Dementia Flashcards
Define mild cognitive impairment
- Focal cognitive impairment
- Not severe enough to interfere with daily life and function
What is dementia?
A syndrome characterised by:
- Progressive global cognitive deficits
- Compared to baseline
- Significant impairment of normal functioning
- Definite Dx: symptoms lasting 6+ months
- Tentative Dx: symptoms lasting less than 6 months
What is included in the routine dementia screen?
- TFTs
- Vit B12; folate
- FBC; ESR; CRP: anaemia and vasculitis
- LFTs; U+Es
- Glucose
- CT head
- Neurosyphilis test
What are the cognitive deficits seen in dementia?
- Memory impairment
- Impaired executive function
- Dysphagia
- Agnosia
- Apraxia (loss of motor function)
- Personality disintegration
What is executive function?
A set of cognitive processes that enable planning, organisation, and completion of tasks.
e.g. Problem solving, abstraction, reasoning, decision making, judgement, planning, organisation, processing
Name four risk factors for Dementia
- Older age
- Mild cognitive impairment
- Intellectual difficulties
- Genetics; FHx of young-onset dementia
- CVD risk factors; stroke
- Parkinson’s disease
- Depression; Alcohol abuse
- Low educational attainment; low social engagement/support
Name four protective factors for Dementia
- Diet: Vitamin E and C
- Exercise
- Mental and social activity
- More complex work ➔ reduced hippocampal atrophy
What are the common causes of dementia?
- Alzheimer’s disease (50-60%)
- Vascular dementia (20-25%)
- Mixed dementia
- Lewy body dementia (10-15%)
- Frontal-temporal dementia (7%)
- Other e.g. CJD, AIDS dementia, Alcohol dementia (3%)
List three behavioural and psychological symptoms of dementia (BPSD)
- Psychosis: delusions and/or hallucinations
- Agitation; emotional lability
- Depression; anxiety
- Withdrawal; apathy
- Disinhibition: social or sexually inappropriate behaviour
- Motor disturbance: wandering; restlessness
- Sleep cycle disturbance; insomnia
- Echolalia (tendency to repeat phrases or questions)
What differential diagnoses must be excluded for a diagnosis of dementia?
- Delirium
- Depression
Name three reversible causes of dementia
- Subdural haematoma
- Normal pressure hydrocephalus
- Chronic alcohol misuse
- Metabolic
- Vitamin B12 deficiency
- Hypothyroidism
- Hypoglycaemia
- Neurosyphilis
What is the characteristic of fronto-temporal cortical dementia?
Prominent personality change
May manifest as frontal lobe syndrome: damage of higher functioning processes eg. motivation, planning, behaviour
What is Alzheimer’s disease?
- Commonest form of dementia
- Degenerative disease of the brain
- Prominent cognitive and behavioural impairment.
- Significantly interferes with social and occupational function
List three risk factors for Alzheimer’s disease
- Increasing age
- FHx of AD or early-onset AD
- Down’s syndrome
- FHx of Down’s syndrome
- Previous head injury
- Hypothyroidism
- Parkinson’s disease
What is the association between Alzheimer’s disease and Down’s syndrome
Chromosome 21:
- AD: gene for amyloid precursor protein ➔ amyloid plaques
- DS: Down’s syndrome have an extra Chromosome 21 ➔ accelerated production of amyloid plaques ➔ earlier dementia
What are the three symptomatic domains of Alzheimer’s disease?
- Cognitive
- Functional: ADLs
- Neuropsychiatric
- Mood/affect disturbances
- Aggression
- Anxiety
- Psychosis
- Sleep disturbances
Describe the memory problems in Alzheimer’s disease
- Early impairment of immediate and short-term memory
- Due to atrophy of the hippocampus.
