Dementia Flashcards
Is dementia a diagnosis or a clinical syndrome
syndrome
Most common type of dementia
55% Alzheimers
2nd most common type of dementia
25% vascular (can be mixed w alzheimers)
3rd most common type of dementia
Lewy body 10%
Prevalence of lewy body dementia?
5%
Prevalence of dementia at 90y
25%
Diagnostic criteria of dementia (3)
Multiple cognitive defecits
Resulting impairment in ADLs
Clear consciousness
Do pts with dementia normally have insight?
No often
Can pts with dementia get psychotic symptoms? If so which ones?
Yes
persecutory delusions (made worse by forgetfulness)
visual and auditory hallucinations
What are BPSDs?
Behavioural and psychological symptoms of dementia
What should you include in an assessment of susp. dementia (1st presentation)?
- ask about concerns, cognitive, behav and psych symptoms
- Risk factors, co-morbidities and drugs
- Discuss possibility of dementia
- Assess cognition
- Assess daily functioning
- Exacerbating factors for BPSD
- Examination
- Investigations
Which co-morbidities are especially relevant in an assessment of susp. dementia (1st presentation)?
Stroke
Epilepsy
Depression
Which risk factors are there in an assessment of susp. dementia (1st presentation)?
FHx
Learning disabilities
Stroke
Parkinsons
Which drugs are relevant in an assessment of susp. dementia (1st presentation)?
Benzos
Anticholinergics
Analgesics
Examples of cognitive symptoms to ask about in an assessment of susp. dementia (1st presentation)?
memory
concentration
Language
Orientation
Examples of behavioural sx to ask in an assessment of susp. dementia (1st presentation)?
aggression
wandering
restless
inappropriate behaviour
Examples of psych sx to ask in an assessment of susp. dementia (1st presentation)?
hallucinations
delusions
mood
What should you include when you discuss the possibility of dementia in an assessment of susp. dementia (1st presentation)?
advise more detailed assessment
Ask if they’d like to know the diagnosis
Who they would want to involve
How do you assess cognition in an assessment of susp. dementia (1st presentation)?
MMSE (accounting for e.g. education level, language, sensory deficits, previous functioning)
What do you assess in daily functioning in an assessment of susp. dementia (1st presentation)?
Personal care, managing finances, taking drug treatments
Safety and home and outside
Social functioning and support
Driving
What are exacerbating factors for BPSD in an assessment of susp. dementia (1st presentation)?
Co-morbs and acute illness (pain, infection, constipation, dehydration, anaemia, delirium)
Underlying psych
Sensory- visual and hearing
Drug SEs
Able to communicate verbally
Carer- emotional upset? Able to communicate w pt?
Environment- change, routine, over or under stimulated?
what examinations do you do in an assessment of susp. dementia (1st presentation)?
Neuro for FND
Gait and balance
Cardio- HTN, arrhyth…
Wt loss
Visual and auditory
Other acute illness
Investigations in an assessment of susp. dementia (1st presentation)?
Bloods: FBC, ESR, Ca, U&Es, LFTs, HbA1c, TFTs, B12 and folate
If indicated- MSU, CXR, ECG, syphilis screen, HIV
What are the 5 As of alzheimers?
amnesia
agnosia
aphasia
apraxia
associated BPSD
Key feature of Alzheimers?
Gradual onset with memory loss
Macroscopic changes seen in Alzheimers?
Cortical atrophy
Enlarged ventricles
Microscopic changes seen in Alzheimers?
Neurofibrillary tangles
Amyloid plaques (beta)
Decreased Acetylcholine
Describe the amyloid cascade hypothesis for Alzheimers
APP gene –>
amyloid precursor protein –>
Aβ protein plaques are cleaved off APP by secretase enzyme (which is coded for by presenelin 1 and 2 genes), these aggregate –>
toxicity, inflammation, oxidative stress, tau dysfunction and neurofibrin tangle formation–>
leads to neuronal death and dysfunction
What are three genes whose mutations are implicated in familial (early onset) Alzheimers?
APP gene
Presenelin 1
Presenelin 2
What are the three varients of the APO gene?
E2, E3, E4
Which APO gene increases risk of Alzheimers?
APO E4
Are there neurotransmitter changes seen in Alzheimers? Which ones? What does this lead to?
Yes- defecit of ACh, serotonin, noradrenaline and somatostatin- this leads to the loss of the cell bodies of neurones that secrete them.
What are two pharmacological management options in Alzheimers
Acetylcholinesterase inhibitors- compensate for the loss of acetylcholine- this can arrest and temporarily reverse cognitive decline and may improve behaviour
Memantine in moderate to severe- glutamate antagonist- prevents excitatory neurotoxicity
What is the progression of vascular dementia like?
