Dementia Flashcards
Dementia is a syndrome, due to disease of the brain, usually of chronic or progressive nature.
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What is there a disturbance of in dementia?
Higher cortical functions
Name some higher cortical functions which are affected in dementia.
- Memory
- Thinking
- Orientation
- Comprehension
- Calculation
- Learning capacity
- Language
- Judgement
Conscisouness is NOT clouded in dementia
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What is impairment of cognitive function commonly accompanied with in PD?
Deterioration in emotional control, social behaviour or motivation.
Dementia is a syndrome which is characterised by?
Global cognitive decline (not just memory problems)
Except from cognitive decline, what other symptoms might dementia present with?
- Behavioural changes
- Mood disturbance
- Personality changes
- Psychosis
Although the incidence and prevalence of dementia increase with age, dementia itself is not actually caused by ageing
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Is dementia caused by increasing age?
NO
Dementia is not one disease, but ….
A clinical syndrome caused by many different disease processes
What is one of the first areas of the brain to be affected by the neuropathological processes of Alzheimer’s?
The nucleus basalis of Meynert in the basal forebrain.
How can Alzheimers affect cognition?
This disruption of cholinergic transmission
What are the 2 characteristic neuronal changes seen in Alzheimers?
- Amyloid plaques.
* Neurofibrillary tangles.
What are the 2 management options for Alzheimers?
- Cholinesterase inhibitors
* Memantine
How do cholinesterase inhibitors work?
Block the action of acetylcholinesterase, an enzyme that removes ACh from the synapse, improving cholinergic transmission
What do cholinesterase inhibitors do in Alzheimers?
- Improve the symptoms of Alzheimer’s
* Delay further cognitive decline
What do cholinesterase inhibitors not do in Alzheimers?
- Cure it
* Stop it in its tracks
Name 3 cholinesterase inhibitors.
- Donezepil.
- Rivastigmine.
- Galantamine.
What do you need to remember about cholinesterase inhibitors?
These don’t affect the underlying pathological processes in Alzheimer’s disease - so can’t cure
But do slow cognitive decline by increasing cholinergic transmission
What are cholinesterase inhibitors licensed for use in?
Mild to moderate Alzheimer’s disease.
What are cholinesterase inhibitors also useful in?
Vascular dementia
Cholinesterase inhibitors are generally well tolerated in patients.
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List some common side effects of cholinesterase inhibitors.
- GI upset (usually settles after first few weeks)
- Tiredness
- Headache
- Sleep disturbance
- Bradycardia
What is Memantine licensed for use in?
Moderate to severe Alzheimer’s disease
Moderate to severe Alzheimer’s disease …
Memantine
Mild to moderate Alzheimer’s disease …
Cholinesterase inhibitors e.g
- Donezepil.
- Rivastigmine.
- Galantamine.
How does Memantine work?
By blocking NMDA-type glutamate receptors.
What is glutamate?
The main excitatory neurotransmitter in the brain
In Alzheimers, as well as in many other neurodegenerative disorders, what role does glutamate play?
Glutamine over-activation causes neurones to be damaged
Memantine is generally well tolerated by patients.
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List some common side effects of memantine.
- Dizziness
- Confusion
- Agitation
- Sedation
- Headache
- Insomnia
- Hallucinations
What is used to differentiate between Alzheimer’s and vascular dementia?
The Hachinski Ischaemic Score
In the Hachinski Ischaemic Score, what scores are suggestive of i) Alzheimer’s ii) vascular dementia?
i) 4 or less.
ii) 7 or more.
List what points to a vascular dementia as opposed to Alzheimer’s.
- Abrupt onset.
- Fluctuating course.
- Stepwise deterioration.
- Previous stroke
- Focal neuro signs/sx
What are the same, and different in DLB and DPD?
Clinical features are the same, although the neurobiology is different
How is DLB and DPD distinguished?
