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Care of the Elderly > Dementia > Flashcards

Dementia Flashcards

1
Q

Define dementia

A

A progressive, degenerative neurological disorder characterised by cognitive decline beyond what is expected from normal ageing.
Irreversible
Presents as memory loss, problems with reasoning, communication, change in personality among many others.

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2
Q

What are the most common types of Dementia?

A

Alzheimers Disease
Vascular Dementia
Lewy Body dementia
Frontotemporal dementia
Mixed
Young Onset

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3
Q

What is the prevalence of dementia?

A

Around 7% of older people in the UK have dementia.
This increase to 10% of 80-84yrs, and up to 41% of 95yrs+
Large numbers are estimated to be living with undiagnosed dementia or probably dementia in primary care settings.

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4
Q

Give an overview of the underlying pathology of Alzheimers disease

A

Atrophy of the cerebral cortex and formation of amyloid plaques and neurofibrillary tangles
This triggers neuroinflammation and reduction in neurotransmitters, particularly Acetylcholine.
Mainly in the parietal and temporal lobes.
Often co-exists with other dementia.

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5
Q

What is the detailed process of Alzheimer’s dementia?

A

Amyloid Precursor Protein (APP) in cell membrane - helps neuron grow and repair
Normally broken down by alpha and gamma secretase - creates soluble products that are disposed of.
1) If beta and gamma secretase break down - creates insoluble amyloid beta monomers
Aggregate to form beta amyloid plaques - accumulate between neurons - impaired signalling
-> trigger neuroinflammation
-> deposit around BV -> inc risk of haemorrhage
-> activates kinase (see next step)
2) Microtubules inside neurons contain tau, kinase enzymes phosphorylated tau leading to formation of neurofibrils tangles inside neuron -> leads to destruction of cytoskeleton -> unable to transport neurotransmitters.

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6
Q

What are some risk factors for Alzhiemers disease?

A

Genetics - APOE (allele ε4 is a risk, ε2 is protective), EOFAD (PSEN1?2 and APP) - around 50% of familial early onsey
Age - doubles every 5yrs after 65yrs
Sex - females, due to life expectance of hormones
Lower education attainment
Vascular risk factors - HTN, DM, obesity, hypercholesterolemia and smoking
Head injury
Diet - high in fats/simple carbs
Lack of regular physical activity
Sleep disorders or chronic sleep deprivation.

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7
Q

What does Alzheimers Disease look like on imaging?

A

Cortical atrophy - increased sulci and decreased gyri
Ventricle enlargement
Particularly enlargement of the temporal horn of the lateral ventricles due to atrophy of the hippocampus

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8
Q

How does alzheimer disease tend to present?

A

Develops insidiously over months/years
Cognitive - memorly loss (recent more than distant, struggle to learn more things, vague with dates or refer to family), decision making, reasoning and communication (not dysphasia)
Behavioural/psychological - fluctuate, depression, agitation, psychosis, apathy, disinhibition
Struggle with ADLS - kitchen appliances, washing, dressing etc

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9
Q

What are the first line investigations for Alzheimers disease?

A

Cogntive testing - MMSE, MoCA, Addenbrookes Cogntivie Examination 3
Bloods - FBC, electrolytes, LFTs, TTT, VB12 and folate - identify reversible causes.
Imaging - CT or MRTI head - exclude other cerebral pathology, pos may see atrophy of medial temporal lobe structures.

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10
Q

What further investgiations may be done on a patient with Alzheimers disease?

A

Cerebrospinal Fluid Analysis - AD likely if beta-amyloid reduced and total tau/phosphorylated tau are increase
Amyloid PET imaging - amyloid plaques in vivo

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11
Q

What is the non-pharmacological management for Alzheimers disease?

A

Range of activities to promote wellbeing tailored to the individual.
Group cognitive stimulation therapy is mild or moderate
Consider group reminiscence therapy and cog rehab
Advanced Care Planning
Signposting patient/family to charity support groups.

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12
Q

What is the pharmacological management for Alzheimer disease?

A

Acetylcholinesterase inhibitors - donepezil, galantamine, rivastigmine
Memantine (NMDA receptor antagonist) is second line.

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13
Q

When may memantine be used to treat Alzheimers disease?

