Dementia Flashcards
Definition of dementia?
A persistent disabling cognitive impairment.
* Decline in both memory and thinking - sufficient to impair personal ADLs.
* Problems with processing incoming information, maintaining attention and directing attention.
* No impairment of consciousness
* Present for 6+ months
Self test on BB definition:
chronic deficit in thinking, memory and/or personality
NICE:
Dementia is a progressive, irreversible clinical syndrome with a range of cognitive and behavioural symptoms including memory loss, problems with reasoning and communication, change in personality, and reduction in the person’s ability to carry out daily activities.
List the types of dementia
Alzheimers
Vascular
Lewy-body dementia
Frontotemporal
Mixed dementia
What do we mean by cognitive impairment?
- disturbance of higher
cortical functions including memory, thinking,
judgement, language, perception and
awareness - Cognitive impairments may be single or
multiple, and may be static or progressive - It is not a specific illness but is a description of
someone’s condition
Describe the inverse care law which applies to dementia?
Those who are most dependent and vulnerable often have the least awareness of their disabilities
Features in the early stage of dementia?
- forgetfulness and memory Sx
- SUBTLE changes in mood and behaviour e.g. loss of motivation/interest
- minimal intrusion into day to day activities if not too demanding
Features in the mid stage of dementia?
- memory probles become more prominent
- cognitive difficulties may start to emerge - e.g. difficulty with language
- changes in behaviour are more marked
- disability starts to become more obvious - simple personal ADLs may be okay, but complex activities will be hard e.g. finances, planning activities.
- pt unaware of this disability
Features in the late stage of dementia?
- severe and pervasive memory problems will be present alog woth major cognitive disabilities e.g. severe disorientation
- marked positve and negative changes in behaviour - severe apathy, agitation, irritability, disinhibition
- disability is severe - affect basic personal functioing and pt needs continuous supervision
Why may dementia diagnosis be overlooked?
diagnostic overshadowing
Compare AD, Vasclar, Frontotemporal, LBD and alcoholic dementia based on their:
1. course and onset
2. early presenting sx
3. neurological features
4. mood and behavioural changes
5. structural brain imaging
Important differentials for dementia?
- hypothyroidism, Addison’s
- B12/folate/thiamine deficiency
- syphilis
- brain tumour
- normal pressure hydrocephalus
- chronic subdural haematoma
- depression
- chronic drug use e.g. Alcohol, barbiturates
Investigations for dementia?
Need to do bloods to exclude reversible causes of cognitive decline:
* FBC, ESR
* CRP
* U&Es
* Calcium / bone profile
* HbA1c
* LFTs
* TFTs
* Serum B12 and folate levels
Assess cognition:
* use cognitive assessment tool - e.g 10-CS, 6CIT, MIS, mini-cog, MOCA, AMT
Other inv:
* urine microscopy and culture
* CXR
* ECG
* syphillis serology
* HIV testing
* neuroimaging
Dementia is a Dx of exclusion. What reversible condition could be found by doing neuroimaging?
Subdural haematoma
Normal pressure hydrocephalus
Brain tumour
Dementia is a Dx of exclusion. What reversible condition could be found by doing FBC, ESR and CRP?
Anaemia
May see high WCC - sign of infection
Vasculitis
Dementia is a Dx of exclusion. What reversible condition could be found by doing U+Es?
Renal failure
Dialysis dementia - neuro complication of renal failure to do with chronic dialysis
What common asessments can be done at the bedside/in primary care to test a patient’s cognitive function?
10-CS (10-point cognitive screener)
6-CIT
GPCOG
MMSE
AMTS
What common asessments can be done at the bedside/in primary care to test a patient’s cognitive function?
10-CS (10-point cognitive screener)
6-CIT
GPCOG
MMSE
AMT
Mini-cog
MoCA
What is Abbey Pain scale for dementia patients?
(in workbook so have added)
Assesses pain in patients with advanced dementia
- vocalisation
- facial expression
- body language
- physiological changes
- physical changes
These are all scored absent, mild (+1), moderate (+2), or severe (+3)
Describe AMT
Assessess mental impairment in elderly pts
Scores out of 10.
6 and below = mild cog impairment
3 and below = severe cog impairment
What is GPCOG?
- Used in GP, for GPs
- Screen dementia
- Can ask pt qu ( see pic).
- Also take collat Hx via informant interview where you ask relative/friend 6 questions - if they score 0-3 = have cog impairment.
If pt scores as having cog impairment from cognitive assessments, what is next step in management?
Refer to memory clinic
Describe MMSE
Screens cog function.
Ask series of qu
A 30-point test
Advantages and disadvantages of MMSE?
Advantages
* Relatively quick and easy to perform
* Requires no additional equipment
* Can provide a method of monitoring deterioration over time
Disadvantages
* Biased against people with poor education due to elements of language and mathematical testing
* Bias against visually impaired
* Limited examination of visuospatial cognitive ability
* Poor sensitivity at detected mild/early dementia
Describe MMSE scoring for cognitive impairment
24-30 = no cognitive impairment
18-23 = mild cognitive impairment
0-17 = severe cognitive impairment
Describe 6-CIT cognitive assessment
6 questions - but qu are weighted so are out of 28.
Uses inverse score. 0-7 = normal. 8+ = significant.
Why is early diagnosis of dementia so important?
- Optimise medical managament
- relief
- maximise decision making autonomy
- access to care and services early
- risk reduction
- clinical and cost effectiveness
What should assessment of dementia in primary care involve?
assessing pt with ?memory problems
- Hx plus collateral Hx
- Physcial exam
- Bloods to exclude reversible causes
- Cog assessment screen –> 6-CIT, mini-cog, 10-CS, GPCOG, MMSE
Clinical features of AD?
4As:
- Amnesia (recent memories lost first)
- Aphasia (word finding problems, speech muddled, disjointed)
- Agnosia ( recognition problems)
- Apraxia (can’t carry out skilled tasks despite normal motor function)
Gradual decline
Usually 60+
Positive FHx
May also have personality changes, apathy, mood changes
ADLs decline.
RF for AD?
- Increasing age
- FHx of AD
- Caucasian
- Down’s syndrome
- High cholestrol - 1) having apopprotein E allele E4 = encodes cholestrol transport protein or 2) from high fat diet
- smoking
- obesity
Pathophysiology of AD?
Macroscopic:
- widespread cortical atrophy - in cortex and hippocampus
Microscopic:
- cortical plaques due to deposition of type A-Beta-amyloid protein
- intraneuronal **neurofibrillary tangles **caused by abnormal aggregation of tau protien.
- hyperphosphorylation of tau protien
Biochemical:
- deficit of Ach from damage
All of these changes = reduced transmission of information and atrophy of brain cells = reduced functioning.
Clinical presentation of VD?
- Stepwise deterioration of cognitive function - can be over several months or years. Will have periods of stable symptoms with sudden decrease in cognition
- focal neurological abnormalities - visual disturbances, sensory or motor symptoms
- difficulty with attention and concentration
- seizures
- memory deficit
- gait disturbance
- speech disturbance
- emotional disturbance - apathy, disinhibition
Clinical presentation of FTD?
- coarsening of personality, social behaviour, and habits
- appear disinhibited and apathetic
- progressive loss of language fluency or comprehension
- development of memory impairment, disorientation, or apraxias
- progressive self-neglect and abandonment of work, activities, and social contacts
- younger than 65 - peak in mid-50s
- altered eating habits
- FHx
- inattentiveness, puerile preoccupations, economy of effort, impulsive responding, and compulsive behaviours\
- Gradual onset but may progress quickly
Compare dementia and delirium
see table
