Dementia Flashcards
What is dementia?
Umbrella term used to describe a range of symptoms associated with cognitive impairment.
Describe the syndrome of dementia itself.
- Chronic, acquired global decline in brain functions.
- Usually progressive and irreversible.
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Neuropsychological deficits:
- Amnesia (memory)
- +
- Aphasia (communication)
- Apraxia (motor execution)
- Agnosia (recognition)
- Executive function (synthesis)
- +
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Significant deterioration in activities of daily living (ADLs):
- Instrumental
- Basic
What are the differential diagnoses of dementia-like symptoms?
- Delirium (acute)
- Depression
- Low mood, poor concentration, ‘don’t know’ answers, good orientation.
- MCI
- Amnestic, ADLs intact.
- Normal ageing
- Person aware and concerned, WFD, important things are rememebered and function is preserved.
Describe the basic brain anatomy outlining which areas of the brain are responsible for which functions.
Which area of the brain is implicated in dementia?
The hippocampus
What is the frontal lobe responsible for?
How do you test this?
- Executive function
- Planning (e.g. clock drawing)
- Sequencing (luria)
- Fluency (naming words beginning with the same letter)
- Cognitive estimates
- Initiative
- Inhibition
- Personality
What are the temporal lobes responsible for?
How do you test this?
- Memory
- Speech (left)
- Address test
- Object recall
- Serial 7s (deduct 7 from 100 and keep subtracting), spelling
- Phrase repetition (fluent receptove aphasia)
- Mood
What are the parietal lobes responsible for?
How do you test this?
- Spatial awareness (R)
- Language (L)
- Serial 7s (L)
- Clock drawing - shared between the parietal and frontal lobe
- Naming objects (pen, watch), severe nominal (expressive) dysphasia.
- 3-stage command (dyspraxia).
- Copying cube and interlocking shapes (visuospatial agnosia and constructed dyspraxia) (R).
- Writing a sentence (L).
- Agnosia.
Which test can be used to monitor dementia?
- Mini-mental state examination.
- Dementia patients lose approximately 3 points per year in the test.
- Problem is that is has been copyrighted so is no longer in popular use.
What does the MoCA test?
- Sensotivity = 90%
- Specificity = 87%
- Short term memory
- Recall
- Visuospatial abilities
- Executive function
- Attention
- Concentration
- Working memory
- Language
- Orientation
What does the TYM test?
- Orientation
- Ability to copy a sentence
- Semantic knowledge
- Calculation
- Verbal fluency
- Similarities
- Visuospatial abilities
- Recall of copied sentence
Describe the Addenbrookes Cognitive Examination.
- 20-25 minutes
- Multi-domain
- Good reliability
- Cut-off 82/100
- Sensitivity 0.93
- Specificity 1
- Cut-off 88/100
- Sensitivity 1
- Specificity 0.96
What are the 3 stages of dementia?
- Preclinical - changes in biomarkers.
- MCI - biomarkers may help determine progression to Alzheimer’s disease.
- Alzheimer’s disease - biomarkers may be helpful in excluding AD as a cause.
Describe the timeline of disease progression.
What defines mild cognitive impairment?
- Subjective memory impairment and cognitive impairment not meeting dementia diagnostic criteria and in particular with no impairment in core ADLs.
- Amnestic MCI in which the prominent impairment is one of memory has a conversion rate from 10-15% per year in clinic-based studies.
- Conversion is not inevitable, up to 25% in some studies show subsequent recovery of normal cognitive function.
What are the benefits of early diagnosis of dementia?
- Disease modifying effect better than targeting MCI
- Slowing of cognitive decline
- Better quality of life
- Better adjustment for disability
- Future planning
- Reduced strain on carer
- Reduced strain on services
What are the risk factors for Alzheimer’s disease?
- Age
- Lack of exercise
- Smoking
- High cholesterol
- Hypertension
- Poorly controlled Diabetes
- Family history
- Education and social engagement
- Depression
- Head injury
- Hearing loss
What are the protective factors for Alzheimer’s disease?
