Dementia

Question 0

Prevalence of dementia

Answer 0

Differs with age group
65-74 --> 1%
75-84 --> 3%
85+ --> 10%
Total prevalence the same for men and women

Question 1

Dementia is

Answer 1

Gradual impairment of multiple cognitive abilities, particularly memory, language and judgement
First signs –> memory loss and personality change
Then –> problem solving and language

Question 2

Alzheimer’s disease (AD)

Answer 2

Memory impairment with one or more:
 - aphasia, apraxia, agnosia, executive dysfunction
Onset in 60-70s
Definite diagnosis is made post-mortem
Most common form of dementia

Question 3

Post-mortem signs of AD

Answer 3

Generalised atrophy with flattened sulci and enlarged ventricles
Pathognomic signs –>Neurofibrillary tangles, Senile plaques, neuronal and synaptic loss
Extent of these changes relates to severity

Question 4

Genetics of AD

Answer 4

Certain genes predispose to late onset and certain for early onset –> preseniliin 1 (chr 14) and 2 (chr 1)
Beta-amyloid gene is on the long arm of chr 21, so Down’s syndrome people suffer severe early onset
Autosomal dominant dementia is very rare, very early onset

Question 5

Risk factors for AD

Answer 5

Risk factors –> age, female, apolipoprotein e4, head injury, declining oestrogen, FH, Down’s syndrome.
Protective factors –> apolipoprotein e2, smoking possibly, NSAIDs, oestrogen, premorbid intelligence and higher education

Question 6

Symptoms of AD

Answer 6

STM lost first then LTM
Disorientation, and expressive and receptive dysphasia.
Lacking insight, possibly with agitation and aggression
Disruption of motor/visual performance and executive function
Agnosia to body parts and sensory stimulation

Question 7

Brain changes in AD

Answer 7

Reduction in Ach transmission, NA and neuropeptides.
CT will show structural abnormalities in parietal and temporal lobes.
MRI will show reduced grey matter in hippocampus, amygdala and temporal lobe.

Question 8

Behavioural changes in AD

Answer 8

Wondering is the major problem and aggression.
Sexual disinhibition, incontience and excessive eating.
Searching behaviour.
If rapid decline can develop psychotic symptoms.

Question 9

Treatments of dementia and AD

Answer 9

Ach agonists - of limited use, improve cognitive functioning temporarily
Can use NMDA Inhibitors
Psychological treatments

Question 10

Ach agonists in AD

Answer 10

Donepezil
Rivastigmine
Galantamine

Question 11

Psychological treatments of AD/dementia

Answer 11

memory wallet
memory skills training
Functional training –> eg using navigational cues to avoid getting lost

Question 12

Psychosis in AD

Answer 12

30-50% prevalence, if severe poverty of thought/affect.
Visual hallucinations –> lilipution
Auditory hallucinations –> often pseudo-hallucinations
Delusions are most common–> persecutory,poorly organised.
Also Capras/fregoli syndromes, Phantom boarder/Mirror signs

Question 13

Mirror signs are

Answer 13

Psychotic mis-identification of your reflection as another person, and the idea that mirrors represent another reality which can be entered.
Similar delusions can occur when watching tv or reading a magazine, believing that the images present reality

Question 14

Capras and fregoli syndromes

Answer 14

Capras syndrome is where the patient believes that one or more important people in their life has been replaced by a exact doppelgänger
Fregoli’s syndrome is where several people the patient meets are actually the same person in disguise

Question 15

Epidemiology of VD

Answer 15

Second most common type of dementia
6x less common than AD
Risk factors are vascular risk factors

Question 16

Vascular dementia (VD) is

Answer 16

Dementia due to cerebrovascular events causing a sidewise reduction in isolated areas of functioning.
May be after a single stroke, Multi-infarct or small vessel disease
May show focal symptoms depending on stroke location
Insight is maintained but personality may change if frontal lobes effected

Question 17

Multi-infarct dementia

Answer 17

Shows a gradual progression as infarcts may be silent

Question 18

Small vessel VD

Answer 18

Preserves grey matter

Damages central white matter

Question 19

VD is diagnosed by

Answer 19

Haschinski score
score above 7 indicates VD
less than four excludes VD

Question 21

Dementia of Lewy bodies

Answer 21

15-25% of dementia
Average 50-83yrs
Fluctuating alertness and at risk of falls and faints (autonomic dysfunction)
Parkinsonian symptoms and fine tremor. STM spared
Complex Visual hallucination
adverse reaction/hypersensitivity to antipsychotics

Question 21

Dementia from prion diseases

Answer 21

Myoclonic jerks
Seizures and cerebellar ataxia
Psychiatric symptoms
Early onset and rapid progression. 
Mainly CJD, vCJD or kuru

Question 22

Fronto-temporal dementia (Pick’s disease)

Answer 22

Prominent behavioural change (aggressive, sexually disinhibited/socially inappropriate, poor planning) from collateral history.
Expressive aphasia, early loss of insight
Occurs in younger people (45-65yrs) - preferential frontal atrophy
25% of dementia - mostly sporadic

Question 23

Normal pressure hydrocephalus

Answer 23

Mental slowing, apathy and Inattention.
Urinary incontience with gait disturbance.
Commonest in young women with vascular symptoms.
Commonest reversible dementia.

Question 25

General pharmacological treatments of dementia

Answer 25

For Behavioural and psychological symptoms you can use benzos or citalopram.
Careful with anti-psychotics as they have a high stroke risk
If you must use low dose queitiapine.

Question 26

Subtypes of Fronto-temporal dementia

Answer 26

Radiological - bifrontal but asymmetric (right sided is more common)
Clinical – dis-inhibited - right orbitofrontal and anterior temporal pathology
Apathetic - extensive frontal pathology
Stereotypic - marked striatal and variable cortical changes

Question 27

Features of fronto-temporal dementia

Answer 27

Starts with social/personal conduct decline and reduced emotionality/insight.
Also: personal neglect, mental rigidity, distractibility, hyper-orality/overeating, perservation and stereotypic behaviour. Can get utilisation behaviour and executive dysfunction.
Psychotic symptoms are rare

Question 28

Supplements in dementia

Answer 28

Gingo biloba
Vitamin E
Folic Acid
Omega 3 fatty acids