Dementia

Question 1

What is dementia?

Answer 1

A syndrome caused by a number of brain disorders, characterised by progressive, irreversible global cognitive decline that causes problems with memory, difficulty thinking, language, problem solving and ADL.

Question 2

Causes of Dementia?

Answer 2

DEMINTIV

1) Degenerative: Alzheimers, Lewi-body, vascular, frontotemporal, Parkinson’s, Huntington’s, Wilson’s, MND, MS.
2) Endocrine: Hypothyroidism, hyperparathyroidism, Cushing’s, Addison’s
3) Metabolic: Electrolyte disturbance (Ca2+ Mg2+), Uraemia, hypoglycaemia
4) Infection: Creutzfeldt-Jakob disease, neurosyphilis, HIV, TB
5) Toxicity: Alcohol/heavy metal
6) Intracranial: Stroke, trauma, tumour, pressure hydrocephalus
7) Vitamin deficiency: Folate, thiamine, niacin

Question 3

Cognitive symptoms of dementia?

Answer 3

Cognition:

1) Memory
2) Attention
3) Language
4) Problem solving
5) Orientation
6) Calculation

Question 4

Neurological symptoms of dementia?

Answer 4

1) Seizures
2) Primitive reflexes
3) Pseudobulbar palsy

Question 5

Psychiatric symptoms of dementia?

Answer 5

1) Personality change - social withdrawal, apathy/fatigue, disinhibition/silliness
2) Anxiety +/- depression
3) Hallucination +/- delusion
4) Sundowner syndrome - confusion and falls in the evening

Question 6

Difficulties with ADL involved in dementia?

Answer 6

1) Driving, shopping, eating and dressing

2) Apraxia

Question 7

What symptoms are shown by pressure hydrocephalus?

Answer 7

MAIN

1) Memory impairment
2) Ataxia
3) Incontinence
4) Nystagmus

Question 8

What screening tools are used to diagnose dementia?

Answer 8

1) MMSE commonly used - 25 or above is normal, 18-24 is mild impairment, 17 or below is serious impairment.
2) Montreal Cognitive assessment (MOCA) - 30 points
3) Addenbrookes Cognitive Examination III (ACE-III) - out of 100 points. Normal score is 82+ (does not exclude), below 82 think dementia. Scores in each of the 5 cognitive domains are just as important as total.

Question 9

Exclusion tests for dementia?

Answer 9

FBC, U&E, TFT, LFT, electrolyte, glucose, CRP, ESR, HIV, Folate, B12, VDRL, blood culture, LP, EEG, CT, MRI, SPECT, PET, CXR, ECG.

Question 10

Initial treatment for dementia?

Answer 10

Inform DVLA

Prevention - Healthy behaviours (smoking cessation, good diet, no alcohol/smoking, exercise). 6 or more leisure activities - music, dancing art, massage and aroma therapy.

Support - Cognitive stimulation programme, memory service specialist, multi sensory stimulation.

Medication - 1) AchE-i in Alzheimers (Rivatigmine/Donepezil)

2) NMDA antagonist - Memantine
3) Blood pressure control (in vascular dementia) - Ace-i (Ramipril)
4) Antidepressant - SSRI (Citalopram)

Question 11

What is Alzheimers?

Answer 11

A degenerative disease of the cerebral cortex with prominent cognitive and behavioural impairment interfering with social and occupational function. Characterised by accumulation of beta-amyloid peptides (degradation product) - neuronal damage and neurofibilliary tangles - loss of Ach and increase in beta-amyloid plaques.

Question 12

Clinical presentation of Alzheimers?

Answer 12

1) Early stages:
Failing memory (first thing we see) - recalling events, forgetting names and places, language difficulties.
Behavioural changes - wandering and irritability.

2) Middle stage:
Personality changes, apathy, aphasia, apraxia, agnosia, confusion, problems with decision making.

3) Late stage:
Behavioural: disinhibition/silliness, wandering, change in eating habit, incontinence, aggression.
Psychiatric: Hallucination, delusion, anxiety and depression.

Question 13

Diagnosis of Alzheimer’s?

Answer 13

As per dementia - history and examination: MMSE, MOCA, ACE-III. Deficit in cognition but no disturbance with consciousness, absence of other diseases, insidious onset over months/years and progressive worsening of memory and cognition.

