Dementia

Question 1

should we screen for dementia?

Answer 1

• The USPSTF concludes that the current evidence is insufficient to asses the balance and benefits and harms of screening for cognitive impairment in older adults
• Remain alert to early signs or symptoms of cognitive impairment and evaluate as appropriate

Question 2

• takes longer to learn and recall new information
• occasional trouble with word finding
• trouble remembering names of new acquaintances
• still able to maintain daily activities

Answer 2

Normal aging

Question 3

Warning signs of dementia

Answer 3

• memory loss that disrupts daily life
• challenges in planning or solving problems
• difficulty with time or place
• trouble understanding visual images or spatial relationships
• new problems with words in speaking or writing
• misplacing things and losing ability to retrace steps
• decreased or poor judgement
• withdrawal from work or social activities
• changes in mood or personality

Question 4

1. three word registration
2. clock draw
3. three word recall

Abnormal screen

• total score < 3 (validated)
• total score < 4 (more sensitive)

Answer 4

Mini-Cog

Question 5

best studied exam for dementia

Answer 5

Mini-Mental Status Exam (MMSE)

Question 6

• Now requires training
• better for detecting mild cognitive impairment
• useful for patients with high education levels

Answer 6

Montreal cognitive assessment (MOCA)

Question 7

• Easy to administer
• Less well studied
• includes animal fluency test

Answer 7

St. Louis University Status examination

Question 8

• cognitive impairment based on history and objective testing
• not causing significatn functional impairment
• decline in cognition from baseline

Answer 8

Mild cognitive impairment

Question 9

• cognitive impairment based on history and objective testing
• causing significant functional impairment
• decline in cognition and function from baseline
• not explained by delirium or major psychiatric disoder

Answer 9

dementia

Question 10

management of mild cognitive impairment?

Answer 10

• Deprescribing
• no benefit of dementia medications for MCI
• exercise
• enjoyable lesiure activities
• mental stimulation
• monitoring for progression

Question 11

• Most common type of dementia (60-80%)
• gradual onset, slowly progressive
• prominent memory deficits; apathy and depression can be early symptoms
• later symptoms: impaired communication, disorientation, poor judgement, behavior change, diffculty speaking, swallowing, walking
• pathology: beta-amyloid protein (plaques) outside neurons, protein tau (tangles) inside neurons–> death of neurons
• mixed pathology is common

Answer 11

Alzheimer’s dementia

Question 12

• abnormal neurlogic exam
• abrupt change in cognition
• stepwise progression
• evidence of stroke on neuroimaging
• onset of dementia < 3 months follwoing stroke
• impaired judgement can be an early symptom
• 5-10% of dementia cases
• commonly mixed with alzheimer’s pathology

Answer 12

Vascular dementia

Question 13

• fluctuating attention and concentration
• sleep difficulties; REM sleep behavior disorder
• recurrent well-formed visual hallucinations
• parkinsonism, frequent falls
• visuospatial impairment
• severe reaction to antipsychotics
• memory may be intact
• 5% of dementia cases
• pathology: Lewy bodies- clumps of alpha synuclein protein in neurons

Answer 13

Dementia Lewy Bodies

Question 14

parkinson’s vs dementia with lewy bodies

Answer 14

parkinson’s disease dementia

• motor symptoms preceded cognitive symptoms by 6-8 years

Dementia with Lewy bodies

• tremor/ motor symptoms start within a year of cognitive symptoms

Question 15

• Early onset (60% age 45-60)
• behavioral variant: personality and behvavior changes (disinhibition, apathy, loss of empathy, compulsive/ritualistic behaviors, excessive/inappropriate eating & drinking, deficits in executive function
• primary progressive aphasia: language impairment - gradual loss of ability to speak, read, write, and understand
• spared memory and visuospatial skills early on
• associated with movement disorders, including amyotrophic lateral sclerosis (ALS)
• Pathology: frontal and temporal lobes become atrophied

Answer 15

Frontotemporal Degeneration (FTD)

Question 16

evaluation of cognitive impairment

Answer 16

• depression screen
• labs: Vitamin B12, tsh
• Imaging: non-contrast head CT or MRI

Question 17

when to consider referral?

Answer 17

• Age < 65
• tremors, falls, hallucinations, ataxia
• atypical presentation
• difficult behavioral symptoms
• functional impairment of proportion to cognitive impairment
• confounding factors (traumatic brain injury, psychiatric symptoms)

Question 18

non-pharmalogical treatment of dementia

Answer 18

• aerobic exercise: improves cognitive function in people with dementia
• cognitive stimulation: improves quality of life
• Music: interventions improve depression, anxiety and quality of life
• Cognitive behavioral therapy improves depression and anxiety

Question 19

pharmacologic treatment of dementia

Answer 19

Acetlycholinesterase Inhibitors (Donepezil, galantamine, rivastigmine)

• SE: nausea, vomiting, diarrhea, weight loss, bradycardia, dizziness, headache, vivid dreams
• fewer side effects with donepezil, more side effects at higher doses

NMDA-receptor antagonist

• Well tolerated
• can be used in combination with donepezil
• in people with moderate to severe alzheimers dementia, 6-7months of memantine vs placebo has a small clinical benefit in cognitive function, ADLs, behavior and mood

Question 20

• an acute, fluctuating syndrome of altered attention, awareness and cognition

Answer 20

delirium

Question 21

what is delirium positive?

Answer 21

Acute onset or fluctuating course

AND
Inattention

AND
Disorganized thinking OR
altered level of consciousness

Question 22

which medications can cause delirium?

Answer 22

anticholinergics
antidepressants
antipsychotics
benzodiazepines
pain medications
neurologic