Stepwise pattern of FND
Difference between vascular and Alzheimers dementia?
Vascular more ‘patchy’ cognitive impairment and stepwise.
Many people have mixed ______ and vascular dementia
Alzheimers
Vascular dementia has at least one area of __________ _________
Cortical infarction
Following a stroke, the risk of dementia is increased by ???
9 times
Vascular risk factors apply to both _____ and ______ dementia
Vascular and alzheimers
What are the vascular risk factors?
Smoking, DM, HTN, high cholesterol
What can you do as well as controlling vascular risk factors to try reduce the risk of further stroke related deterioration in VD?
low dose aspirin
How does Lewy Body dementia present? (4)
Fluctuating cognition and alertness
Vivid visual hallucinations
Spontaneous parkinsonism
Sleep disorder
Can you give antipsychotics to LBD?
No- severe reaction
What is a pharmacological treatment option for LBD?
AChEi
What is the microscopic changes found in LBD?
lewy bodies and neurites in basal ganglia and cerebral cortex
Often also Alzheimer’s-like changes
Parkinson’s disease dementia is similar to what type? When can it be diagnosed?
Lewy body
If the parkinson’s preceded the dementia by >1y
what % people with parkinson’s develop dementia?
25% (and if they survive 20y, 80%)
Frontotemporal dementia has a younger or older mean age of onset?
Younger
Features of FTD?
Early personality changes
Relative intellectual sparing- memory problems tend to come later
Which lobes are affected in FTD?
frontal
anterior temporal
What is the pathology of FTD?
It varies… tend to have ubiquitin or tau positive inclusions
Diagnostic criteria for alcohol related dementia
Aren’t any.
Difficult to distinguish from other types, especially Alz. May occur in combination.
Features of alcohol related dementia
Global deterioration in intellectual function
Some have frontal lobe damage- disinhibition, worse planning and executive function
Korsakoff’s features- memory changes.
Generally somewhere on a spectrum between global dementia and Korsakoff’s psychosis.
Can have psychosis, depression, anxiety, apathy, personality changes
May also get peripheral neuropathy and cerebellar ataxia.
Can alcohol related dementia be treated?
Yes if early enough- stop alcohol and replace vitamins (esp thiamine)
Onset and severity of alcohol related dementia directly linked to _____
amount of alcohol consumed
Onset of alcohol related dementia can be as early as ___ but is normally ___–____
30
50-70
Why does damage occur in alcohol related dementia?
Alcohol is a neurotoxin
Or because of malnutrition- thiamine defic.
What are other forms of dementia?
Repeated head trauma
Subdural haematoma
SAH/head inj/meningitis –> normal pressure hydrocephalus
Huntington’s Chorea
MND
Infection (HIV, syphilis, prion)
Metabolic (rare) (hyperparathyroid and hypothyroid)
MND dementia is always what type?
Fronto-temporal
Which dementias can have pharmacological treatment? Which treatments?
AChEi in Alzheimers and Lewy body
Memantine in Alzheimers
Aspirin in vascular
What is it important to rule out in dementia?
Reversible causes (these could be superimposed)
Psycho management of dementia?
Cognitive stimulation e.g. group activities
Teach carers techniques for behavioural management
Social management of dementia
Home care
Day centres
Intermittent respite
Residential/nursing care
What do people with dementia often die of ?
Bronchopneumonia
How is the life expectancy of someone with dementia altered?
Reduced even accounting for physical health
Is vascular dementia prognosis worse or better than alzheimers?
worse- progression less consistent and vulnerable to cardiac and stroke related death
What are 4 reasons for cognitive impairment without dementia?
mild cognitive impairment
Subjective cognitive impairment
Severe depression in old age
Slowly progressive acute confusional state
What is mild cognitive impairment?
Deterioration in cognition insufficient to meet dementia criteria. About 15%–> dementia within a year. 50% within 3 years
What is subjective cognitive impairment?
Report cognitive impairment e.g. remembering names, but perform within normal ranges on psychometric tests for age and education
How do MCI and SCI link?
MCI often preceded by 15y of SCI
What proportion of the population report being forgetful?
1/3
Severe depression in old age can present as____? Features?
pseudodementia- prominent forgetfulness and poor self care
what are slowly progressive acute confusional states?
May present with a dementia-like picture e.g. subdural haematoma, myxoedema, vitamin deficiencies.
Does a diagnosis of dementia stop you from driving?
Must inform the DVLA. Doesn’t in itself stop you, but must do so when unsafe. Can do an assessment with DVLA if you want. The Alzheimer’s society website has v good advice. Most people stop within about 3y