By the timing of the symptoms
In DLB, cognitive impairment occurs before or around the same time as the movement disorder
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In DPD, movement disorder is present for at least a year prior to the onset of cognitive impairment
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If a patient has movement disorders for 1 year then after the year starts to have some cognitive impairment, what do they have?
DPD
If a patient has cognitive impairment which occurs around the same time as their movement disorder, what do they have?
DLB
Can direct pt to Alzheimer Scotland – an organisation for people in Scotland with Dementia, and their families, friends and carers.
- Website has lots of useful information.
- 24 hour free helpline
OSCE
What essentially is dementia?
An irreversible global decline in cognitive function
What are the 3 categories that symptoms of dementia fall into?
- Cognitive impairment
- Psychiatric
- Behavioural disturbances
Difficulties with activities of daily living.
What is the most common cause of Dementia?
Alzheimers disease
Alzheimers disease accounts for __% of cases of dementia
50%
Pathologically, what is dementia?
A progressive degeneration of the cerebral cortex with …
- Cortical atrophy
- Neurofibrillary tangles
- Amyloid plaque formation
- Reduction in acetylcholine production from affected neurons.
Patients experience irreversible global, progressive impairment of brain function, leading to reduced intellectual ability
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Sporadic cases of Alzheimers are more common
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Familiar cases of Alzheimers are rare
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List some risk factors for Alzheimers.
- Age.
- Caucasian.
- FHx.
- Apolipoprotein E4 variant.
- Head injury.
- Vascular disease, particularly hypercholesterolaemia, hypertension, diabetes.
Apolipoprotein E4 variant can acts as a risk of Alzheimers
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What is the criteria that is POSSIBLE for Alzheimers.
Dementia with an atypical onset or course (ie sudden onset or insufficient documentation of progressive decline)
OR
Aetiologically mixed presentation (ie other criteria fit the diagnosis, but features of other brain disorders or causes of dementia are present).
What is the criteria that is PROBABLE for Alzheimers?
- Dementia established by examination and neuropsychological tests.
- Deficits in 2 or more areas of cognition.
- Insidious onset (months-years); progressive worsening of memory and other cognitive functions.
- No disturbances of consciousness.
- Onset between 40 and 90.
- Absence of systemic disorders or other brain diseases that could account for the sx.
The presentation of Alzheimers is an __________ onset
Insidious
Over how many years does Alzheimers slowly progress
7-10 years
List some early stage symptoms of Alzheimers.
- Memory lapses.
- Forgetting names of people and places.
- Difficulty finding words for things.
- Inability to remember recent events.
- Forgetting appointments.
List some mid-late stage symptoms of Alzheimers.
- Difficulties with language.
- Apraxia (inability to perform particular purposive actions, as a result of brain damage).
- Problems with planning and decision making.
- Confusion.
List some late stage symptoms of Alzheimers disease.
- Wandering, disorientation.
- Apathy.
- Psychiatric problems – depression, hallucinations, delusions.
- Behavioural problems – disinhibition, aggression, agitation.
- Altered eating habits.
- Incontinence.
What 3 Ix’s should be done in someone with suspected Alzheimers?
- Screening for cognitive impairment.
- MRI to exclude other cerebral pathology.
- SPECT scan to differentiate Alzheimer’s from vascular and frontotemporal dementia
What is the management of Alzheimer’s?
1st Line: Acetylcholinesterase inhibitor e.g. donepezil, galantamine or rivastigmine.
- 2nd Line: Memantine
What drugs should be prescribed first in Alzheimers?
- Donapezil
- Galantamine
- Rivastigmine
- Memantime
There us currently no cure and no way to slow progression of Alzheimers
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What is the most common cause of death in someone with Alzheimers?
Infection !!
Infection is the most common cause of death in someone with Alzheimers.
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Vascular dementia accounts for ___% of cases of dementia
25%
Pathologically, what is vascular dementia?
Brain damage due to cerebrovascular disease – either major stroke, multiple smaller unrecognised strokes (multi-infarct) or chronic changes in smaller vessels (subcortical dementia).
Vascular dementia is not a single disease, but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.
