Dementia Flashcards
What is dementia?
It is a neurodegenerative syndrome which results in progressive impairment of multiple cognitive domains, resulting in the loss of acquired skills and interference in the patient’s occupational and social roles
What are the four classifications of dementia?
Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
Frontotemporal Dementia
What is the most common classification of dementia?
Alzheimer’s disease
What is Alzheimer’s disease?
It is a condition, in which there is cognitive decline related to hyperphosphorylation of the tau protein
What is the function of the tau protein?
It interacts with tubulin to stabilise microtubules and promote tubulin assembly into microtubules
What is the macroscopic change seen in Alzheimer’s disease?
Cerebral atrophy, involving the temporal neocortex and hippocampus
What are the three microscopic changes seen in Alzheimer’s disease?
Type-A beta amyloid protein plaques
Neurofibrillary tangles
Hyperphosphorylation of the tau protein
What are neurofibrillary tangles?
They are paired helical filaments composed of tau proteins
What is the biochemical change seen in Alzheimer’s disease?
Decreased acetylcholine levels
What four areas of the brain does Alzheimer’s disease tend to affect?
Hippocampus
Amygdala
Temporal neocortex
Subcortical nuclei
What are the five risk factors associated with Alzheimer’s disease?
White Race
Family History
Down’s Syndrome
Vascular Conditions
Smoking
What are the five genes associated with Alzheimer’s disease?
Apolipoprotein E4 (ApoE4)
Amyloid precursor protein (APP)
Presenilin-1 (PSEN1)
Presenilin-2 (PSEN2)
Trisomy 21 (Down’s Syndrome)
What three genes are associated with early onset familiar Alzheimer’s disease?
Amyloid precursor protein gene (APP)
Presenilin 1 gene (PSEN1)
Presenilin 2 gene (PSEN2)
What gene is associated with early onset familiar Alzheimer’s disease and Down’s syndrome?
Amyloid precursor protein (APP)
What are the five vascular conditions associated with Alzheimer’s disease?
Hypertension
Diabetes
Dyslipidaemia
Atrial fibrillation
Wilson’s disease
How long should clinical features be present for before a diagnosis of Alzheimer’s can be obtained?
> 6 months
What are the five clinical features associated with Alzheimer’ disease?
Dysmnesia
Dysphasia
Dyspraxia
Dysgnosia
Personality Changes
What is dysmnesia?
This is defined as memory impairment
What is dysphasia?
This is defined as communication impairment
What are the two types of dysphasia?
Expressive dysphasia
Receptive dysphasia
What is expressive dysphasia?
It is defined as the inability to formulate language - they struggle to get words out or use the wrong words
What is receptive dysphasia?
It is defined as the inability to comprehend language
What is dyspraxia?
It is defined as motor skill dysfunction
What is dysgnosia?
It isdefined as the inability to process sensory information, resulting in an inability to recognise objects, people, sounds, shapes or smells
Which investigation is used to diagnose Alzheimer’s disease - in addition to cognitive function tests and blood tests?
SPECT Scan
What is a SPECT scan? What information does it provide?
It is a nuclear imaging test involving the injection of a gamma-emitting radioisotope into the patient’s bloodstream
It provides information about the blood flow to tissues and organs
What is a feature of Alzheimer’s disease on SPECT scans?
Hypoperfusion within the temporal and parietal lobes of the brain
What is the second most common classification of dementia?
Vascular dementia
What is vascular dementia?
It is a condition in which there is cognitive decline related to ischaemia or haemorrhage to the cerebral blood vessels
What are the eight risk factors of vascular dementia?
Stroke/Transient Ischaemic Attack
Coronary Artery Disease
Hyperlipidaemia
Hypertension
Atrial Fibrillation
Diabetes Mellitus
Smoking
Obesity
How does vascular dementia generally present?
The onset is sudden
The progression is stepwise
What are the six clinical features of vascular dementia?
Dysmnesia
Dysarthria
Dysphagia
Seizures
Gait Disturbance
Emotional Disturbance
What is dysarthria?
It is defined as slowed speech
What investigation is used to diagnose vascular dementia - in addition to cognitive function tests and blood tests?
MRI scan
What are the two features of vascular dementia on MRI scans?
