DEMENTIA

Question 1

Dementia is described as the progressive decline in intellectual function that is severe enough to ________________.

Answer 1

compromise social or occupational functioning

Question 2

what differentiates delirium and dementia?

Answer 2

dementia has disturbance in cognition but does NOT have disturbance in consciousness (distractibility), while delirium has both

Question 3

Dementia has cognitive decline but ________ in level of function.

Answer 3

no change in level of function

Question 4

what are the common causes of dementia? which one is the most common?

Answer 4

1. Alzheimer’s disease*
2. Vascular dementia
3. Frontotemporal dementia
4. Lewy body dementia

Question 5

what is the pathogenesis of Alzheimer’s disease?

Answer 5

Loss of neurons resulting in gross atrophy, likely due to overproduction/decreased clearance of AMYLOID BETA PEPTIDES and alteration in shape of tau protein that leads to NEUROFIBRILLARY TANGLES.

Question 6

what is the pathogenesis of vascular dementia?

Answer 6

damage in the area of ischemia after stroke

Question 7

what is the pathogenesis of Lewy Body Dementia?

Answer 7

abnormal collection of Lewy bodies (alpha-synuclein protein) in cytoplasm of neurons in cortex.

Question 8

what is the pathogenesis of frontotemporal dementia?

Answer 8

abnormal protein inclusions in the cytoplasm or and/or nuclei of neurons or glial cells, leads to neuronal loss.
there are 3 variants that are defined by which protein is found.

Question 9

what are the risk factors for dementia (any type)?

Answer 9

family history, DM, vascular disease, significant head injury, female

Question 10

what are some protective factors against dementia (any type)?

Answer 10

maintaining cognitive reserve via education and ongoing intellectual stimulation

Question 11

what is the general clinical presentation of dementia?

Answer 11

short term memory loss (hippocampus)
word finding difficulty (left tempoparietal junction)
visuospatial dysfunction (right parietal lobe)
executive dysfunction (frontal lobe, subcortical areas)
apathy (frontal lobe, subcortical areas)

Question 12

presentation for Alzheimer dementia?

Answer 12

• usually > 60 y/o
• short term memory loss (first sx, most prominent)
• variable deficits (exec. dysf., visuospatial function, language)

Question 13

presentation of vascular dementia?

Answer 13

• PMHx of CVA
• step-wise accumulation of deficits assoc/w/ strokes
• variable deficits depending on location of stroke
• focal neurologic deficits*****

Question 14

presentation of Lewy Body dementia?

Answer 14

• similar motor deficits as Parkinson’s and similar sx as Alzheimer’s.
• psych disturbances (visual hallucinations**, fluctuating delirium, anxiety)
• cognitive dysfunction (visuospatial, executive)

Question 15

presentation of frontotemporal dementia - behavioral variant?

Answer 15

behavioral disinhibition
apathy or inertia
loss of sympathy/empathy
compulsive

Question 16

presentation of frontotemporal dementia - semantic variant?

Answer 16

impaired single-word comprehension
fluent
can remember things day to day
can’t remember what some words mean
can’t find words they are looking for

Question 17

presentation of frontotemporal dementia - progressive nonfluent aphasia?

Answer 17

• appears like Broca’s aphasia
• agrammatism in production or apraxia of speech (difficulty producing sound)
• understand speech in small pieces (impaired comprehension of complex sentences)
• has single word comprehension

Question 18

what should you perform on a neuropsychological evaluation of a pt you suspect has dementia?

Answer 18

• quick screen pts > 70 y/o (repeat 3 simple nouns, do clock test, recall 3 simple nouns)
• any deficit in quick screen&raquo_space; full mini mental state exam (MMSE)
• any deficit in MMSE&raquo_space; full neuropsych eval

Question 19

what are the guidelines for imaging when you suspect pt has dementia?

Answer 19

• goal: r/o ischemia, tumor, structural abnormality
• MRI preferred, but CT w/o contrast also acceptable
• may not see any evidence of neurodegen dz unless severe gross atrophy present
• PET scan can help differentiate between Alzheimer’s dementia and FTD

Question 20

The same sets of labs are ordered on pts suspected to have any of the 4 types of dementia. But when you suspect Alzheimer’s dementia, what additional lab is needed and what will be the result if positive?

Answer 20

CSF analysis (will see beta amyloid decrease, tau protein increase)

Question 21

what is the nonpharmacologic trx of dementia?

Answer 21

• goal: decrease rate of decline
• aerobic exercise
• frequent mental stimulation (but they cannot regain lost skills*)
• discontinue driving*

Question 22

what is the COGNITIVE pharmacotherapy for dementia?

Answer 22

*cholinesterase inhibitors
- Donezepil, rivastigmine, galatamine
- First line, but not very effective
- for AD and Lewy body dementia
- C/I in FTD

*Memantine
- for AD and possibly Lewy body
- C/I in FTD

Question 23

what is the BEHAVIORAL pharmacotherapy for dementia?

Answer 23

*SSRIs for depression
- bupropion, or venlafaxine
- avoid Paxil due to anticholinergic effect

*Trazodone for insomnia
- avoid antihistamines, benzos, zolpidem

*Methylphenidate for apathy
- for select pts only, can cause agitation

Question 24

what are some safety concerns to consider when managing a pt with dementia?

Answer 24

• r/o delirium if pt is agitated, impulsive
• avoid atypical antipsychotics (quetiapine; increased fall risk, caution in Parkinson’s dz)
• avoid benzos (lorazepam; can worsen agitation)