Dementia Flashcards
What could be confused for dementia,
Depression- may also cause personality change, memory disturbance & intellectual decline.
What should be excluded?!
Delirium
Define delirium
Acute confusional state caused by infection, drug intoxication/ or withdrawal, metabolic disturbance or systemic illness.
Cause of altered cerebral function.
How many people are affected by dementia?
5-10% over the age of 65, 20% over 80s.
What makes up dementia?
Alzheimers disease
Vascular dementia
Dementia woth Lewy bodies
Whats Alzheimers?
⬆️ with age B- amyloid peptide plaques accumulation in around neurons wth neurofibrillaty tangles in cerebral cortex. Rare under 50 20% in those over 85 10-15% familial
65% of dementias
What are the main featurs of alzheimers?
Earliest: memory loss,
Dominenst: progressive loss of ability to retain and recall new info.
Apathy: may appear depressed.
Advanced disease: dysphasia, apraxia, (diff using tools and implements. Visuospatial difficulties often develop.
What is Vascular dementia?
May occur in isolation, may coexist with alzheimers
(Mixed dementia)
In pts with signfcnt vascular RFs.
(20% of dementias)
Stepwise deterioration in cognitive function
Neuropsychological assesment- reveals patchy cognitive impairment.
Hx of stroke, O/E, cerbral imaging.
Define demetia with Lewy bodies
Characterised by Lewy bodies( aggregates of protein within nerve cells) in cerebrum.
Overlap with PD, cz pts experiencing parkinsonian motor features.
What can Lewy bodies dementia be mimicked with?
Delirium
Cz the main feature is fluctuating cognitive impairment with visual hallucinations.
10% of dementias
3d commonest cause of dementia.
Other causes of dementia
Huntingtons disease Wilsons disease 1/3 of PD Advanced MS And may be a feature of HIV/AIDS Long Hx of chronic alcohol abuse- alcohol related dementia.
Invx
🔶Largely clinical
Extensive invg not required, apart from exclusion.
Young or atypical presentation :
🔹Vit B12
🔸syphils
🔹thyroid function
🔸calcium & glucose
🔹Cerebral Imaging (CT or MRI) to exclude a space- occupying lesion or hydrocephalus, –> indicating cerebral atrophy in dementia. (Diagnostic? Maybe ischaemic changes in vascular dementia)
🔹Neuropsychology assesment to document the pattern of cognitive impairment.
EEG
Lumbarpuncture: evidence of raised intracranial pressure in inflammation, infx.
Mx of dementia
Largely supportive
Cholinestarease inhibitors - rivastigmine and galantamine, modestly deruce cognitive deterioration in Alzheimers D.
Tx of vascular RFs in vascular dementia reduces progssion.
Mostly, long term care required.
Whats huntigtons,
Progressive neurodegenerative disease inherited in an autosomal dominent fashion.(50%) of kid to get it. Present :30-50s
Wilsons
Rare autosomal recessive disorder of copper metabolism
Accumulation of Cu in liver, brain esp basal ganglia.
Cu deposits rings in cornea.
Define Dementia
Aquired global ( impairamanet)neuroprogressive deterioration of intellect, behaviour & personality Sufficient severity to interaupt ocupational & social function. Often associated with deterioration in emotional control, social control & motivation.
Whats pre-senile dementia?
65Y
Degenerative Causes of dementia
Alzheimers,
Lewy body
Fronto-temporal dementia.
Vascular causes of dementia & what percentage do they occupy?
& metabolic causes?
25%
Cerebrovascular disease
Cranial arteritis
Metabolic: uraemia, liver failure.
Traumatic causes of dementia
& other.
Post-head injury
Punch-drunk (boxers)
Other: Alcohol/drug abuse Vit B12 & thiamine deficiency Subdural haemoatoma Cardiac arrest Resp failure, CO poisoning, encephalitis e.g. Werinckes in cirrhosis.. (Thats why liver F) CJD, HIV/AIDS, syphillis, hypothyroidism (T4 levels) Hypocalcaemia, Huntingtons, PD.
Signs & symptoms of Alzheimers
No stx Hx. AD- impaired abilit to learn or recall new info, ⬇️ language funtion, diff w/ names & understanding whats being said.–> nominal & comprehensive dysphasia
Agnosia- F to recognise objects.
Dysbraxia
Behavioural changes- aggression, wandering,agitation, delusions, impairment at planning.
What are the SS of vascular dementia?
Multi- infractions usually. Distinguish from Hx from Alzheimers, CFs & cause. Hx of TIA w/ brief impairment of consciousness, pareses, visual loss.
Dementia may follow succession of acute CV events, or single major stroke.
Vawcular occlusions = Vascular dementia.m
SS of Lewy bodies
Neuronal, inclusion bodies (markers of neural loss)
Similar to delerium (acute deterioration of mental state usually underlined by physical illness)
Confusion, tension, hallucinations.
