Dementia Flashcards
What are the likely presenting features of dementia?
Chronic confusion
Personality change
Amnesia
What neurological-functions are affected in dementia and which ones are NOT affected?
Affected - memory, ability to learn new info, judgement and thinking, processing information, emotional behaviour and social control, motivation
Not affected - Consciousness
How long do symptoms have to have persisted for before a diagnosis of dementia is given?
6 months or longer
What are some different types of dementia?
Alzheimer's disease Lewy body dementia Vascular dementia Parkinsonian dementia HIV dementia Fronto-temporal dementia
What are some differentials for dementia?
DEMENTIA Drugs/delirium Emotional / depression Metabolic disorders Eye and ear disorders Nutritional disorders Trauma, toxins and tumours Infections Alcohol, atherosclerosis
What neurotransmitter is lacking in AD and how does this shape the theory of treatment?
Acetycholine
First line pharmacological management is acetylcholinesterase inhibitors
What are some examples of first line drug treatment options in AD?
Rivastigmine, Neostigmine and Donepezil
In some severe cases of AD an additional drug is used, what is it?
Memantine
What are first line drug treatments in DLB?
Rivastigmine and Donepezil
Should anti-psychotics be given to patients with dementia?
They can sometimes be given but only if the patient is at risk of hurting themselves and/or is experiencing, BPSDs or symptoms of hallucinations/delusions and agitation
Give at low dose ask review every 6 weeks
What scans are recommended in vascular dementia?
MRI
What is the most common cause of dementia and what is the difference between early and late onset?
Alzheimer’s disease
Early onset <65
Late onset >65
What is the organic, neurological pathology in Alzheimer’s disease?
Deposition of Beta-Amyloid plaques
Implications of ApoE4 gene (involved in cholesterol metabolism)
Reduction in amount of Ach - due to reduction in number of cholinergic neurones at nucleus basalis
T21 at greater risk
3x greater risk with FH
What findings will be found upon imaging the brain?
Cerebral atrophy Plaque formation Senile plaques Neurofibrillary tangles Ach depletion
***REVIEW IMAGES
What tests can be used to formally assess cognition in possible AD?
MoCA or Adenbrooks (ACE-III)
What are the clinical features of AD?
THE 5 As: Aphasia Amnesia Agnosia Apraxia - loss of motor function Associated behaviours (BPSDs)
What are some examples of BPSDs in dementia?
Physical aggression, wandering, agitation, restless, screaming, crying, cursing
*it’s these symptoms which usually mean people end up in care
Using the bio-psycho-social model how should AD be managed?
BIO - Rivastigmine add in memantine if not working. Consider a/ps if considerable BPSDs
PSYCHO - Supportive therapy, reminiscence therapy, cognitive rehab, treatment for comorbid conditions
SOCIAL - Carer support, OT input and social care interventions
What are the risks associated with prescribing a/ps for BPSDs in elderly people?
Higher risk of stroke and cardiovascular disease
High risk of Parkinsonian effects
Higher risk of falls
Some of the symptoms of dementia can be acutely exacerbated by organic disease, what are some causes?
PINCH ME P - pain I - Infection N - Nutritional depletion C - Constipation H - Hydration M - Medication E - Environment
What is the characteristic disease pattern in vascular dementia?
STEPWISE DETERIORATION with every vascular event
Vascular dementia can arise from a single cortical infarct or as a sum of multiple smaller infarcts
What are some risk factors for vascular dementia?
All the same as for vascular disease:
HTN, High cholesterol, diabetes, smoking, obese
***link of a dominant gene on chromosome 19
What investigations should be done in a patient with suspected vascular dementia?
FBC, U&E, Ca, Glucose, TFTs
CT head
ECG
UTI - rule out delirium
What is the management of vascular dementia?
BIO - treat reversible causes and consider anti-coagulation
PSYCHO - Emotional support, cognitive rehab and treatment for comorbid psych conditions (CBT for anxiety)
SOCIAL - carer support, OT input and social care interventions
What management is NOT given in vascular dementia?
ACH-ESTERASE INHIBITORS
However the NMDA antagonist Memantine does seem to have some beneficial effect
What is the second most common dementia in people under the age of 65 in the UK?
Fronto-Temporal dementia
What are some different sub-types of FTD?
Behavioural variant
Progressive, non-fluent aphasia
Semantic
What investigations should be done in a patient with suspected FTD?
Fluency assessment (word and categorical design)
Abstract thinking and metaphor interpretation
Sorting tasks (wisconsin sorting)
Stroop test (word orange is written in blue and have to say colour not word)
Hand position test
Copying task
Rhythm tapping task
Trail making tests
Cognitive assessment
What would you see on an MRI scan of a patient with FTD?
Atrophy of the frontal and temporal lobes
What are the three different histological types of FTD?
Microvaculoar (60%)
Pick’s type (25%)
Combined (15%)
How should we treat FTDs?
Do NOT give Ach-esterase inhibs
SSRIs have shown some use
Treat symptoms
What is different about some of the features of DLB?
There is FLUCTUATING COGNITION
A lot of people (70%) will experience PARKINSONIAN symptoms
Approx 70% will also experience VISUAL HALLUCINATIONS
What are some other, less common, features of DLB?
Disorder in REM High neuroleptic sensitivity Changes in PET scan Systematised delusions Depressive episodes Recurrent falls, syncope and LOC
What should be done to treat DLB?
Treating the parkinsonism symptoms with L-DOPA is NOT effective and often appears to make things worse
ACh-esterase inhibitors appear to work and Rivastigmine often used
Psychological interventions VITAL
Treatment often not very effective
