Dementia Flashcards
Aphasia
失語症
Frontotemporal lobar degeneration spectrum (frontotemporal dementia)
Built up abnormal protein in the brain
Often starts younger than Alzheimer’s.
Usually have personality change/speech
Naming and emotion and behavioural problems, fluent speech with loss of word
Apathy, disinhibition, lack empathy
Dementia
A syndrome due to disease of the brain. Chronic and progressive in nature. Disturbance of multiple higher cortical functions. Consciousness is not impaired. Impairments of cognitive function are accompanied by deterioration in memory loss, emotional control, social behaviour (clothing), communication, or motivation and reasoning
Progressive, global cognitive impairment
Epidemiology in dementia in uk
Two third are women
One in three over 65 years old will develop dementia
Dementia sighs and symptoms
Struggling to remember recent events but easily recalling past events (Alzheimer’s)
Finding hard to follow conversation or program on tv
Forgetting the names of friends or everyday objects
Repeating yourself
Problem with thinking and reasoning
Feeling depressed, anxious or angry about forgetfulness
Confused even in a family environment
A decline in the ability to read and write
Diagnosing /assessing dementia
Screening (primary care)
-MMSE/mini mental state exam(below 24/30) or ACE-R (below 88)
Then pre-assessment planning(explaining the purpose of referral/assessment)
Then assessment
- blood test (vitamin/thyroid/UTI)
- brain scan: CT scan for brain area/degeneration
- clinical interview with client, carer, staff
- neuropsychological testing
Interpret the best explanation
Dementia type vs MCI vs normal aging
Drug treatment for Alzheimer’s disease
For mild to moderate AD, or mixed dementia, cholinesterase inhibitors are recommended (it prevents breakdown of acetylcholine that improves neuron communication)
For severe AD/when cholinesterase not effective, memantine (NMDA antagonist) is licensed for treatment
It improves alertness, motivation, and daily living , ease distressing behaviour and delusion
Types of dementia
Alzheimer's 62% Vascular 17% Mixed 10% DLB (dementia Lewy bodies) 4% Frontotemporal 2%
Alzheimer’s disease
Caused by accumulation of Amyloid plaques and Neurofibrillary tangles
–> senses remain intact, higher cognitive function are affected
Only one of dementia which Symptoms modification with drug treatment (cholinesterase inhibitor) is possible
Global cerebral atrophy (esp medial temporal lobes) with increase in ventricles and sulci size
Symptoms of Alzheimer’s disease
Short term memory loss Difficulty with finding the right word Solving problems Making decision Perceiving things in 3D
Vascular dementia
Due to gradual reduced blood supply AND mini strokes
O2 supply to brain reduce –>killing brain cell
Risk factor for vascular dementia
Hypertension, smoking, overweight, genetics
Difference between Alzheimer’s and vascular dementia
Onset and course are different
Vascular ; sudden onset and stepwise decline
Symptoms may be more focal
Usually less impairment in episodic memory than AD and more in visual skills, semantic memory, executive functioning (problem solving, planning, thinking and concentrating )
Lewy bodies dementia
Share pathology and symptoms with Parkinson’s disease (motor symptom) and Alzheimer’s
Protein deposit in brain lead to brain cell death
DAT scan is used to differentiate LBD from Alzheimer’s. DAT scan can detect changes in dopamine transporter.
Lewy bodies dementia symptoms
Fluctuation of alertness and cognition
Episodic memory is less affected
Visuospatial problems are more common
Visual hallucination without auditory hallucination is common (60-70%)
Motor symptoms of Parkinson’s disease are followed
Differential diagnosis between dementia and normal aging
Short term memory impairment
- delayed episodic memory
AND poor category fluency together
Normal aging- they forget old memory
Difference between dementia and mild cognitive impairment
Objective cognitive impairment but no day to day social functional impairment
10%of them develop dementia later
Difference between dementia and depression
Similar clinical presentation
Similarities : deficits in episodic memory, and learning, working memory, processing speed, and categorical fluency, motor speed and attention shift
Difference: depressive symptoms tend to be detente by patients rather than family members.