- Mediterranean diet
- Physical activity
- Minimising vascular risks
- Social activity
- Lifelong learning
Describe the pathophysiology of Alzheimer’s disease.
- Senile plaques, neurofibrillary tangles and cell death.
- Reduction of acetyl choline reduces neuronal signalling.
- Presence of glutamate in the wrong place interferes with signalling.
What is the clinical picture of Alzheimer’s disease?
- Insidious onset and slow steady progression
- Memory deficits, language, visual-spatial
- Disorientation
- Decline in self care
- Executive decline
- Apathy
Describe the clinical picture of vascular dementia.
- Less insidious onset
- Stepwise decline
- Emotional lability
- Preserved personality
- CVD (brain infarcts)
- Vascular risk factors
What are the risk factors for vascular dementia?
- Age
- Lack of exercise
- Smoking
- High cholesterol
- Hypertension
- Poorly controlled Diabetes
Describe dementia with Lewy bodies.
- Fluctuating course
- Visual hallucinations
- Postural instability
- Parkinsonism
- Sensitivity to antipsychotics
- Memory relatively preserved
- DaTSCAN can be of use
Describe frontotemporal dementia.
- Personality changes
- Behavioural changes
- Language problems
- Memory relatively preserved
- Younger onset
- AChEI not effective
What are the other types of dementia?
- cc 100
- Alcohol related
- Huntington’s
- MS
- Down’s syndrome
- Corticobasal degeneration
- Prion disease
- Parkinson’s disease
Describe the assessment and diagnosis of dementia.
- Screening tests identify 90% but don’t establish the diagnosis.
- Dementia is diagnosed when progressive cognitive decline has occurred and this has had noticeable impacts upon a person’s ability to carry out important everyday activities.
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Informant interview
- This is often one of the most important issues in the diagnostic process allowing someone close to the patient to describe any changes that they have noticed in the memory abilities or level of functioning in the patient
- A structured informant questionnaire may be used (eg IQCODE, p48 SIGN86)
- Neuropsychiatric Inventory; Bristol ADL Scale
- Specialist Assessments
- Consideration of the need for further specialist input including:
- Psychometric assessment (Clinical Psychologist)
- Assessment of ADLs, Claudia Allen Test (OT)
- Assessment and management of Language & Speech (SALT)
- Neurological assessment (Neurologist)
- Significant medical co-morbidity or frailty (MftE)
-
Diagnostic Confirmation
- Dementia diagnosis made following reference to ICD or DSM
diagnostic schedules (eg p34-40 SIGN86)
Which tests can be done when you suspect dementia?
What might these tests show?
Describe the use of neuroimaging in patients with dementia.
Describe the pathology associated with Alzheimer’s disease.
Describe the management of dementia.
- Acetylcholinesterase inhibitors approved (NICE) in mild to moderate dementia (AD, DLB, PD, even VaD) may slow progression and help behavioural sy, and 10-25% may improve:
- Donepezil (Aricept)
- Rivastigmine (Exelon) Galantamine (Reminyl)
- NMDA receptor antagonists eg Memantine (Ebixa) licenced in moderate to severe AD slows rate of decline and helps behavioural symptoms
- Combination may be used in moderate to severe dementia
- Stopping medication may cause more rapid decline
- No medication for MCI
What ‘treatments’ are NOT beneficial in dementia?
- Vitamin B6, B12, E, folate, souvenaid
- Ginko biloba
- Coconut oil
- Hormones (testosterone, estrogen)
- Statins
- Aspirin and other NSAIDs
- Vaccines
How long are patients likely to survive after symptom onset in Alzheimer’s disease?
9-12 years
What are the big considerations when managing a patient with Alzheimer’s disease?
- Maintaining independence
- Managing risk
- Co-morbidities
- Behavioural management
- Cognitive stimulation
- Reminiscence therapy
- Supporting the carers
What are the behavioural and psychological symptoms of dementia?
- 90% patients have symptoms
- Present throughout the course of the disease
- More common with disease progression
- Remitting but highly recurrent (6 week cycle)
- Very problematic aspect for carers and major source of career distress
- Strongly associated with nursing home placement
