Dementia:

Question 1

You suspect a patient may have a form of dementia - what may you use to assess their cognitive state?

Answer 1

• GPCOG
• Mini-mental state examination (MMSE)
• Six-item Cognitive Impairment Test (6CIT)

(dont use AMT score - too short/not effective enough)

Question 2

What 3 reversible causes may present as Dementia?

Answer 2

• Normal pressure hydrocephalus
• Tumour (meningioma)
• Subdural haematoma

Question 3

What would you seen on MRI in someone with Alzheimers?

Answer 3

Atrophy, in:

• Hippocampus
• Amygdala
• Temporal neocortex
• Subcortical nuclei

Question 4

What medication class would you use to manage Alzheimers? Give and example of 2 drugs in this class:

Answer 4

Acetylcholinesterase inhibitors.

E.g. Donepezil, rivastigmine

Question 5

What would you see on biopsy in someone with Alzheimers?

Answer 5

• Beta-amyloid plaques
• Neurofibrillary tangles
• Loss of acetycholine neuronal damage

Question 6

In someone with Lewy Body dementia, what would you see on MRI?

Answer 6

Lewy bodies in brainstem and neocortex

Question 7

What is a prominent feature in Lewy Body dementia which usually isn’t present in other forms?

Answer 7

Visual hallucinations

Question 8

What pharmaceutical management could be used in Lewy body dementia?

Answer 8

• Antipsychotics

- Acetylcholinesterase inhibitors (e.g. Donepezil, rivastigmine)

Question 9

Why should antipsychotics be used with caution in those with Lewy Body dementia?

Answer 9

Increase risk of:

• Parkinsonism
• Neuroleptic malignant syndrome

Question 10

What would you see on biopsy of someone with Lewy Body dementia?

Answer 10

In brainstem and neocortical nuclei:

• Eosinophilic intracytoplasmic neuronal inclusions
• Ubiquitin and alpha-synuclein
• Neuronal loss

Question 11

What is Lewy body dementia associated with?

Answer 11

Parkinsonism

Question 12

What features are commonly present in Lewy body dementia?

Answer 12

• Poor sleep
• Fluctuations from day to day in symptoms
• Visual hallucinations

Question 13

What features are present in Alzheimers?

Answer 13

Global impairment:
- Visuo-spatial skill
- Memory
- Verbal abilities
- Executive function
Later:
- Irritability
- Psychosis

Question 14

What criteria is used to define Vascular dementia?

Answer 14

NINDS-AIREN criteria

Question 15

What is the progression of vascular dementia like?

Answer 15

Step-wise - due to cerebrovascular events.

Question 16

What might you see on MRI in someone with vascular dementia?

Answer 16

(cerebrovascular disease)

• Lacunar infarcts
• White matter lesions

Question 17

What features are typically present in vascular dementia?

Answer 17

• Focal neuro features
• Seizures
• Depression/anxiety
• Disturbance in gait (early)
• Bladder symptoms

Question 18

What management is useful in those with vascular dementia?

Answer 18

• Addressing CV risk factors

- Cognitive stimulation

Question 19

What is Fronto-temporal dementia also know as?

Answer 19

Picks dementia

Question 20

What can be seen of MRI in those with fronto-temporal dementia?

Answer 20

Fronto- temporal atrophy.

No plaque formation.

Question 21

What features are present in the presentation of fronto-temporal dementia?

Answer 21

• Behavioural changes
• Non-fluent aphasia
• Emotional blunting

Question 22

What is the management in those with fronto-temporal dementia?

Answer 22

SSRI - behavioural symptoms

Atypical antipsychotic

Speech therapy

Question 23

Outline the common causes of delirium:

Answer 23

(PICHME - as in ‘I think I’m delirious - PINCH ME’)

P - Pain
I - Infection
N - Nutrition
C - Constipation
H - Hydration

M - Medication
E - Environment

Question 24

What investigations would you perform in someone with delirium?

Answer 24

• ABCDE
• AMT score (abbreviated mental test)
• Search for cause of delirium….

Question 25

What AMT score would you be concerned over?

Answer 25

Less than or equal to 6.

Question 26

What is the difference between dementia and delirium?

Answer 26

Dementia:

• Onset = gradual (months)
• Course = progressively worse
• LOC = Alert
• Thoughts = Reduced
• Hallucinations = sometimes

Delirium:

• Onset = Acute (hours/days)
• Course= fluctuant
• LOC= Impaired
• Thoughts = Complicated and vivid
• Hallucinations = very common - visual

Question 27

How does one assess capacity in someone?

Answer 27

1) Understand the information
2) Retain the information
3) Weight up benefits and risks (of receiving care)
4) Communicate a decision

( It is TIME and DECISION specific)

Question 28

What are the main principles of the mental capacity act?

Answer 28

1) Presumed to have capacity
2) Steps taken to help you make decision
3) An unwise decision does not mean you lack capacity
4) Decisions must be in your best interest
5) Decisions and actions must be as least restrictive as possible

Question 29

If someone lacks capacity, how is decision making done?

Answer 29

1) Consider family options (Lasting Power of Attorney)
2) Any Advanced Directives made?
3) If no family: Consider Independent Mental Capacity Advocate (IMCA) and the persons best interests
4) If time is critical, act in the persons best interest

Question 30

What is a Independent Mental Capacity Advocate (IMCA)?

Answer 30

Legal safeguard for people who lack the capacity to make specific important decisions. Represent someone when there is no such family member or friend.