Dementia

Question 1

What is dementia?

Answer 1

A syndrome of acquired global impairment of higher cerebral function

Question 2

How common is dementia?

Answer 2

5% of >65yrs

20% of >80yrs

Question 3

What are the diagnostic criteria for dementia?

Answer 3

Evidence of impairment of memory + >1 of:
   -language impairment
   -apraxia
   -agnosia
   -impairment of executive functioning
Impairment of functioning
No other medical/psychiatric explanation
Present for >6mo

Question 4

What is mild cognitive impairment?

Answer 4

Evidence of early memory decline on formal memory tests w/o clinical evidence of other features of dementia

Question 5

What are the three main phases of dementia?

Answer 5

Early phase
Middle phase
Late phase

Question 6

What are the features of the early phase of dementia?

Answer 6

Short term memory loss
Difficulty embracing change
Repetition of qs
Minor behavioural changes
Lasts 3-4yrs

Question 7

What are the features of the middle phase of dementia?

Answer 7

Difficulty w/ daily tasks
Need frequent prompting
Failure to recognise people
Hallucinations
Increasing support required for daily life

Question 8

What are the features of the late phase of dementia?

Answer 8

Incontinence
Aggression
Wt loss
Occurs in last 1-2yrs of life

Question 9

What frontal lobe sx can be present in dementia?

Answer 9

Personality change (dulling of personality, social withdrawal, disinhibition)
Difficulties w/ reasoning/abstract thought
Difficulty initiating actions

Question 10

What temporal lobe sx can be present in dementia?

Answer 10

Difficulty w/ short term memory
Difficulty holding attention on tasks
Poor speech production

Question 11

What parietal lobe sx can be present in dementia?

Answer 11

Problems recognising faces/objects (Agnosia)
Difficulty carrying out sequence of actions
Clumsiness

Question 12

What are the causes of dementia?

Answer 12

Degenerative
Vascular
Trauma
Malignancy
Hydrostatic
Toxic
Endocrine
Metabolic
Infective
Psychiatric

Question 13

What are the degenerative causes of dementia?

Answer 13

Alzheimer's disease
Frontotemporal dementia
Lewy Body dementia
Parkinson's disease
Huntington's disease

Question 14

What are the vascular causes of dementia?

Answer 14

Multi-infarct dementia
Cerebral infarcts
Binswanger’s disease
Systemic vasculitis

Question 15

What are the traumatic causes of dementia?

Answer 15

Major head injuries

Repetitive minor trauma

Question 16

What are the malignant causes of dementia?

Answer 16

1o/2o neoplasm

Question 17

What are the hydrostatic causes of dementia?

Answer 17

Hydrocephalus
Normal-pressure hydrocephalus
Intracranial haematomas

Question 18

What are the toxic causes of dementia?

Answer 18

Alcohol-related
Heavy metal poisoning (Wilson’s)
Drug related

Question 19

What are the endocrine causes of dementia?

Answer 19

Hypothyroidism

Question 20

What are the metabolic causes of dementia?

Answer 20

B1/B12/Folate deficiencies

Uraemia/liver failure

Question 21

What are the infective causes of dementia?

Answer 21

3o syphilis
HIV
Creutzfeld-Jakob disease
Cryptococcus

Question 22

What are the psychiatric causes of dementia?

Answer 22

Depressive pseudodementia

Question 23

What are the common causes of dementia?

Answer 23

Alzheimer's (62%)
Vascular (17%)
Mixed AD/vascular (10%)
Lewy Body (4%)
Frontotemporal (2%)
Parkinson's (2%)

Question 24

What investigations are appropriate in suspected dementia?

Answer 24

MMSE/MOCA (insensitive to frontal-executive dysfunction/visuo-spatial deficits)
Bloods (FBC, U&Es, LFTs, ESR, Ca, TFTs, glucose, lipids)
CT/MRI head
ECG

Question 25

How can MMSE scores be used to assess severity of disease?