A

Second line
->if moderate disease and intolerant or contraindicated for acetylcholinesterase inhibitors
-> as an add on to moderate or severe
-> monotherapy in severe

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14
Q

How should behavioural/psychologycal symptoms of dementia be managed?

A

Do NOT recommend antidepressant for mild to moderate
Antipsychotics are only given if risk of harm to themselves/others or if agitation/hallucination/delusion causing severe distress.

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15
Q

What are the drawbacks of donepezil in Alzheimers management?

A

Contraindicated in bradycardia
Adverse effects = insomnia

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16
Q

Define vascular dementia

A

A severe vascular cognitive impairment secondary to ischaemia or haemorrhage (from CVD).
Second most common type of dementia
Syndrome with a spectrum of presentations

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17
Q

What are the relevant risk factors for vascular dementia?

A

History of TIA
Atrial fibrillation
HTN
DM
Hyperlipidaemia
Smoking
Obesity
Coronary Heart Disease
FM of stroke or cardiovascular disease
Rarely inherited in CADASIL.

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18
Q

What are the different types of vascular dementia?

A

Stroke related - multiple or single infarct
Subcortical - small vessel disease
Mixed dementia - the presence of both VD and Alzheimers disease

19
Q

What are the symptoms key to vascular dementia?

A

Sudden Stepwise deterioration of cognitive function - over months or years
Can have focal neurological deficits -> visual disturbance, sensory or motor deficits
Attention and concentration loss
Seizures
Memory loss
GAIT problems
Speech problems
Emotional disturbance

20
Q

What criteria do NICE recommend is used to diagnose vascular dementia?
What is this?

A

NINDS-AIREN
1) cognitive decline so struggle with ADLs, cause is not due to secondary effect of CV event
2) Cerebrovascular disease
3) Relationship between 1+2 -> aka dementia within 3m stroke, sudden deterioration

21
Q

What is the management plan for vascular dementia?

A

Mainly symptomatic - therapy targeted to neurological defect either focal or global decline in cognition
Detect and address cardiovascular risk factors - to slow down the progression.

22
Q

What is frontotemporal dementia?

A

Primary neurodegenerative condition = 2% of dementia cases.
Progressive illness - behavioural changes and language problems.
Early onset compared to other dementias at around 50-60yrs

23
Q

What is the aetiology of frontotemporal dementia?

A

Combination of genetics and lifestyle
50% have a positive family history
10% show autosomal dominant inheritance
Genes include:
MAPT - resulting in tau inclusion bodies
Progranuline (PGRN) - TDP-43 inclusion bodies
C90rf72 - uncertain

24
Q

What is the pathophysiology of frontotemporal dementia?

A

Degeneration in the frontal and temporal lobes
Behavioural variant - mainly frontal lobes
Non-fluent/agrammatic variant - posterior frontal lobe, insular and temporal (including hippo)
Semantic - left-sided temporal and hippo, frontal lobes are relatively spared.
All tend to show axonal injury and inclusion bodies of tau (MAPT gene) or immunoreactive ubiquitin (PGRN)

25
Q

What are the different types of Frontal Temporal Dementia?

A

behavioural - change in personaility and behaviour -> disinhibition, apathy, compulsion, loss of empathy
Semantic - concepts or facts relating to language, loss of word/name recall, unable to recognise familiar people or objects or understand words
Progressive Nonfluent - progressive language disorder non-fluent speech and grammatical errors - agrammatism or apraxia of speech - left persylvian or insula atrohy.

26
Q

What are the key signs and symptoms of frontotemporal dementia?

A

Behavioural changes main and early - apathy, disinhibited, hyperorality, perseverative.
Difficulty with speech also main and early- language or aphasia
Decline in executive functioning and cognition
Memory problems (tend to be later onset)

27
Q

What bloods should be done to exclude organic causes of dementia?

A

FBC - anaemia
ESR and CRP - infection or vasculitis
T4 and TSH - hypothyroidism
U&Es - renal failure or electrolyte distrubances
B12 and folate - vitamin deficiencies
Coagulation screen and albumin - liver function
GLucose
MSU - delirium from infection
Syphylis serology and HIV testing if clinically indicated.