Exclusion.

Question 14

Treatment of Alzheimer’s?

Answer 14

1) As per dementia - non-pharmacological initially.
2) 1st line - AchE-i - Donepezil or Rivastigmine
2nd line - NMDA antagonist - Memantine
3rd line - if mod-severe - antipsychotic in Risperidone.

Question 15

Summary regarding fronto-temporal dementia:

Answer 15

Preferential atrophy of frontotemporal regions (unlike Alzheimers which affects posterior parietal. Has an early onset of 65 years+.

Question 16

What are the functions of the different lobes of the brain?

Answer 16

Frontal lobe - initiates voluntary movements on the opposite side of the body, speech (Broca’s) and writing, intellectual features - reasoning, thought process and memory, and personality.

Temporal lobe - Understanding broke word (Wernicke’s area), memory and emotion.

Parietal lobe - Receive and interprets sensations from opposite side of body, and proprioception.

Occipital lobe - Understands visual images and meaning of written words.

Cerebellum function - Coordinates movement and balance

Question 17

Presentation of Fronto-Temporal dementia?

Answer 17

1) Insidious onset and gradual progression, early signs include emotional lability and personality changes!!!!!!!!
2) Early decline in social, interpersonal and personal conduct: Disinhibition/silliness,
pacing and wandering, behavioural changes.
3)Early emotional blunting lacking happiness, sadness, fear, embarrassment, sympathy and empathy.
4) Loss of insight of symptoms and expression of distress
5) Speech and language (altered output and mutism)
6) Cognitive - memory, attention, orientation.

Question 18

Diagnosis of frontotemporal dementia?

Answer 18

1) Neuropsychology - will show impaired frontal lobe function - spared memory, speech and perceptuospatial function
2) CT/MRI/SPECT - bilateral abnormalities in the FT lobes
3) EEG
4) Dementia screen

Question 19

How to treat FT dementia?

Answer 19

AchE-i unlikely to be beneficial. SSRI’s have limited benefit with behavioural symptoms. Supportive therapy with education, speech and language therapy for swallowing and communication.

Question 20

How does Lewy-body dementia present?

Answer 20

1) Fluctuating cognition with pronounced variation in attention and alertness - gradual onset but progressive.
2) Prominent/persistent memory loss
3) Hallucinations (COMMON) and personality changes
4) Spontaneous Parkinsonism - triad of rigidity, tremor and bradykinesia. (Repeated falls, syncope and sleep problems). Other features associated with Parkinsonism - postural hypotension, mask-like face, micrographic, anosmia, loss of arm swing.
5) Different from Parkinsonism as memory changes occur first before movement problems.

Question 21

Diagnosis of Lewy-body dementia?

Answer 21

As per dementia - MMSE, MOCA, ACE-III.

Exclusion - CT/MRI, DAT/(SPECT), dementia screen

Question 22

Treatment of Lewy-body dementia?

Answer 22

1) Non-pharmacological as per dementia

2) Antipsychotic - Risperidone

Question 23

How does vascular dementia present?

Answer 23

1) (STEPWISE deterioration) with declines followed by short periods of stability.
2) No personality changes and there is insight.
3) Cognitive and memory deficits.
3) Focal neurological signs - visual disturbance, sensory/motor symptoms (dysphasia and semiparesis), extrapyramidal signs (dystonia, parkinsonian features).
4) Gait disorder - unsteady and frequent unprovoked falls.
5) Bladder symptoms - incontinence
6) Pseudobulbar palsy

Question 24

Diagnosis of vascular dementia?

Answer 24

As per dementia - history/exam, dementia screen.
Imaging essential - CT/MRI, ECG, CXR
Criteria - Dementia and signs of stroke on exam +/- imaging, onset of dementia usually occurs within 3m of stroke, abrupt deterioration in cognitive function (more acute than other dementias), fluctuating and stepwise deterioration. Evidence of stroke history or atheropathy.

Question 25

Treating vascular dementia?

Answer 25

As per dementia:

1) Diet, exercise, stop smoking/alcohol, manage HT and DM.
2) Ramipril (ACE-i) to minimise further vascular damage.