Dementia Flashcards
What is a synonym for “Dementia”?
Major neurocognitive disorder
Diagnostic criteria for dementia (4)
- Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains both subjectively and objectively reported
- Deficits interfere with independent functioning
- No delirium
- No other more probable diagnosis
Name the cognitive domains (6)
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
Name 6 instrumental activities of daily living
- Dressing
- Eating
- Ambulating
- Toileting
- Hygiene
- Showering
Name 7 activities of daily living
- Shopping
- Housework
- Accounting
- Food preparation
- Telephone
- Transportation
- Taking medication
Differential diagnosis for Memory loss
- Major neurocognitive disorder
- Mild neurocognitive disorder
- Delirium
- Depression
- Stoke/TIA
- Seizure
Physical exam for patient with memory loss
- Neurological exam
- Gait assessment
- Extrapyramidal symptoms assessment
- Parkinson’s symptoms (cogwheeling, rigidity, tremors)
Investigations
- Memory testing
- Depression screening
- HGB
- WBC
- Glucose
- Creatinine
- Calcium
- TSH
- B 12
- Syphilis
- CT Head
Name one investigation to do before initiating pharmacotherapy for dementia
EKG
Indications for CT head
< 60 yo Abrupt, rapid decline Focal neurological symptoms Urinary incontinence Gait disorder Previous malignancy Trauma Anticoagulants or history of bleeding disorder If presence of cerebrovascular disease would change management
List four memory testing tools
MMSE
MOCA
Mini-cog (Clock drawing and 3 word recall)
Hopkins Verbal learning test
MMSE score for diagnosis of major neurocognitive disorder
<24/30
MoCA Interpretation
27-30 Normal
18-26 Mild impairment
10-17 Moderate impairment
<10 Severe impairment
MMSE Interpretation
26 to 30 Normal 20 To 25 Mild cognitive impairment 10 to 18 moderate cognitive impairment 3 to 9 severe cognitive impairment Less than 3 very severe cognitive impairment
Name possible causes of delirium
Infection Medications Thyroid dysregulation Sodium dysregulation Glucose abnormalities Vitamin B 12 deficiency Pain
Name possible medication causes of Delirium
Polypharmacy Opioids Cholinergic and anticholinergic Benzodiazepines Antidepressants Antipsychotics Steroids
Name 6 types of dementia
Alzheimer’s disease Vascular dementia Mixed Alzheimer’s and vascular dementia Lewy body dementia Frontotemporal dementia Parkingson’s disease with dementia
Which is the most common type of dementia?
Alzheimer’s disease accounts for 50% of dementia
Is the onset of Alzheimer’s disease gradual or abrupt?
Gradual onset
What is the initial and most prominent deficit in Alzheimer’s disease?
Amnestic impairment: impairment in learning and recall of recently learned information
Describe the evolution of vascular dementia
Abrupt onset with stepwise deterioration
Which type of risk factors are associated with vascular dementia?
Cardiovascular risk factors (Smoking, hypertension, dyslipidemia, previous myocardial infarction, previous strokes, documented TIAs, strong family history)
True or false. Impairment of executive function is associated with Alzheimer’s disease than with vascular dementia.
False: impairment of executive function is more related to vascular dementia.
If patient presents with history of memory loss and focal neurological features, which type of dementia do you suspect?
Vascular dementia
What are the main features of frontotemporal dementia?
Behavioural problems such as disinhibition and loss of social awareness
Language impairment
How do you differentiate between Louis body dementia and Parkinson disease with dementia?
In Lewy body dementia, dementia occurs at the same time as parkinsonian signs or dementia occurs before parkinsonian signs.
In Parkinson disease, dementia occurs more than one year after the appearance of parkinsonian signs.
A patient with Parkinson disease can develop dementia with what type of impairments?
Impaired executive function and visual-spatial function
What are the core features of Lewy body dementia? (4)
Fluctuating cognition
Detailed visual hallucinations
REM sleep behaviour disorder
Parkinsonism
Name five parkinsonian signs
Bradykinesia Tremor Rigidity Postural instability Shuffling gait Masked faeces Micrographia Dystonia
What are the major components of management in dementia?
Lifestyle management Pharmacotherapy Management of Behavioural and psychological symptoms of dementia Referral Genetic testing Driving assessment Caregiver assessment
When do you refer in dementia?
