Dementia

Question 1

Dementia - definition

Answer 1

A syndrome caused by brain disorders causing memory loss, reduced cognition and difficulties with ADLs

Question 2

Dementia: General symptoms - 3 categories with examples

Answer 2

Behavioural/personality
- Mood, hallucinations, restless, rigid routines

Cognitive impairment
- Speech impairment, thinking slow/muddled, poor memory (with confabulation)

Difficulties with ADLs
-driving, eating, shopping, dressing

Question 3

Dementia: Epidemiology Qs

1) how many people affected in UK?
2) how many deaths attributable to dementia/year in UK?
3a) %prevalence at age 65-69@?
3b) %prevalence at age 95+?

Answer 3

1) 800,000
2) 60,000
3a) 1.5%
3b) 25%

Question 4

Name 4 main causes of dementia

Answer 4

Alzheimers (50%)
Vascular (50%)
Dementia with Lewy bodies (15%)
Frontotemporal dementia (5%)

Mixed dementia common

Question 5

Causes continued: name the reversible causes of dementia

Answer 5

Substance misuse (MCV, folate, B12)
Hypothyroidism (TSH, T4)
Space occupying intracranial lesion (CT/MRI)
Normal pressure hydrocephalus
Syphilis (serology)
Vitamin b12/folate/b3 (pellagra) deficiency

Question 6

Alzheimer’s disease - pathophysiology (1/3)

Answer 6

1) Cerebral cortex atrophy
2) Neurofibrillary tangles and amyloid plaques
3) Decreased ACh production from affected neurons

Amyloid Precursor protein - normally repairs neurons and is effectively broken down. When badly broken down - the reminenants accumulate into B plaques. These cause Tau (on microtubules) to accumulate - which are tangles. Affected neurons are bad at neurotransmission

Question 7

Alzheimer’s disease - the 4 A’s (2/3)

Answer 7

Amnesia - memory probs
Agnosia - inability to interpret sensations and hence to recognize things
Aphasia - speech probs
Aprexia - motor probs

Question 8

Alzheimer’s disease - pharmacological management (3/3)

Answer 8

Acetylcholinesterase inhibitors
- Donepezil, galantamine, rivastigmine

2nd line - Memantine

Question 9

Vascular dementia - pathophysiology (1/2)

Answer 9

Cerebrovascular damage - big stroke or mini strokes, or chronic changes in small vessels

Question 10

Vascular dementia - how might it seem different to other types? (2/2)

Answer 10

Visual, sensory, motor problems, seizures
MRI will look different

QRISK

Question 11

Dementia with Lewy bodies

Overview

Answer 11

Lewy bodies in brainstem/neocortex
Mild parkinsonian signs, faints
FLUCTUATING attention/concentration

Question 12

Frontotemporal dementia

Answer 12

Specific degeneration of frontal/temporal lobes in lobar fashion, rather than diffuse as in AD

Question 13

Dementia: making a diagnosis

Answer 13

Clinical - collateral history important
Mini mental state examination or equivalent

Tests of exclusion
Bloods - FBC. B12, folate, B3, (MCV), ESR, U&Es, LFTs, GGT, Ca, TSH, syphilis serology,
CT/MRI

Question 14

Management of Dementia

Answer 14

Carers - needs assessments
Practical stuff - routines, leaving notes/reminders
CBT for depression etc
* be careful with antidepressants which interfere with ACh

Question 15

Can you drive with dementia?

Answer 15

DVLA must be informed of diagnosis.

Won’t be able to drive buses, but cars may be okay

Question 16

Mild cognitive impairment (MCI)

What?

Answer 16

Decreased cognitive function, greater than expected for age.

Often a pre-dementia state.

Question 17

Mr C. is a 56 yr old teacher who has been admitted to the Medical Assessment Unit after a large overdose of paracetamol
He believes that the Ebola crisis is all his fault. He went to Africa last year on holiday and thinks that he may have passed on a cold he had which then mutated into Ebola and spread locally.
He is absolutely convinced by this, so much so that he has tried to kill himself
He has been under a lot of stress at work and has been feeling low. He has been unable to concentrate at work, he forgets important things, he is not sleeping well and he has lost a lot of weight. At times he does not feel real.
He was signed off sick with stress by his GP, last week and felt bad about missing work. He was watching TV last week and made the connection with his visit to Africa. He has felt very guilty about this and made the decision to end his life, believing that this may cure all those afflicted.

Answer 17

This is manic depression.
= Severe depression with psychotic symptoms.

The other type of severe depression is

severe depression without psychotic symptoms (:

Question 18

Alzheimers dementia - early/late onset differences

Is early onset caused by a dominant or recessive gene?

Answer 18

Sporadic/late onset - 90-95% cases
Caused by genes which are bad at copping up plaques

Familial/early onset - 5-10%
Caused by dominant genes

Question 19

Alzheimer dementia - progression of symptoms

Answer 19

Short term memory problems
loss of motor skills
language problems
long term memory problems (forget significant people)
disorientated
bedridden
death usually due to infection (pneumonia)

Question 20

Lewy body dementia

what happens in the early phase?

Answer 20

Misfolded proteins accumulate and cause the cell to die

Cognitive symptoms come first

• focus problems
• memory problems
• visual hallucinations
• speech problems
• depression

Question 21

Lewy body dementia - late phase symptoms

Answer 21

Motor symptoms are late

resting tremor
stiff/slow movements
facial expression changes

a bit like parkinsons - lewy bodys accumulate in substantia nigra

sleep disorders also occur

Question 22

Delirium - causes

Answer 22

Acute infections
Prescribed drugs (benzo's, morphine, steroids etc)
Post-operative
Vascular disorder
Metabolic causes
vitamin causes 
endocrine cause
trauma, epilepsy, neoplastic syndrome
urinary retention/faecal impaction

Question 23

Symptoms of hyperactive delirium

Answer 23

agitated
aggressive
incoherent
disorganised thoughts
delusions (things that havent happened/or long time ago)
hallucinations
disorientation

Question 24

Hypoactive symptoms of delirium

Answer 24

sluggish, drowsy
less reactive
looks withdrawn