Answer 25

``` >27 - normal 21-26 - mild dementia 14-20 - moderate dementia 10-13 - moderate/sev dementia <10 - sev dementia ```

Question 26

What is the cause of Alzheimer's Disease (AD)?

Answer 26

Protein plaques/tangles in cortical areas causing cell death

Question 27

How does AD present?

Answer 27

Progressive loss of ability to learn/retain/process new information In later stages behavioural changes develop

Question 28

What are the subtypes of Vascular Dementia (VD)?

Answer 28

Post-stroke dementia -develops in 25% of stroke sufferers w/i 1yr Cortical vascular dementia -multiple small infarcts in cerebral cortex Subcortical vascular dementia -affects subcortical areas only, associated w/ HTN -if widespread known as Binswanger's

Question 29

How does VD present?

Answer 29

Similar to AD but - stepwise progression of disease - personal/family hx OR sx/signs of vascular disease - early gait disturbance w/ unsteadiness/falls

Question 30

What is required for the diagnosis of VD?

Answer 30

Radiological evidence of cerebrovascular disease

Question 31

What is the cause of Lewy Body Dementia (LBD)?

Answer 31

Formation of 'Lewy Bodies' in basal ganglia/cortex

Question 32

How does LBD present?

Answer 32

Progressive cognitive decline AND - visual hallucinations - fluctuating cognition - features of parkinsonism

Question 33

What are the supportive features of an LBD diagnosis?

Answer 33

Falls/syncope Sensitivity to neuroleptics REM sleep behaviour disturbance

Question 34

How does Parkinson's disease dementia present?

Answer 34

Around 30% of pts w/ PD Classic PD w/ initial unilateral sx for a few years followed by decline in cognitive function -if early bilateral signs think LBD

Question 35

How does FTD present?

Answer 35

``` In early stages cognition remains intact Behavioural changes (blunting, loss of inhibition, decline in personal hygiene, hyperorality) Language difficulties (echolalia, complete aphasia) Early loss of insight, primitive reflexes present ```

Question 36

What is the cause of Creutzfedlt-Jakob (CJ) disease?

Answer 36

``` Prion disease (mad cow disease) Inheritable forms ```

Question 37

How does CJ disease present?

Answer 37

In middle age w/ dementia Visual disturbance UMN signs in limbs EEG diagnostic

Question 38

What is the cause of Huntington's disease?

Answer 38

Autosomal dominant inheritance of Huntington's gene | Anticipation

Question 39

How does Huntington's present?

Answer 39

Progressive dementia | Chorea

Question 40

What is Delirium?

Answer 40

Change in cognition developing over a short period of time, typified by disturbance of attention/arousal

Question 41

What are the features of Delirium?

Answer 41

Change in cognition, acute confusional state Tendency for sx to fluctuate w/ sleep-wake cycle Evidence that delirium is a direct consequence of -medical condition -drug withdrawal -intoxication

Question 42

What are the three main types of delirium?

Answer 42

Hypoactive (40%) Hyperactive (25%) Mixed (35%)

Question 43

What are the features of hypoactive delirium?

Answer 43

Apathy Withdrawal Lethargy Reduced motor activity

Question 44

What are the features of hyperactive delirium?

Answer 44

Increased motor activity Agitation Hallucinations Challenging behaviour

Question 45

What are the features of mixed delirium?

Answer 45

Mixed picture w/ fluctuation throughout day

Question 46

What is the management of delirium?

Answer 46

Identify/treat underlying cause Non-pharmacological - promote orientation, maintain hydration/nutrition, 1:1 nursing Pharmacological - control pain, avoid sedation Prevent complications Pt/relative explanations

Question 47

What are the common complications of delirium?

Answer 47

Pressure ulcers Falls Incontinence Nosocomial infections

Question 48

What is the prognosis of delirium?

Answer 48

1/3 get completely better 1/3 get a little better 1/3 stay the same/get worse

Question 49

What is the management of dementia?

Answer 49

``` MDT care, assess social needs, OT/physio Reduce vascular risk Cognitive stimulation therapy Mild-mod AD/LBD -AChE inhibitors (donezepil, galantamine, rivastigmine) Severe AD/LBD -NMDA antagonists (memantin) Manage BPSDs ```