Dementia

Question 1

Alpha-synuclein cytoplasmic inclusions

Answer 1

Lewy body dementia shows alpha-synuclein cytoplasmic inclusions (Lewy Bodies) on post mortem.

Question 2

Epidemiology Lewy Body dementia

Answer 2

third most common type of dementia

Question 3

Core features of Lewy Body dementia

Answer 3

fluctuating cognition, parkinsonism and visual hallucinations

Question 4

Ix Lewy body dementia

Answer 4

clinical
single-photon emission computed tomography (SPECT)/DaTscan

Question 5

Mx Lewy body dementia

Answer 5

acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
memantine

Question 6

Epidemiollogy Alzheimer

Answer 6

most common dementia

Question 7

Beta-amyloid plaques and neurofibrillary tangles with hyperphosphorylated TAU proteins
Acetylcholine deficiency

Answer 7

Alzheimer’s

Question 8

Clinical presentation of Alzheimer (5 AS)

Answer 8

Amnesia (recent memories lost first)
Aphasia ( problem with speech/words)
Agnosia ( problems with recognition of something )
Apraxia (difficulty with movement/tasks)
Associated behaviours e.g. apathy, irritability

Question 9

Ix Alzeihmer

Answer 9

Imaging: Cortical atrophy or ventricular enlargement, temporal lobe, paraphippocampus and hippocampus affected

Cognitive testing: ACE III,MOCA, Neurophysiology

Question 10

Mx Alzeihmer disease

Answer 10

Mild moderate disease
Acetylcholinesterase inhibitors
Donepezil
Rivastigmine ( comes in patch form)
Galantamine

Severe disease
NMDA receptor antagonist memantine

Question 11

Epidemiology Vascular dementia

Answer 11

second most common form of dementia

Question 12

Clinical presentation vascular dementia

Answer 12

Several months or several years of a history of a sudden or stepwise deterioration of cognitive function

Focal neurological abnormalities
difficulty with attention and concentration
Seizures
Memory disturbance
Gait disturbance
Speech disturbance
Emotional disturbance

Question 13

Mx Vascular dementia

Answer 13

Treatment is mainly symptomatic
address cardiovascular risk factors
Non-pharmacological management like cognitive stimulation programmes, music and art therapy
no specific pharmacological treatment

Question 14

3 types of Frontotemporal lobar degeneration/dementia

Answer 14

Frontotemporal dementia (Pick’s disease)
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia

Question 15

Behavioural variant (picks disease)

Answer 15

*most common type and is characterised by personality change and impaired social conduct.
*Stereotypical, repetitive and compulsive behaviour
*Relative preservation of memory, visuo spatial functioning in early stages.
*Early Language problems

Question 16

Ix Pick’s disease

Answer 16

Focal gyral atrophy with a knife-blade appearance is characteristic in MRI

Macroscopic changes include:-
Atrophy of the frontal and temporal lobes

Microscopic changes include:-
Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques

Question 17

Progressive non fluent aphasia (chronic progressive aphasia, CPA)

Answer 17

*Reduced speech fluency
*Articulation problems
*Phonological ( organisation of sounds) and syntactical ( sentence structure) errors
*Preservation of comprehension , understanding of speech

Question 18

Semantic dementia

Answer 18

*Semantic = interpretation of meaning
*Preservation of fluency
*Normally phonology and syntax
*Difficulty with naming and comprehension
*Unlike in Alzheimer’s memory is better for recent rather than remote events.

Question 19

Definition delirium

Answer 19

Acute, fluctuating syndrome
Disturbance of consciousness, cognitive function, perception and affect

Question 20

Distinguishing Delirium from Dementia

Answer 20

Dementia
*Longer history, insidious onset occurring over months and years
*fluctuation is Less likely (except DLB lewy body)
*Psychotic symptoms much less likely, if they do appear they are less prominent, more simple (except DLB)
*Disturbance in motor activity is less likely (although sun dowing is where people with dementia might become more restless and confused in late afternoon/early evening)
*Emotional changes are less likely

Question 21

Causes of delirium-

Answer 21

CHIMPS PHONED

Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment inc retention)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)

Question 22

Clinical presentation of delirum

Answer 22

Fluctuating cognition/cognitive impairment
Inattention
Altered conscious level
Disorientation
Disorientated thinking
Hallucinations, illusions, delusions
Memory problems
Change in emotion mood or personality
Disturbed sleep wake cycles
Acute onset- Onset usually 1- 2days
Usually triggered by underlying medical condition

Question 22

Ix Delirium

Answer 22

Confusion screen
Concentration tests
Urinalysis

Blood tests:
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)

Imaging:CT head/CXR

Question 23

4A’s Test

Answer 23

*Alertness - state name and address
*AMT4 - Age, date of birth, place (name of the hospital or building), current year
*Attention- Instruct patient to list months in reverse order, starting at December
*Acute change or fluctuating course
*Maximum score of 12
*Score of 4 and above indicates possible delirium

Question 24

Tx Delirium

Answer 24

Recognise patient has delirium
Identify and treat underlying cause
Manage pain
nUtritional Needs
Regular reorientation
De-escalation - meeting those inmet needs
Education and support
Maintain a stable environment
Falls risk assessment
Simple non medication steps
Family members
Butterfly scheme
Medication if needed
Referral to liaison service if needed

Question 25

‘Reversible causes’ as differentials for dementia

Answer 25

Space Occupying Lesions (SOL)
Alcohol abuse
Medication effects eg anticonvulsants, antidepressants, antipsychotics , anticholinergics
Thyroid problems
NPH normal pressure hydrocephalus
Vitamin deficiencies (e.g. B12, folate,ca etc)