Cerebral infarcts
Extensive white matter changes
What criteria is used to diagnose vascular dementia?
NINDS-AIREN criteria
What does the NINDS-AIREN criteria state?
It states that there must be evidence of a correlation between cognitive decline and cerebrovascular disease…
- The onset of dementia within three months following a stroke
- An abrupt deterioration in cognitive functions
- A stepwise progression of cognitive deficits
What is the third most common classification of dementia?
Lewy body dementia
What is Lewy body dementia?
It is a condition in which there is cognitive decline related to an accumulation of Lewy bodies within the brain
What are Lewy bodies?
They are deposits of alpha synuclein proteins
In what three cerebral locations do Lewy bodies accumulate?
Substantia nigra
Paralimbic areas
Neocortical areas
What are the triad of clinical features associated with Lewy body dementia?
Cognitive Impairment
Visual Hallucinations
Parkinsonism
What is a key clinical feature of Lewy body dementia?
There are FLUCTUATIONS in cognitive impairment
How do we differentiate between Lewy body dementia and Parkinson’s disease?
Lewy body dementia = The cognitive impairment present a year before the Parkinsonism
Parkinson’s disease = The motor features present a year before cognitive impairment
What is the additional clinical feature associated with Lewy body dementia?
Sleep disturbances
What are the two investigations used to diagnose Lewy body dementia – in addition to cognitive function tests and blood tests?
DIAMOND Screening Test
DAT Scan
What is a DIAMOND screening test?
It is a series of questions used to identify features of Lewy body dementia
What is a DAT scan? What information does it provide?
It is a nuclear imaging test involving the injection of a gamma-emitting radioisotope into the patient’s bloodstream – subtype of SPECT scans
It provides information about dopamine transporter levels within the brain
Describe the features of a normal DAT scan
There is normal re-uptake of the dopamine transporter in the head of the caudate nucleus and putamen, resulting in the shape of a comma
How does Lewy body dementia present on DAT scans?
There is reduced re-uptake of dopamine in the putamen, resulting in the presentation of a ‘full-stop’ sign
What is the fourth most common type of dementia?
Frontotemporal dementia
What is another term for frontotemporal dementia?
Pick’s disease
What is the frontotemporal dementia?
It is a condition in which there cognitive decline related to atrophy of nerve cells and their connections within the frontal and temporal lobes of the brain
These are the areas generally associated with personality, behaviour and language
What is the macroscopic change seen in frontotemporal dementia?
Cerebral atrophy in frontal and temporal lobes
What are the four microscopic changes seen in frontotemporal dementia?
Spherical aggregations of tau proteins (pick bodies)
Gliosis
Neurofibrillary tangles
Senile plaques
What are the three clinical features of frontotemporal dementia?
Personality Changes
Behavioural Changes
Speech Disorders
What are the three key features of frontotemporal dementia?
Onset < 65 Years Old
Insidious Onset
A relatively preserved memory and visuospatial skills
In general how do we differentiate between a diagnosis of frontotemporal dementia and bipolar, schizophrenia or borderline personality disorder?
Frontotemporal dementia tends to present later on in life
What investigation is used to diagnose frontotemporal dementia?
MRI scan
What is a feature of frontotemporal dementia on MRI scans?
Focal gyral atrophy with a knife-bade appearance
What are three investigations used to diagnose dementia?
Cognitive Function Test
Blood Tests
Neuroimaging
What are cognitive function tests?
These tests involves the patient answering a series of questions and performing simple tasks
They are designed to test various domain functions, including memory, language, visuospatial awareness, emotion, apraxia, agnosia, etc
What are the two cognitive function tests recommended in non-specialist settings?
10 Point Cognitive Screener (10-CS)
6 Item Cognitive Impairment Test (6CIT)
What are the two cognitive function tests recommended in specialist settings?
Mini-Mental Screening Examination (MMSE)
Montreal Cognitive Assessment (MOCA)
What is the MMSE test?
It involves a series of questions designed to test a range of everyday mental skills, focussing on the deficits present in Alzheimer’s disease
What MMSE score indicates Alzheimer’s disease?
< 24
What MMSE score indicates mild Alzheimer’s?
20-24
What MMSE score indicates moderate Alzheimer’s?
