Dementia

Question 1

You see a patient in GP who you suspect could have dementia. How would you screen?

Answer 1

Take a history

Do a short cognitive assessment: mini-mental state examination, Addenbrooke’s

Physical examination

Routine bloods

CXR and ECG if indicated

Question 2

What are the types of dementia?

Answer 2

Alzheimer’s
Vascular
Lewy body
Fronto-temporal

Organic dementias

Question 3

Clinical features of dementia?

Answer 3

Cognitive impairment:

• memory
• language
• attention
• problem solving

Behavioural:

• personality change
• emotionally labile
• poor social skills

Psych:

• depression
• hallucinations + delusions

Struggle with ADLs

Memory loss for recent events

Question 4

List some ADLs?

Answer 4

Driving
Shopping
Cooking + eating
Dressing + washing

Question 5

What’s the difference between subcortical and cortical?

Answer 5

Cortical: higher areas of brain, grey matter, the lobes

Subcortical: white matter, the basal ganglia etc.

Question 6

Pathophysiology of Alzheimer’s?

Answer 6

Degeneration of cerebral cortex, cortical atrophy, neurofibrillary tangles and amyloid plaques

Increased glutamate production which excites neuron so much it dies.

Reduced Ach and dopamine production

Question 7

What distinguishes Alzheimer’s from other dementias?

Answer 7

Insidious onset and decline

No effect on consciousness

Question 8

What are 4 signs of cognitive function decline?

Answer 8

The 4 As

Amnesia
Apraxia
Agnosia (can’t process sensory info)
Aphasia (receptive and expressive)

Question 9

What distinguishes Vascular dementia from other dementias?

Answer 9

Step-wise deterioration
Acute-ish onset

Fewer mood problems

There may be focal neurological deficit (facial palsy for eg.)

Also have hypertension, hypercholesterol, peripheral vascular disease

Question 10

Pathophysiology of vascular dementia?

Answer 10

Cerebrovascular disease and ischemic or haemorrhagic brain injury resulting in cognitive impairment

Often many mild events

Question 11

What distinguishes Fronto-temporal dementia from other dementias?

Answer 11

Personality change is forefront

Disinhibition

Memory problems come later than in other dementias

Younger age of onset

Semantic dementia associated with it

Question 12

What’s semantic dementia?

Answer 12

When they lose understanding and meanings of words, phrases, pictures etc.

Question 13

What distinguishes Lewy body dementia from other dementias?

Answer 13

They get hallucinations

Fluctuations of alertness

Mood changes

Links with Parkinsons

Question 14

Pathophysiology of fronto-temporal dementia?

Answer 14

As with alzheimers but only affects the frontal lobe

Cortical atrophy, neurofibrillary tangles, amyloid plaques etc.

Question 15

Pathophysiology of Lewy body dementia?

Answer 15

Lewy bodies deposited in higher cortex (lobes)

Causing damage and loss of function

Question 16

What’s the connection between Parkinson’s and LB dementia?

Answer 16

Both caused by Lewy body deposition.

Parkinson’s: in the substantia nigra, so movement problems

LB dementia: in the cortical part (lobes) so memory and cognitive problems

Question 17

What are the organic causes of dementia?

Answer 17

Parkinson’s

Huntingtons

CJD

Normal pressure hydrocephalus

Question 18

Management of dementia?

Answer 18

Holistic approach

Psychological work with patient and carers

Social support: housing, finances, care, safety

Drugs: Ach inhibitors, NMDA antagonists

Question 19

How do these drugs help in dementia? What type of drug are they?

• Donepezil
• Memantine

Answer 19

Donepezil is an Acetyl choline esterase inhibitor, which prevents break down of Ach in the brain

Memantine is a NMDA antagonist, blocks the NMDA receptor which means less glutamate can bind. Glutamate can damage nerves.

Question 20

What’s the difference between delirium and dementia?

Answer 20

1. Delirium acute onset, dementia insidious
2. Delirium fluctuating course, dementia progressive
3. Delirium lasts for hours to weeks, dementia for months to years
4. Delirium consciousness is affected, dementia it isn’t usually
5. Delirium hallucinations and delusions are common, dementia less so
6. Delirium is reversible, dementia isn’t

Question 21

What types of delirium are there? Briefly describe.

Answer 21

Hyperactive: agitated, upset
Hypoactive: drowsy, withdrawn
Mixed

Delirium tremens: alcohol withdrawal

Question 22

Clinical features of delirium.

Answer 22

Cognitive:

• poor concentration
• confusion
• disorientation

Perception:

• hallucinations
• delusions

Physical:

• restlessness
• changes in appetite
• reversal of sleep-wake cycle
• tremor

Social:

• withdrawn
• mood changes
• lack of co-operation

Question 23

Management of delirium?

Answer 23

Keep patient settled, give them a clock, remind them where they are, etc.

Try to avoid sedation but if can’t give:

• haloperidol
• olanzapine

Question 24

Which sedatives are best not to give in delirium?

Answer 24

Benzos, they worsen delirium except if its delirium tremens

Question 25

Management of Lewy body dementia?

Answer 25

1st line: achesterase inhibitors

2nd line: Memantine or atypical anti-psychotic

Question 26

Which atypical anti-psychotics can you use in dementia?

Answer 26

Quetiapine, clozapine