Rapidly progressive dementia
Young patient
Frontotemporal, Lewy body or Parkinson dementia
When do you suspect it genetic causes for Alzheimer’s disease?
In patients with early onset disease and a Mendelian pattern of transmission
Which proportion of the general population above 55 years old happy first-degree relative with dementia?
25%
What is the lifetime risk of dementia in the general population?
10%
What is the lifetime risk of dementia in those with a family history?
20%
How do you assess for unsafe driving?
Memory testing with MMSE of 24 or less Self restricted driving Family concerns Multiple tickets Accidents Aggressive or impulsive behaviour History of feeling lost on the road
Which tool can you use to assess risk of driving?
Clinical dementia rating scale
Patient with dementia presents with severe agitation and violent behavior. What are the possible underlying causes?
Physical: Pain, constipation, infection
Environmental: set routines, sounds and lights, position, daytime activities
Psychiatric conditions: depression
Medications
Name some environmental interventions for behavioural and psychological symptoms of dementia
Relaxation techniques
Social contact
Sensory interventions such as music and aromatherapy
Increased services and care
Which medications can be considered for behavioural and psychological symptoms of dementia?
Newer anti-psychotics
Risperidone, olanzapine, Seroquel
What are the possible adverse outcomes of the use of antipsychotics in the geriatric patient with dementia?
Increased risk of death CVA EPS Falls Somnolence Weight gain Diabetes
Name three acetylcholine esterase inhibitors
Donepezil
Rivastigmine
Galantamine
In which patients do you consider treatment with Donepezil?
In patient with mild to moderate Alzheimer’s disease
What are the possible adverse effects of Acetylcholine esterase inhibitors?
G.I.: nausea, diarrhoea, vomiting
Cardiac: bradycardia, hypotension, dizziness, syncope
Sleep: insomnia
QT prolongation and torsades de point
What is the class and generic name for a medication used in severe Alzheimer’s disease?
Memantine, NMDA receptor antagonist
Which medications can be used to manage frontotemporal dementia?
SSRI: Paroxetine or trazodone
True or false. There is evidence for the use of acetylcholine esterase inhibitors in frontotemporal dementia and vascular dementia.
False
How do you manage vascular dementia differently?
Manage hypertension, diabetes, smoking, dyslipidaemia
What is the risk of using antipsychotics and Lewy body dementia?
It may cause neuroleptic malignant syndrome
When can you consider using an acetylcholinesterase inhibitor?
Alzheimer’s disease
Lewy body dementia
Parkinson disease with dementia
Name five lifestyle management points that you should bring up with patients and their families when dealing with dementia
Creating a will, power of attorney, personal directives
Safety issues at home and on the road
Healthy diet
Smoking cessation
Exercise program
Eliminating medications
Alternative therapies such as aromatherapy, multi sensory stimulation, music therapy, animal assisted therapy, massage therapy
Name community resources to which you can refer the patient with dementia and their family
The Alzheimer Society
Occupational therapy
Social services
Home care services
How often should you follow up with a patient with mild neurocognitive disorder?
Follow up every 3 to 6 months.
Define mild neurocognitive disorder
Decline reported by patient informant or clinician with an objective findings of deficits in one or more domain typically memory, with preserved function
What is the risk of conversion of mild neurocognitive disorder into Alzheimer’s disease on a yearly basis?
15% of patients with mild neurocognitive disorder will convert into Alzheimer’s disease every year
What is severe neuroleptic sensitivity?
Increased risk of neuroleptic malignant syndrome seen in patients with Lewy body dementia
What are the features of neuroleptic malignant syndrome?
Parkinsonism Drowsiness Falls Hyperthermia Autonomic instability
A patient presents with fluctuating cognition and newly onset parkinsonism as well as postural instability and hypersomnia. What is the most likely cause of his dementia?
Lewy Body dementia
A patient with dementia presents with autonomic dysfunction and depression. What is the most likely cause of his dementia?
Lewy body dementia
A patient with dementia presents with worsening function, what should you do?
Do not assume the dementia is worsening.
Look for other possible causes such as depression, infection or medications.
How do you disclose the diagnosis of dementia?
Disclose the diagnosis of dementia compassionately, and respect the patients right autonomy, confidentiality, and safety.
In patients with dementia assess ________, in order to see whether they can make their own decisions or not.
Competency
In patients with dementia, how do you follow up?
Assess function and cognition on an ongoing basis