- Long-term (remote) memory declines with progression
- Common to also have disorientation of time and place
List three early symptoms of Alzheimer’s disease
- Impaired immediate and short-term memory
- Disorientation of time and place
- Muddled efficacy with ADLs
- Spatial dysfunction
- Behavioural: Wandering, irritability
List three middle symptoms of Alzheimer’s disease
- Intellectual and personality deterioration
- Aphasia
- Apraxia
- Agnosia (inability to process sensory information)
- Impaired executive function
- Impaired visuospatial skills: getting lost, impaired driving
List three late symptoms of Alzheimer’s disease
- Fully dependent
- Physical deterioration
- Incontinence
- Gait abnormalities
- Spasticity Seizures (3%)
- Tremors
- Extrapyramidal signs
How does early-onset Alzheimer’s disease differ from typical AD?
- More aphasia and apraxia
- Rapid course with severe intellectual decline
- Poor survival rate
Request four investigations for Alzheimer’s disease
- Cognitive testing: Clock drawing test, MMSE
- FBC
- TFTs
- Haematinics: B12; folate
- Neurosyphilis screen
- LFT, U+Es, TSH, HIV
-
CT head:
- Cortical atrophy esp in medial temporal lobes (hippocampus), ventricular enlargement
Outline the management of Alzheimer’s disease
- Promoting cognition, independence and wellbeing:
- Group cognitive stimulation therapy
- Cognitive rehabilitation; occupational therapy
- Medication:
- AChEi: donepezil; galantamine; rivastigmine
- Memantine
What are the indications for Memantine?
- Moderate Alzheimer’s disease
- AChEi contraindicated or not tolerated
- Severe Alzheimer’s disease
Name three risk factors for Vascular dementia
- Male
- PMH or FHx of cardiovascular disease
- CV risk: smoking, diabetes, HTN, hyperlipidaemia
List three characteristics suggestive of Vascular dementia
- Sudden onset
- Stepwise deterioration
- Cardiovascular risk factors
How can the presentation of vascular dementia be categorised?
- Cognitive deficits following a single stroke
- Deficits depend on site of infarct
- Multi-infarct dementia
- Stepwise deterioration in cognitive function
- Relative stability between strokes
- Binwangers disease: progressive small-vessel disease
- Gradual intellectual decline
- Generalised slowing
- Motor problems
List four presenting features of Vascular dementia
- Acute onset; may follow a stroke
- Early:
- Emotional and personality changes
- Cognitive deficits - fluctuate
- Behavioural slowing and anxiety
- Depression with affective lability and confusion, esp at night
- Physical signs of arteriovascular disease
- Neurological impairment
Outline the management of Vascular dementia
-
Manage modifiable risk factors:
- Diet; exercise
- Smoking cessation; reduce alcohol intake
- Medication:
- Aspirin
- Clopidogrel
- Statins
- ACEi
- Anti-hyperglycaemics if needed
When may a CXR be indicated when investigating dementia?
Indication of malignancy, esp of small-cell lung cancer
Paraneoplastic syndromes resembling neurological deficits in dementia
Name one infectious cause of reversible dementia
- HIV
- Syphilis
- TB
- Meningitis
Outline pathophysiology of Lewy body dementia
Accumulation of Lewy bodies (alpha-synuclein and ubiquitin) in the cerebrum and substantia nigra.
Name two characteristic clinical features of Lewy body dementia
- Fluctuating cognitive impairment
- Spontaneous parkinsonism
- Vivid visual hallucinations
- Additional: REM sleep disturbance - treated with clonazepam
Why should antipsychotics be avoided in Lewy body dementia?
Antipsychotics can:
- Precipitate irreversible parkinsonism
- Preceipitate autonomic dysregulation
- similar to neuroleptic malignant syndrome
- Reduce consciousness
- Increases mortality rates (2-3x)
Differentiate dementia from delirium
Delirium has altered consciousness and attention
Dementia:
- Gradual onset (months to years); progressive
- Normal consciousness; late perceptional disturbances
- Normal sleep-wake cycle
Delirium:
- Acute onset (hours to weeks); fluctuating course
- Impaired consciousness; perceptional disturbances often
- Disrupted sleep-wake cycle.