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What are the 3 different aetiological types of vascular dementia?
- Stroke related
- Subcortical
- Mixed
What is stroke related vascular dementia?
Incorporates multi-infarct dementia, and single-infarct dementia.
What is mixed vascular dementia?
Changes of both VaD and Alzheimer’s disease are found together
Most cases of vascular dementia are ________ although some cases show familial traits
Sporadic
List some risk factors for vascular dementia.
Basically all just risks CVS risks:
- Previous stroke or TIA
- AF.
- Hypertension.
- Diabetes.
- Hyperlipidaemia.
- Smoking.
- Obesity.
- CHD.
- Family history of stroke of CHD
What is the 2nd most common form of Dementia in the West?
Vascular dementia
Deteriorations may be sudden or gradual, but tend to progress in a stepwise manner in vascular dementia
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List presenting features which may suggest vascular causes of dementia.
- Focal neurological abnormalities.
- Difficulty with attention and concentration.
- Seizures.
- Depression +/- anxiety accompanying the memory disturbance.
- Early presence of disturbance in gait, unsteadiness and frequent, unprovoked falls.
- Bladder sx.
- Emotional problems ie. emotional lability, psychomotor retardation or depression.
Outline the criteria for the diagnosis of PROBABLE vascular dementia.
- Presence of dementia.
- Cerebrovascular disease, defined by the presence of signs on neuro examination and/or by brain imaging.
- A relationship between the above 2 disorders, inferred by:
- Onset of dementia within 3 months following a stroke.
- An abrupt deterioration in cognitive functions.
- Fluctuating, stepwise progression of cognitive disorders.
“Fluctuating, stepwise progression of cognitive disorders” is seen in?
Vascular dementia
The management for vascular dementia is mainly …
- Symptomatic.
* Detecting and addressing CV risk factors
Don’t use antipsychotics in mild-moderate VaD because of increased risk of cerebrovascular adverse events and death
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There are not really any drugs available to treat vascular dementia
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What is the single most important modifiable risk factor for vascular dementia?
HYPERTENSION !!
Vascular dementia is ___________
Preventable
Modifying vascular risk factors in midlife may help prevent stroke and VaD
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What are the 4 main complications of vascular dementia?
- Behavioural problems – wandering, delusions, hallucinations, poor judgement.
- Depression.
- Falls and gait abnormality.
- Aspiration pneumonia.
Is the prognosis of vascular dementia worse than for Alzheimers.
YES
What is the average life expectancy of someone with vascular dementia?
3-5 years
What accounts for 15% of dementia cases?
Dementia with Lewy bodies
Pathologically, what is dementia with lewy bodies?
Deposition of abnormal protein within neurons in the brain stem and neocortex
What does dementia with lewy bodies share characteristic with?
Alzheimer’s and Parkinson’s
How is dementia lewy bodies caused?
Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (Lewy bodies) in the brainstem and neocortex
There is a spectrum of lewy body disorders which may overlap. What are these?
DLB, Parkinson’s disease and Parkinson’s disease-associated dementia
Outline the typical presentation of someone with dementia with lewy bodies.
- Dementia, with memory loss, decline in problem solving ability and spatial awareness difficulties.
- Fluctuating levels of awareness and attention.
- Signs of mild Parkinsonism (tremor, rigidity, poverty of facial expression, festinating gait). Frequent falls.
- Visual hallucinations.
- Sleep disorders: REM sleep disorder, restless legs syndrome, nocturnal cramps.
- Fainting spells.
Outline the criteria for the diagnosis of dementia with lewy bodies.
Presence of dementia + 2/3 of (core features):
- Fluctuating attention and concentration.
- Recurrent well-formed visual hallucinations.
- Spontaneous Parkinsonism.
If there is an absence of 2 core features the diagnosis of probable DLB can also be made if there is dementia along with one core feature and at least one suggestive feature. Suggestive features include …
- REM sleep behaviour disorder
- Severe neuroleptic sensitivity.