28
Q

What additional tests may be done to diagnose a patient with frontotemporal dementia?

A

Bloods (see card)
Structural imagin
FDG-PET or SPECT scan - if diagnosis unclear
Genetic testing - if positive family history

29
Q

What is the treatment for frontotemporal dementia?

A

No DMARDs - so suportive and symptom management
Often refer to specialist psychiatry or neurology services, care plan 6/12m follow up, end of life planning
May give if needed:
SSRI - depression, anxiety, disinhibition, irritability
Benzodiazepines - acute agitation and distress
Antipsychotics - low dose as last resort
Oxytocin -> love improve empathy

30
Q

Define Lewy Body dementia

A

Type of dementia
Abnormal aggregates of alpha-synuclein cytoplasmic inclusion called Lewy bodies accumulate in the brain.
Results in cognitive decline alongside motor symptoms

31
Q

Describe the basic pathology of lewy body dementia?

A

Lewy body formation - intracellular inclusion of misfolded alpha-synuclein protein.
These are insoluble fibres - can impair mitochondrial function and promote oxidative stress = cell death.
Impair ubiquitin-proteosome system - leads to more toxic protein accumulation
Causes synaptic vesicles malfunctioning preventing NT release
Disrupts neuronal communication

32
Q

What are the different regions of the brain that are commonly affected in Lewy Body dementia?

A

Congitive impairement - cortical regions = frontal and temporal lobes
Parkinsonism - substantial nigra pars compact
Visual hallucination - occipital cortex and visual processing areas
Autonomic dysfunction - PANS - sympathetic and enteric etc

33
Q

What are the key clinical features of lewy body dementia?

A

Progressive cognitive impairment- early impaired attention and executive function aswell as memory loss
Cognition can fluctuate
Parkinsonism
Visual Hallucinations (Delusions and non-visual may also occur)
REM sleep behaviour disorder

34
Q

What test can be used to diagnosed Lewy Body dementia?

A

DaT scan - 90% sensitivity and 100% specificity

35
Q

What is the treatment for Lewy Body dementia?

A

Acetylcholinesterase inhibitors and memantine can be used
Neuroleptics/Antipsychotics should be avoided to prevent irreversible parkinsonism

36
Q

Define young onset dementia

A

When a person develops dementia before the age of 65yrs.

37
Q

What are the key features of young onset dementia?

A

More likely to have a severe dementia
Less likely to have memory los as one of first symptoms
More likely to cause problems with movement, walking, co-ordination or balance
Often inherited (10%)

38
Q

How does the MMSE examine congition?

A

Scores patients answers to questions:
Orientation to time
Orientation to location
Repeat words - count trails needed for recall of three words
Attention and calculation (serials 7 or spell world backward)
Repeat asking to recall 3 objects from above
Language - name objects, repeat no, ifs, buts, follow three stage command, read and follow instruction, write a sentence, copy a design
Assess drowsiness

39
Q

What do the different MMSE scores mean?

A

25 or higher is normal
20-24 is mild dementia
13-20 moderate dementia
less than 12 - severe dementia
less than 10 - severe impairement

40
Q

What is the difference between Parkinsons Dementia and LBD?

A

Parkinson’s - motor symptoms appear at least a year before dementia cognitive symptoms
Dementia with LB - dementia appears before or at the same time as movement symptoms.

41
Q

What gene is most strongly associated with Alzheimers disease?

A

APOE4

42
Q

What are the 4As of Alzheimer disease?

A

Amnesia
Aphasia - poor communication, speech, writing, understanding of spoken and written.
Apraxia - unable to do tasks
Agnosia - unable to recognise objects, people, sounds etc - although senses are working correctly

43
Q

What are the common behavioural and psychological symptoms of dementia?

A

Psychosis
Agitation
Emotional liability
Depression
Withdrawl
Disinhibition
Sleep cycle disturbances
Difficulties with activities of daily living

44
Q

What are some common differential diagnosis for dementia?

A

Delirium
Mental health conditions e.g depression
Brain tumours
Parkinsons disease
Huntingtons disease
Hypothyroidism
Cushing syndrome
Hypercalcemia
VB12/thiamine deficiency
Adverse effect of medication

Care of the Elderly (22 decks)

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