Falls: common symptom.
How do you diagnose dementia?
Based on Hx & examination
Esp cognitive testing- Mini Mental State test.
Can be confirmed by psychometric testing.
Hx must also be taken from someone that has known the patient for a long time.
What could be a differential diagnosis to dementia?
Pseudo-dementia (Depressive disorder, prev Hx of depression for FHx of mood disorder) Anxiety disorders (GAD, phobias, stess) Mania Depression
How would you investigate Dementia?
Exclude 2o causes: FBC- anaemic? ESR/CRP, U&Es, baseline, renal F? Glucose- hypoglycaemic? Confused? LFTs-- cirrhosis? Werinkes encephalopathy. Serum Ca Vit B12 Folate TFTs (T4 levels) Syphillis serology HIV antibodies. Radiology: CXR, CT/MRI to confirm cortical atrophy & exclude tumours etc. EEG- Lewy bodies identified.
How would you treat dementia?
DONEPEZIL ACh-ase Inhibitor NICE/ mild- moderate Alzheimers. NSAIDs & HRT are prebpventative of developing Alzheimers. Treat reversible cause. GPs especially- care management plan. Neuropsych referral.
What happens in delirium?
Toxic confusional state
Acute or subacute condition
1. Impaired of consciousness 4. FLUCTUATES
2. Abn in perception + 3. Mood
Conf 🌙✨ Worse at night.
-/+ hallucinations, delusions, restelness + aggression.
Infx + drugs Commonest
What are some causes of delirium?
Systemic infection
Drugs
Drug/alcohol withdrawal
Metabolic disturbance - Hepatic failure, renal F, Electrolyte imbalance, hypoxia, Hypoglycaemia, Vitamin B12 + B1( Weeinkes-Korsakoff syndrome)
Brain damage- tumours, trauma, SAH, abscess,
What drugs can cause delirium?
TCA
Benzodiazepines
Opiates
Anticonvulsants
How do we treat delirium?
Invx + tx of underlying disease. 1. Withdraw drugs possible 2. Rehydrate 3. Pain relief 4. Sedation if aggressive or for management Quiet area.
Benzos usually given.
Severe delirium though: haloperidol 2.5mg -5mg IM.
Is consciousness affected in Dementia?
Who is affectd?
No
10% 80s
What are the clinical features of Alzheimers?
1o degenerative cerebral disease CFs: Steady progression over years 1. Short memory loss prominent 2. Slow disibtegration of personality and intelelct
Whats dementia?
Progressive decline of cognitive function ie loss of mind,
Cerebral cortex, all or patches.
Patho features of Alzheimers?
- Neuronal reduction in several areas
- Neurofibrillary tangles
- Argentophile plaques–> amyloid-b + granulovacuolar bodies
Investigations of Alzheimers?
Simple mental state assesment: abbreviated Hodgkinsons one (10)
Age, time, year, address recall, place, recognition of 2 ppl(dr, nurse)
DOB, 1st world war, name of present president, count backwards 20
Healthy >8
Exclude other causes of dementia ie vascular, Huntingtons, lewy bodies
Bloods: LFTs (HepF), TFTs(hypo), FBC, vitB12, folate.
Imaging: CT in young presenile.
Mx of Alzheimers?
Anxiety + depression need tx.
- Impaired cortical cholinergic fx due to reduced cerebral production of choline acetyl transferase +
- ⬇️ in acetylcholine synthesis.
Acetyl cholinesterase inhibitors ⬆️ cholinergic submission by inhibitting cholinesterase at the synaptic cleft.
Modest benefit
1. Intellectual deterioration is slower in MILD-MODERATE
2. Community managed ! Home care, day care, –> eventually care home
What are some examples of Acetyl cholinesterase inhibitors?
Donepezil
Rivastigmine
Galantamine
Prognosis of dementia?
8-10years
What happens in vascular D?
Multi infract.
Stepwise deterioration with declines followed by periods of stability.
Hx of TIAs, stroke, HTN, CVs rfs, smoker?
What should not be used in Lewy body dementia?
Neuroepileptic drugs
What characterises Lewy body dementia?
Fluctuating cognition + pronounced variation in attention + alertness .
⭐️ prominent or persistent memory loss may NOT happen at the early stages.
Prominent: impairment in attention, visuospacial ability,
Visual hallucinations : strange faces, frightening creatures Common
⭐️Parkinsonism: slowing, rigidity w/ repeated falls.
Delusions + transient loss of consciousness occur.
Autopsy: cortical Lewy bodies
Could be confused with delirium.
Some causes of Dementia
Alzh
Vasc D
Xs alcohol- Werinkes -Korsakoff syndrome- Vit B1
Hypothyroidism
Intracranial mass: subdural haematoma, hydrocephalus
Chronic traumatic encephalopathy: punch drunkeness
Syphillis
Huntingtons
Creutzfeld-Jakob disease
Late Parkinsons
