Dementia Flashcards
What is dementia?
A syndrome of acquired global impairment of higher cerebral function
How common is dementia?
5% of >65yrs
20% of >80yrs
What are the diagnostic criteria for dementia?
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
What is mild cognitive impairment?
Evidence of early memory decline on formal memory tests w/o clinical evidence of other features of dementia
What are the three main phases of dementia?
Early phase
Middle phase
Late phase
What are the features of the early phase of dementia?
Short term memory loss Difficulty embracing change Repetition of qs Minor behavioural changes Lasts 3-4yrs
What are the features of the middle phase of dementia?
Difficulty w/ daily tasks Need frequent prompting Failure to recognise people Hallucinations Increasing support required for daily life
What are the features of the late phase of dementia?
Incontinence
Aggression
Wt loss
Occurs in last 1-2yrs of life
What frontal lobe sx can be present in dementia?
Personality change (dulling of personality, social withdrawal, disinhibition)
Difficulties w/ reasoning/abstract thought
Difficulty initiating actions
What temporal lobe sx can be present in dementia?
Difficulty w/ short term memory
Difficulty holding attention on tasks
Poor speech production
What parietal lobe sx can be present in dementia?
Problems recognising faces/objects (Agnosia)
Difficulty carrying out sequence of actions
Clumsiness
What are the causes of dementia?
Degenerative Vascular Trauma Malignancy Hydrostatic Toxic Endocrine Metabolic Infective Psychiatric
What are the degenerative causes of dementia?
Alzheimer's disease Frontotemporal dementia Lewy Body dementia Parkinson's disease Huntington's disease
What are the vascular causes of dementia?
Multi-infarct dementia
Cerebral infarcts
Binswanger’s disease
Systemic vasculitis
What are the traumatic causes of dementia?
Major head injuries
Repetitive minor trauma
What are the malignant causes of dementia?
1o/2o neoplasm
What are the hydrostatic causes of dementia?
Hydrocephalus
Normal-pressure hydrocephalus
Intracranial haematomas
What are the toxic causes of dementia?
Alcohol-related
Heavy metal poisoning (Wilson’s)
Drug related
What are the endocrine causes of dementia?
Hypothyroidism
What are the metabolic causes of dementia?
B1/B12/Folate deficiencies
Uraemia/liver failure
What are the infective causes of dementia?
3o syphilis
HIV
Creutzfeld-Jakob disease
Cryptococcus
What are the psychiatric causes of dementia?
Depressive pseudodementia
What are the common causes of dementia?
Alzheimer's (62%) Vascular (17%) Mixed AD/vascular (10%) Lewy Body (4%) Frontotemporal (2%) Parkinson's (2%)
What investigations are appropriate in suspected dementia?
MMSE/MOCA (insensitive to frontal-executive dysfunction/visuo-spatial deficits)
Bloods (FBC, U&Es, LFTs, ESR, Ca, TFTs, glucose, lipids)
CT/MRI head
ECG
How can MMSE scores be used to assess severity of disease?
>27 - normal 21-26 - mild dementia 14-20 - moderate dementia 10-13 - moderate/sev dementia <10 - sev dementia
What is the cause of Alzheimer’s Disease (AD)?
Protein plaques/tangles in cortical areas causing cell death
How does AD present?
Progressive loss of ability to learn/retain/process new information
In later stages behavioural changes develop
What are the subtypes of Vascular Dementia (VD)?
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
How does VD present?
Similar to AD but
- stepwise progression of disease
- personal/family hx OR sx/signs of vascular disease
- early gait disturbance w/ unsteadiness/falls
What is required for the diagnosis of VD?
Radiological evidence of cerebrovascular disease
What is the cause of Lewy Body Dementia (LBD)?
Formation of ‘Lewy Bodies’ in basal ganglia/cortex
How does LBD present?
Progressive cognitive decline AND
- visual hallucinations
- fluctuating cognition
- features of parkinsonism
What are the supportive features of an LBD diagnosis?
Falls/syncope
Sensitivity to neuroleptics
REM sleep behaviour disturbance
How does Parkinson’s disease dementia present?
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
How does FTD present?
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
What is the cause of Creutzfedlt-Jakob (CJ) disease?
Prion disease (mad cow disease) Inheritable forms
How does CJ disease present?
In middle age w/ dementia
Visual disturbance
UMN signs in limbs
EEG diagnostic
What is the cause of Huntington’s disease?
Autosomal dominant inheritance of Huntington’s gene
Anticipation
How does Huntington’s present?
Progressive dementia
Chorea
What is Delirium?
Change in cognition developing over a short period of time, typified by disturbance of attention/arousal
What are the features of Delirium?
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
What are the three main types of delirium?
Hypoactive (40%)
Hyperactive (25%)
Mixed (35%)
What are the features of hypoactive delirium?
Apathy
Withdrawal
Lethargy
Reduced motor activity
What are the features of hyperactive delirium?
Increased motor activity
Agitation
Hallucinations
Challenging behaviour
What are the features of mixed delirium?
Mixed picture w/ fluctuation throughout day
What is the management of delirium?
Identify/treat underlying cause
Non-pharmacological - promote orientation, maintain hydration/nutrition, 1:1 nursing
Pharmacological - control pain, avoid sedation
Prevent complications
Pt/relative explanations
What are the common complications of delirium?
Pressure ulcers
Falls
Incontinence
Nosocomial infections
What is the prognosis of delirium?
1/3 get completely better
1/3 get a little better
1/3 stay the same/get worse
What is the management of dementia?
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
