dementia

Question 1

what is dementia?

Answer 1

consisting of progressive impairment in two or more areas of cognition (I.e. memory, language, visuo-spatial and perceptual ability, thinking and problem solving and behaviour) sufficient to interfere with day to day functioning (e.g. work, social function or relationships) in the absence of delirium or other major psychiatric disorder.

Question 2

symptoms of dementia?

Answer 2

aggression ampathy depression psychomotoragitatioj psychosis

Question 3

subtypes of dememtia?

Answer 3

DEGENERATIVE (~60-70%) –Alzheimer’s disease –Dementia with Lewy Bodies –Fronto-temporal dementia (Pick’s disease) – Huntington’s disease VASCULAR (~20-30%) –multi-infarct (large vessel) –single stroke (large vessel) –Binswanger’s disease (small vessel) OTHER (~5%) –space occupying lesion (tumour, haematoma) –normal pressure hydrocephalus –prion disease (CJD) –infections (syphilis, neuroAIDS) –nutritional and metabolic disorders –boxing (dementia pugilistica)

Question 4

differential diagnosis of dementia?

Answer 4

DELIRIUM (short history, fluctuating consciousness, poor attention span, psychomotor changes) DEPRESSION (fluctuating cognition, tendency to highlight failures, “don’t know answers, sleep/appetite disturbance DRUGS (especially CNS and anticholinergic) DRINKING ALCOHOL (in excess and on withdrawal) DEAFNESS (slow comprehension, inappropriate answers) DYSPHASIA/DYSPRAXIA (isolated cognitive deficits)

Question 5

alzheimers risk factors?

Answer 5

Genetic (e.g. Apo E/ PICALM/CLU, Downs syndrome, mutations in the presenilin & APP genes in young onset familial AD) Age (doubling incidence every 5 years over 60) Environmental (e.g. low education, previous head trauma, social network, mental & physical activity) Medical (e.g. vascular risk factors, previous depression)

Question 6

mild cognitive impairement?

Answer 6

A ‘predementia’ syndrome …. Subjective and objective cognitive deficit No major impairment of ADL Not inevitably progressive, but up to 10-15% conversion to dementia (mainly AD) each year in clinic samples compared to 1-2% in controls Recognition allows attention to vascular risk, forward planning, cognitive rehabilitation etc.

Question 7

pathways of lewy bodies?

Question 8

frontotemporal dementia?

Answer 8

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Question 9

cognitive assessments?

Answer 9

Mini mental state examination (MMSE) –Previously widely used as brief cognitive screen, but recent copyright issues •Montreal Cognitive Assessment (MoCA) –covers orientation, attention, memory, language, visuo-constructional skills etc. –always consider factors that may affect performance (education, language, sensory impairment etc.) Clock-drawing (planning, comprehension, visuo- spatial skills, memory) is quick and non threatening Verbal fluency (name animals in one minute) or proverb interpretation test frontal skills

Question 10

blood test?

Answer 10

Routine for all patients •FBC, U&E, LFT, glucose, Ca, thyroid profile, B12 & folate Selected patients (if risk factors or clinical picture dictates) Syphilis serology, HIV Genotyping (familial dementias) CXR, ECG, MSU EEG (characteristic triphasic spike in CJD, suspected delirium, associated seizure disorder) CSF (14-3-3 in CJD; syphilis serology; amyloid/tau ratio in AD) Brain biopsy (rarely, if potentially reversible cause suspected)

Question 11

biomarkers?

Answer 11

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Question 12

factors?

Answer 12

Non-modifiable High age Low education Family history Specific genetic factors Modifiable Mid life hypertension Mid life obesity Hypercholesterolaemia Smoking Diabetes IHD Homocysteine Lack of physical and mental activity

Question 13

pharmacotherapy?

Answer 13

No efficacy (or doubtful) Vasodilators Lecitihin/choline Nootropics Cholinergic agonists NSAIDs/steroids Oestrogen Vitamin E Ginkgo biloba Statins Proven efficacy Cholinesterase inhibitors -Donepezil -Rivastigmine -Galantamine Memantine Uncertain efficacy Neurotrophins Anti-amyloid Anti-tau

Question 14

anti amyloid drugs?

Answer 14

Beta and gamma secretase inhibitors •Anti-fibrillar agents •Immunotherapy –Active immunisation with beta amyloid (AN1792) or amyloid fragment –Passive immunisation with anti-amyloid antibodies –?need to be used early (at prodromal stage)