- Low dopamine transporter uptake in basal ganglia demonstrated by single photon emission computed tomography (SPECT) or positron emission tomography (PET) imaging (see ‘Investigations’, below).
What should a basic dementia screen include?
- Routine haematology - FBC, ferritin, vitamin B12, folate.
- Biochemistry (including electrolytes, calcium, glucose, and renal and liver
- function).
- TFTs.
- Midstream specimen of urine (MSU).
- CXR and ECG where clinically indicated.
- CT or MRI scan where indicated to exclude other causes of dementia
What will a PET scan of someone with dementia show?
Decreased dopamine transporter uptake
When someone is diagnosed with dementia, what issue should always be discussed?
Driving
DO NOT give antipsychotics to treat psychosis in DLB
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How can dementia with lewy bodies be managed?
No pharmacological methods
- Cognitive stimulation programmes
- Multisensory stimulation
- Art therapy etc
What is the average survival of someone with dementia with lewy bodies?
5-8 years
In dementia with lewy bodies, the rate of cognitive decline is similar too that of?
Alzheimer’s
List the causes of dementia in order from most to least common.
- Alzheimers
- Vascular
- Dementia with lewy bodies
- Frontotemporal dementia
What is the 2nd/3rd most common type of dementia in <65’s?
Frontotemporal dementia
What age group usually gets frontotemporal dementia?
50’s
Frontotemporal dementia has an _________ onset and ________ progression
- Insidious
2. Gradual
What are the 3 main clinical syndromes/types of FTD?
- Behavioural variant FTD.
- Progressive non-fluent aphasia.
- Semantic dementia.
List the symptoms of the behavioural variant of FTD.
- Loss of inhibition.
- Inappropriate social behaviour.
- Loss of motivation but without depression.
- Loss of empathy and sympathy.
- Change in preferences.
- Repetitive or compulsive behaviours, rituals.
- Loss of control over eating or drinking.
- Difficulties with planning, organisation or decision making.
- Memory and visuospatial skills usually preserved in early stages. Cognitive deficit less apparent than behavioural changes.
- Lack of insight.
- Loss of awareness of personal hygiene, and incontinence as the disease progresses.
What are the 2 main symptoms seen in the behavioural variant of FTD?
- Loss of inhibition
* Loss of motivation WITHOUT depression
What would be seen on examination of someone with FTD?
- No neurological signs usually.
- Primitive reflexes in later stages.
- There may be echolalia (repetition of sounds made by another person), perseveration (continued repetition of a particular response) or mutism.
- inappropriate or disinhibited behaviour during consultation.
What are the common early symptoms of semantic dementia (a subtype of FTD)?
- Loss of vocabulary with fluency of speech maintained.
- Asking the meaning of familiar words.
- Difficulty finding right word; having to talk around it or describe it.
- Loss of recognition of familiar faces or objects.
- Memory and visuospatial skills comparatively well preserved.
What are the common early symptoms of progressive non-fluent aphasia?
- Slow, hesitant, difficult speech.
- Grammatical errors in speech.
- Impaired understanding of complex sentences, although recognition of individual words is preserved.
- Loss of literacy skills.
What would exam findings be of someone with progressive non-fluent aphasia?
- Possible impairment of orofacial movements such as swallowing, coughing or yawning on command.
- Stuttering.
What 2 conditions does FTD commonly overlap with?
- Progressive supranuclear palsy.
* Motor Neurone Disease.
What investigations should be done in someone with suspected FTD?
- Dementia screen, including: B12, U+E’s, TFT’s, ESR etc
- Genetic test for Huntington’s
- MRI
- PET
What drugs should be STOPPED in FTD?
Anticholinergics - they may exacerbate memory problems or confusion
What drugs can be used in the management of behavioural problems in FTD?
- SSRI’s
* Atypical antipsychotics
What side effect do you need to be wary of when prescribing someone an atypical antipsychotic?
Extra-pyramidal side effects
What is the average survival of someone with FTD?
8-10 years
What type of FTD has the best prognosis?
Semantic type