13-20
What MMSE score indicates severe Alzheimer’s?
<12
What is the MOCA test?
It involves a series of questions designed to test a range of everyday mental skills
What is the first line cognitive function test in a secondary care setting?
MOCA
What MOCA score indicates a diagnosis of dementia?
< 26
What is the investigation used to investigate dementia in a primary care setting?
Blood tests
How are blood tests used to diagnose dementia?
They are used to exclude reversible causes of dementia – such as hypothyroidism, Addison’s disease, vitamin B12 deficiency, folate deficiency, thiamine deficiency
What are the nine blood tests used to diagnose dementia?
Full Blood Count
Urea & Electrolytes
Liver Function Tests
Thyroid Function Tests
CRP/ ESR Levels
Glucose Levels
Vitamin B12 Levels
Folate Levels
Bone Profile
What is the investigation used to investigate dementia in a secondary care setting?
Neuroimaging
How is neuroimaging used to diagnose dementia?
It is used to exclude reversible causes of dementia - such as subdural haematomas and normal pressure hydrocephalus
What are the twelve differential diagnoses of dementia?
Hypothyroidism
Addison’s disease
Vitamin B3 deficiency
Vitamin B12 deficiency
Folate deficiency
Thiamine deficiency
Syphillis
Brain tumour
Normal pressure hydrocephalus
Subdural haematoma
Depression
Chronic drug use
How do we conservatively manage dementia?
It involves providing the patient and their families with adequate social and physical support
This may involve the use of dementia services, occupational therapists, social workers or care home admission
What occurs when dementia patients are exposed to new surroundings?
Delirium
What two classes of dementia can be managed pharmacologically?
Alzheimer’s disease
Lewy body dementia
What are the two pharmacological management options available for dementia?
Acetylcholinesterase Inhibitors
NDMA Antagonists
What is the first line pharmacological management option of dementia?
Acetylcholinesterase inhibitors
What are the mechanism of acetylcholinesterase inhibitors?
They are drugs that inhibit the normal breakdown of acetylcholine, thus increasing its levels within the brain
This slows the progression of disease
Name three acetylcholinesterase inhibitors used to treat dementia
Donepezil
Galantamine
Rivastigmine
What is a contraindication of donepezil?
Bradycardia
What is a side effect of donepezil?
Insomnia
What is the second line management option of dementia?
NDMA antagonists
In which three circumstances do we administer NDMA antagonists to manage dementia?
In moderate Alzheimer’s disease and Lewy body disease, in which individuals have an intolerance or contraindication to acetylcholinesterase inhibitors
In moderate to severe Alzheimer’s disease and Lewy body dementia, as an add on drug to acetylcholinesterase inhibitors
In severe Alzheimer’s disease, as monotherapy
What are the mechanism of NDMA antagonists?
They are drugs that inhibit the N-Methyl-D-aspartate receptor
Name an NDMA antagonist used to manage dementia
Memantine
Can antidepressants be used to manage dementia?
It is recommended by NICE that antidepressants are not used to treat mild to moderate depression in dementia
Which drug class should be considered with caution in dementia, due to its significant increase in mortality rate?
Antipsychotics
When can antipsychotics be used to manage dementia?
It is recommended by NICE that antipsychotics should only be used for patients at risk of harming themselves or other, OR when the agitation, hallucinations or delusions are causing severe distress
Which drug class should be considered with caution in dementia, due to its side effect of cognitive impairment?
Tricyclic Antidepressants
In which dementia classification should neuroleptics be avoided? Why?
Lewy body dementia
It can cause irreversible Parkinsonism
Do individuals need to notify the DVLA of a dementia diagnosis?
Yes
How do we differentiate between dementia and delerium?
Delirium is indicated by the following features…
- Acute onset
- Impaired consciousness
- Fluctuating symptoms
- Abnormal perceptions (hallucinations, illusions)
- Agitation
- Delusions
How do we differentiate between dementia and depression?
Depression is indicated by the following features…
- A short history, rapid onset
- Biological features, such as weight loss and sleep issues
- The patient is worried about poor memory
- A variable cognitive test result
- A global memory loss
What memory loss is associated with dementia?
Recent memory loss