Negative thought processing and Physical symptoms (insomnia, lack of appetite)
Cognitive task; dementia people tend to guess the answer, but depressives people are not attempt to answer
Difference between dementia and delirium
Usually due to infection (UTI)
Usually drowsy and fluctuating cognitive ability
Dementia shouldn’t diagnosed in acute hospital setting
Behaviour and psychiatric symptoms of dementia
Agitation 75% Wandering 60% Depression 50% Psychosis 30% Vocalist ion 25% Aggression 20%
Risk factor for dementia
Aging Gender (female 60% more risk) Genetics (stronger link for early onset) Medical history (cardiovascular disease, head injury) Diet , lifestyle Level of education
Prevention
Healthy lifestyle No smoking Physical exercise Healthy weight Less drinking Intelligence to increase cognitive reserve Socially and mentally active Treat depression early
Mini mental state examination
Orientation to time, orientation to place, Registration(repeating named prompts), attention and calculation, recall language, repetition, ability to follow simple commands
What year are we in? What season ? What month ? What's the date today ? What day of the week ? What country ? What city? What's the name of this place ? Which floor ? Name 3 objects and repeat them and remember Spell backward 7 away from 100 Show object and name them ( name recalling)
Behavioural symptoms of dementia
Restlessness Boredom Resistant to do anything new or different from routine Agitation Repeating Walking and pacing up and down Aggression Suspicious of others
Steps for diagnosis and treatment of dementia
- GP assess physical health, blood tests, MMSE
- GP recommend further memory investigation and refer consultant psychiatry or memory clinic
- psychiatrist collect detailed history, brain scan, blood test so that physical health problem can be ruled out
- If a diagnosis is made, they are referred to cognitive stimulation therapy, OT, dementia navigator, social service. Medication will start if necessary
- if medication is started, memory service nurse will visit after a few weeks.
- Advanced care planning could be offered
Cognitive stimulation therapy
A brief treatment for people with mild to moderate dementia
Dementia navigator
A new service in islington.
Offer one off contact to all people who have had diagnosis of dementia
Therapy that doesn’t work
Light therapy
Aromatherapy
Home like care
Effective intervention for agitation
Activity
Music therapy following a specific protocol
Sensory intervention
Dementia care mapping
Training staff in person centred or communication skills was effective in reducing severe agitation but only if this was supervised on an ongoing fashion
Treatment for Lewy bodies
Although they show psychotic symptoms, antipsychotic medication should be avoided or used very carefully because 50% of them might experience severe neuroleptic sensitivity
Cholinesterase inhibitor (for mild to moderate AD) is also effective in reducing psychotic symptoms of Lewy bodies
Treatment for frontotemporal dementia
The use of antipsychotic and antidepressant drugs are still not well supported to be effective
SSRI may help control the loss of inhibitions, compulsive behaviour
Treatment for vascular dementia
Antipsychotic can increase the risk of stroke so not really recommended
Cholinesterase inhibitor might be used but not really effective since its for AD
Ministerial announcement
10/8 2014
75% of patients refereed for talking therapies should be seen within 6weeks , 100% in 18 weeks
Ethic and clinical care
Non maleficence -no harm
Autonomy -respecting the patients’ right to make decision
Beneficence-act in patients best interest
Justice- being fair in decision about which patients receive which treatment
Mental state examination
A&B: appearance and behaviour S: speech M: mood T: thoughts P: perception C: cognition I: insights
Investigation for dementia
Primary care
-Blood test (for vitamin deficiency, hypothyroidism)
Secondary care
- CT scan
- MRI
- SPECT to assess regional blood flaw and dopamine scan to detect Lewy body
Behavioural and psychiatric symptom of dementia (BPSD)
BPSD are very frequent, affecting, around 90% of people at some stage in their illness
Management/treatment of dementia -cognition.
Vitamins & supplements Cholinesterase inhibitor Memantine (hardly ever used) Cognitive stimulation Cognitive rehabilitation Reminiscence (story telling)
Cholinesterase inhibitor
Prevent break down of acetylcholine to top up the level
Improve symptoms or temporary stop progression
40-70% patient benefit
Side effect: nausea, diarrhea, vomiting, fatigue, muscle pain
Psychological therapy
Counselling: to come to terms with diagnosis
Intervention: coping with depression/anxiety
Cognitive rehabilitation: retain mental skills & raise confidence
Consultation: for change to be made at home to support independence
Cognitive stimulation: to keep mind active
Reminiscence therapy: telling story
