Dementia Flashcards

1
Q

How is dementia defined?

A

Acquired decline in memory and other cognitive functions

In an alert person (non-delirious)

Sufficiently severe to impair daily life

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2
Q

What symptoms are seen in dementia pts?

A

Memory loss

Difficulty performing familiar tasks

Problems with language

Disorientation to time and place

Poor or decreased judgement

Problems with keeping track of things

Misplacing things

Changes in mood or behaviour

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3
Q

How should dementia be investigated?

A
  • Cognitive testing – MMSE (<24/30), MoCA, ACE III
  • Biochem = glucose, Na, K, Cl, HCO3, urea, and creatinine
  • Fasting blood glucose (if random blood glucose is abnormal or equivocal)
  • FBC with differential
  • TSH, LFTs, U+Es
  • Cobalamin level
  • Folate/vit B12
  • ESR (abnormal is >25 mm/hour or age in years + 10 [if female] divided by 2)
  • CRP
  • Urinalysis, microscopy and culture
  • CXR
  • ECG
  • CT head – atrophy, vascular lesions, dilation of ventricles
  • MRI – atrophy of frontal/temporal lobes in frontotemporal dementia, vascular disease
  • Amyloid PET – Alzheimer’s
  • EEG – frontotemporal dementia, CJD, seizure
  • LP – CNS infection/Ca, <55ys, atypical manifestations, CJD
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4
Q

How is dementia assessed?

A

Hx from pt, family, friends

Note onset, progression and symptoms

Alcohol and FH

Impairment = Retention of new info and STM, complex tasks, language, behaviours, orientation, recognising familiar people

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5
Q

Describe Alzheimer’s and its management

A

Insidious onset

Short term memory probs, progress to global cognitive impairment

Accum beta-amyloid peptide = progressive neuronal damage, neurofibrillary tangles, amyloid plaques, loss of ACh

TREATMENT

  • 1st LINE: AChase inhibitors (donepezil, rivastigmine, galantamine) - slow disease progression
  • Antiglutamatergic - