Dementia Flashcards
Definition (4)
Acquired
General
Progressive impairment of cognitive function
Impaired activity of daily living
Cognitive functions impaired
Memory Recall Orientation Language Abstraction
Prevalence at 60yo and doubling time
1% at 60, doubles every 5 years
Prevalence at 85yo
30-50%
Categories of dementia (Vitamin D Vest)
Primary degenerative Vascular Infectious Trauma Rheumatological Neoplastic Vitamin, Intracranial tumor, Trauma, Anoxia, Metabolic, Infection, NPH, Degenerative, Huntingtons, Vascular, Endocrine, SOL, Toxic
Reversible causes of dementia
Alcohol (withdrawal, intoxication) Medications (benzodiazepines, anticholinergics) Heavy metal toxicity Hepatic/renal failure Wilsons Vit B12 Hypo/hyperglycemia Cortisol Thyroid Normal pressure encephalus Depression Intracranial tumor Subdural hematoma
Common differentials
MCI Delirium Depression Alzheimers Vascular dementia Lewy body dementia
Uncommon differentials
Amnesia Aphasia FTD Parkinsons Huntingtons Brain tumors Cushings Hypothyroid \+PTH SLE Syphillis Wilsons TB Lyme disease CJD
Primary neurodegenerative causes (4) with key clinical features
Alzheimers- Anterograde amnesia, aphasia, apraxia, agnosia, disturbance in executive function
Dementia with lewy body- visual halluncinations, parkinsonism, fluctuating cognition
Frontotemporal dementia- behavioural / language presentation
Huntingtons disease- chorea
Vascular causes of dementia with key clinical features
Multi-infarct dementia->acute onset, stepwise, focal neurological signs, dysexecutive
Vasculitis->systemic S&S of vasculitis
Infectious causes (6) with key clinical features
HIV
Syphillis->ataxia, myoclonu, tabes dorsalis
Chronic encephalitis
Chronic meningitis->F,H,N, meningismus, localising neurological defects
Abscess->+ICP, localising neuro signs
CJD->rapidly progressive, myoclonus
Traumatic causes
DAI, subdural, epidural hematoma->history, +ICP, papilloedema, localising neuro signs
Neoplastic causes
Mass effect, edema, hemorrhage, seizure->+ICP, localising signs, systemic symptoms of cancer
Emergency consideration for suspected dementia
Delirium
Initial test to order when delirium not ruled out
FBC, UEC, fasting blood glucose, urinalysis MCS, UDS
Importance of herpes simplex
Most common cause of sporadic encephalitis
How does HSV encephalitis present
Acute febrile illness
Altered mental status
Headache, seizure, focal neurology
What to give in all cases of suspected HSV encephalitis
Aciclovir
History
Psychiatric evaluation
Premorbid function
Geriatric giants
Changes in cognition, function, personality, language, skills, behaviour
Abrupt, step wise, gradual->vascular
Acute->infection, metabolic, lesion, medication, stroke, hydrocephalus
Rapid decline->delirium
Gait abnormalities, urinary incontinence
Change in ability to manage ADLs, and instrumental activities
Family history
Drug and alcohol
Past medical history
Stroke risk factors->hx, TIA, hypertension, cholesterol, diabetes, CAD, AF
Parkinson’s disease inquiry
Transient neurological->gait, incontinence
What are the activities of daily living (6)
Eating Bathing Dressing Toileting Transferring Continence
What are the instrumental activities of daily living (8)
Housework Cooking Cleaning Shopping Finances Telephone Transport
Cognitive assessment tool and score when indicates an abnormal result
MMSE
Components of MMSE
Orientation Registration Attention and calculation Recall Language
Components of language assessment (6)
Name two objects Repeat "no ifs, ands, or buts" Follow a three stage command Read and obey the following Write a sentence Copy the design
Physical examination- what to test and what it may mean
General: vitals, BP, hearing and vision
CN->vascular may have visual field defects. Ataxia, nystagmus and lateral gaze palsy may suggest alcohol
Motor->vascular and hemiparesis
Sensory->peripheral neuropathy may indicate vitamin, toxic metabolic
Co-ordination and gait->vitamin B12, NPH, vascular
Reflexes-> may have primitive, asymetric in vascular, myoclonus in CJD
CV->hypertension, dysrhythmias, PVD, vascular disease, CHF
What are the geriatric giants in history
Confusion, incontinence, falls, polypharmacy
Memory and safety
Behavioural
Behaviour issues in dementia
Mood Anxiety Psychosis Suicide Personality Aggression
Safety issues in dementia
Wandering
Leaving electrical items on
Losing objects
Leaving doors unlocked
Laboratory investigations
UEC, glucose FBC w. differential TSH Vit B12 Folate ESR CRP Urinalysis Urine MCS CXR
Other tests to consider based on history
HIV Urine toxicology Collage vascular Urinalysis for heavy metals Syphyllis serology CSF FDG-PET
Imaging
CT or MRI
Definition of alzheimers
Progressive chronic neurocognitive decline
Define aphasia
Language disturbance
Define apraxia
Inability to perform motor tasks despite normal motor function
Define agnosia
Difficulty recognising objects despite intact sensory modality
Epidemiology of AD
60-70% of all dementias
5% of 80
More common in women
Gender preference in AD
More common in women
How is early onset AD inherited, genes involved and how common
Autosomal dominant->APP, presenilin 1 and 2
Pathophysiology of AD- two theories
Amyloid hypothesis->excess interneuronal amyloid (abeta) as overproduction/reduced clearance of beta amyloid->dense amyloid as plaques. Cause inflammation, microglial activation, complement cascade->neuritic plaques leading to cell death.
