lewy bodies - protein deposits inside neurons
  • Cholinergic neurons - acetylcholine
  • Substantia nigra - initiate movement/motor function (dopaminergic)
  • Alpha synuclein gets misfolded within the neurons and aggregates to form Lewy bodies
48
Q

What are the key features of dementia?

A
  • Decline in memory
  • Decline in other cognitive domains (planning, organizing, thinking, judgement, language, orientation, recognition)
  • WITH functional impairments e.g. self-care, struggling to find the words for things
49
Q

What are the diagnostic criteria for dementia?

A
  • Cognitive impairment
  • Clouding of consciousness i.e. reduced clarity of awareness of the environment, with reduced ability to focus, sustain or shift attention
  • Psychomotor disturbances - usually hyper- or hypo-activity
  • Disturbance of sleep or sleep-wake cycle
  • Caused by underlying cerebral or systemic disease
50
Q

What is mild cognitive impairment?

A
  • A disorder in cognitive function for most of the time for at least 2 weeks
  • The disorder is exemplified by difficulties in any of the following areas: new learning, memory, concentration, thinking, language
  • Abnormality or decline in performance on neuropsychological tests (or quantified cognitive assessments)
  • BUT not sufficient to meet dementia criteria - no major impact in functioning
  • Patients with MCI at increased risk of going on to develop dementia
51
Q

What are the features of FTD?

A
  • Often younger age onset
  • Slow onset with steady deterioration
  • Predominance of frontal lobe involvement evidenced by 2 or more of the following: emotional blunting, coarsening of social behaviour, disinhibition, apathy or restlessness and aphasia
  • Relative preservation
52
Q

What are the risks in older adult care?

A 
Suicide/SH, Self-neglect, Susceptibility to illness
Abuse, Aggression
Wandering
Falls, Fire
Exploitation
Non-compliance with medication
Driving, Drugs and alcohol
53
Q

What is assessed in the Frontal Assessment Battery?

A
  • Similarities
  • Lexical fluency
  • Motor series ‘Luria test’
  • Conflicting instructions
  • Go-no-go
  • Prehension behaviour

Mental Health (12 decks)

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