Dementia Flashcards
What is dementia?
clinical syndrome due to disease of brain
numerous causes
impairment of multiple higher cortical functions (memory, abstract thinking, comprehension, cognitive and non-cognitive sx)
significantly interferes with occupation, ADLs or relationships
at least 6 months duration
Cognitive symptoms of dementia
amnesia: loss of memory
aphasia: difficulty with language
agnosia: inability to recognise objects or people
apraxia: inability to carry out physical tasks
Non-cognitive symptoms of dementia
psychiatric symptoms - delusions, hallucinations, depression, anxiety, misidentification syndrome
behavioural disturbance - agitation, aggression, disinhibition, abnormal vocalisation, wandering, restlessness
personality change: irritability, impulsive behaviour
Types of dementia
Alzheimer’s dementia
Vascular dementia
Dementia with lewy bodies
Frontotemporal dementia
Huntington disease dementia
CJD dementia
Parkinson’s disease dementia
Alcoholic dementia
Dementia pugilistica
When is it more common to get Alzheimer’s disease <65?
family history
Down’s syndrome
Risk factors for Alzheimer’s disease
presenelin 1 + 2, APOE, APP
age, premorbid IQ, female, lower education
hypertension, diabetes, obesity, hypercholesterolaemia, physical inactivity, smoking
head trauma
Presentation of Alzheimer’s disease
insidious onset, slow deterioration
early memory loss
difficulties with language
difficulties with planning or organisation, visuospatial skills, orientation
loss of insight
absence of systemic or brain disease as cause
Neuropathology of Alzheimer’s
temporo-parietal lobe mainly affected, widening of sulci and narrowing of gyri, ventricular enlargement, amyloid plaques, neurofibrillary tangles (tau protein)
Neuroimaging findings in Alzheimer’s
atrophy of medial temporal lobe
How are neurotransmitters affected in Alzheimer’s disease?
decrease acetylcholine, noradrenaline, serotonin
Risk factors for vascular dementia
hypertension
hypercholesterolaemia
diabetes
Clinical features of vascular dementia
abrupt onset
stepwise deterioration
fluctuating course
emotional lability
personality changes
insight maintained until late stages
depression and epileptic fits more frequent
may be signs and symptoms of stroke
How is vascular dementia diagnosed?
NINDS-AIREN criteria based on neuroimaging
multiple large vessel disease-related stroke in critical areas
or massive small vessel disease
or multiple lacunes in the basal ganglia and frontal white matter, or bilateral thalamic lacunes
Core symptoms of dementia with lewy bodies
fluctuating cognition, alertness and attention
parkinsonian motor sx (bradykinesia, limb rigidity, gait and balance disturbance, blank facial expression)
visual hallucinations
REM behaviour sleep disorder
Dementia with lewy bodies pathology
lewy bodies in cerebral cortex/substantia nigra, senile plaques, no neurofibrillary tangles
Dementia with lewy bodies biomarker
reduced dopamine transporter uptake in the basal ganglia on SPECT/PET scan
What CT/MRI findings are present in dementia with lewy bodies?
generalised atrophy with more preservation in the medial temporal lobe compared with Alzheimer’s
ventricular enlargement
What is the other name for frontotemporal dementia?
Pick’s disease
Frontotemporal dementia variants
behavioural:
early changes in personality, behaviour and judgement
socially inappropriate behaviour
disinhibition
apathy
perseveration
hyperorality/dietary changes
loss of empathy
primary progressive aphasia:
- semantic dementia (loss of meaning of words)
- progressive non-fluent aphasia (impaired speech production)
Frontotemporal dementia pathology
gross atrophy of frontal and anterior temporal lobe
Frontotemporal dementia pathology
tau protein present in frontal and temporal lobes
Name some cognitive screening tools
abbreviated mental test score
mini mental state examination
montreal cognitive assessment
general practitioner assessment of cognition
addenbrookes cognitive examination
cambridge cognition examination
AMTS components
1) age
2) time to nearest hour
3) an address to be repeated
4) year
5) name of hospital/home address
6) recognition of 2 persons
7) date of birth
8) date WW1 started
9) name of present monarch
10) count backwards from 20-1
<7 suggests impairment
Dementia investigations
dementia bloods screen: FBC, U&E, TFT, LFT, blood glucose, folate, vitamin B12, calcium
urine MC&S
neuroimaging: CT, MRI, DAT scan, SPECT
neuropsychological testing
gold standard is autopsy
Dementia differentials
metabolic: hypothyroidism, hyperparathyroidism, hypoglycaemia
nutritional
inflammatory: MS, sarcoidosis, SLE
structural: normal pressure hydrocephalus, space-occupying lesion, subdural haematoma
infections: neurosyphilis, encephalitis, Lyme disease
inherited: Wilson’s disease
depression/pseudodementia
medications
delirium
Driving with dementia guidelines
DVLA must be informed
most are unfit to drive
in early dementia, a licence may be issued subject to annual review
formal driving assessment may be necessary
group 2 licence must be revoked
Dementia pharmacological treatment
cholinesterase inhibitors:
- donepezil
- rivastigmine
- galantamine
NMDA antagonist:
- memantine
antipsychotics:
- risperidone
- haloperidol
benzodiazepines
anticonvulsants, antidepressants etc
How do cholinesterase inhibitors work in dementia?
stop the breakdown of acetylcholine (an important neurotransmitter in memory and cognition)
do not prevent progression of disease
Cholinesterase inhibitors side effects
nausea
vomiting
diarrhoea
dizziness
headache
muscle cramps
Who should cholinesterase inhibitors be used in caution with?
gastric ulcer
heart disease
COPD
How does memantine work in dementia?
blocks pathological effects of glutamate release
allows better function of impaired brain
slows cognitive decline and functional decline
decreases agitation
Side effects of memantine
headaches
dizziness
Who should memantine be avoided in?
kidney disease
seizure disorders
Risks of antipsychotics in dementia
accelerated cognitive decline
cerebrovascular events
mortality