Tau-protein theory->tau protein accumulation as neurofibrillary tangles.
Gross pathology of AD
Cortical atrophy +in frontal, parietal, temporal lobes
Microscopic pathology of AD
Senile plaques Loss of synapses Hyperphosphorylate tau Neurofibrillary tangles Loss of cholinergic neurons
Biochemical pathology of AD
50-90% reduction in choline acetyltransferase
Risk factors for AD (6)
Age Family history Down syndrome Genetics Cerebrovascular disease Hyperlipidemia (Weak= brain injury, obesity, low IQ, female, depression, female, DM)
Clinical presentation catgories (3)
Cognitive
Psychiatric
Motor
Cognitive impairment in AD
Impaired memory, language, abstract, executive
Psychiatric manifestations in AD
Mood
Psychosis
Apathy
Motor manifestations in AD
Occurs late–>Parkinsonism
Key diagnostic factors in AD (9)
Presence of risk factors Memory loss Disorientation Nominal aphasia Misplacing/getting lost Apathy Decline in ADL, IADL Personality change Unremarkable physical examination
Investigations for AD (9)
Bedside cognitive assessment FBC ESR Glucose TSH Vit B12 and folate Metabolic panel UDS CT, MRI
DSM 5 criteria for AD
Memory impairment + one >
aphasia, apraxia, agnosia, disturbed executive function
Gradual and progressive
Not due to general medical condition, psychiatric illness or other neurological illness or substance use
Findings on MRI of AD (3)
Cortical atrophy, +in hipocampua
Dilitation of lateral ventricles
Widened cortical sulci
Management overview of AD
Supportive
Environmental control
Cholinesterase inhibitors
Symptomatic management
Supportive management of AD
Carer support Home safety evaluation OT assessment Driving, shopping, finances Self care Written instructions and explanations for carers Calenders, clocks, charts for orientation Lighting Exercise AHD
Environmental control measures for AD
Identification bracelets
Tagging devices with GPS
Cholinesterase inhibitor goals, when to start, first line
To slow the decline
Begin when mild AD diagnosed
Donepezil 5mg OD or rivastigmine OR Galantaine
Symptomatic management AD- mood, psychosis, insomnia, behavioural
Antidepressant->sertraline, citalopram, escitalopram
Agitation, wandering, psychosis->risperidone, olanzepine, quetiapine, aripiprazole
Insomnia->sleep hygeine
Behavioural->environmental and behavioural modification
When should you consider mirtazepine
If poor appetite and insomnia
When antipsychotics not to be used in dementia
Evidence of vascular dementia
When antipsychottic treatment should be stopped
Evidence of worsening neurology
What environmental factors should you consider with exacerbation of psychosis and confusion
Poor lighting
Disorientation
Isolation
MOA of donepezil
Decrease breakdown of ACh- alleviating the relative deficiency
Donepezil CI and cautions, pregnancy and breastfeeding
CI in active peptic ulcer and GI/ureteric obstruction
Caution in hx peptic ulcer, heart block/bradyA, parkinsons, asthma, COPD
Common side effects of donepezil (10)
Nausea, abdominal pain
Urinary frequency, diarrhea
Insomnia, fatigue, depression, drowsy
Sweating, hypertension
Counselling use of donepezil
Initial dose 5mg
May cause dizzy/drowsy, if it does do not use heavy machinery
Omit one or more if adverse effects
If interrupted treatment, start back at low dose to minimise risk of severe vomiting
Key diagnostic factors in Lewy body dementia
Presence of risk factors (old age, male) Cognitive impariment Fluctuations in mental state Visual hallucinations Depression EPS REM sleep disturbance Severe antipsychotic sensitivity Others- auditory, falls and syncope, delusions
Etiology and pathogenesis of LBD
protein alpha-synuclein, a cytoplasmic protein associated with synaptic vesicles
Epidemiology of LBD
15-25% of all dementias
Treatment of lewy body dementia
Donepezil
Prognosis of lewy body dementia
3-5 years
Key diagnostic factors in FTD
Coarsening of personality, social behaviour and habits
Progressive loss of language fluency/comprehension
Memory impairment, disorientation, apraxias
Self neglect, abandonment of work, activity and social contacts
Two variants of FTD
Behavioural
Language
Which FTD variant is more common
Bahavioural
Language variants of FTD
Progressive non fluent aphasia
Semantic dementia
Features of progressive non-fluent aphasia
non fluent, laboured speech, anomia, preserved single word comprehentions, word finding deficit, impaired repetition
Features of semantic dementia
fluent, normal rate, impaired single word comprehension, intact repetition, use of words of generalisation (things) or supraordinate categories (animal for dog)
What are supraordinate categories
Use of animal for dog
Two histology types of FTD
Frontal lobe degeneration with microvacuolar change
Pick type with astrocytic gliosis +/- ballooned cells and inclusion bodies
Epidemiology of FTD
10% of all dementias
Core features in FTD
Insidious decline and gradual
Early decline in social interpersonal conduct
Early impairment of regulation of personal conduct
Early emotional blunting
Early loss of insight
Supportive features in FTD
Behavioural
Language
Motor
Motor features of FTD
Primitive reflexes Incontinence Akinesia Rigid Tremor Low and labile blood pressure
Management of FTD
Supportive care Treat irritability with benzodiazepine Treat any concurrent illness Home assistance, respite Treat mania etc with valproate Organise and manage end of life care
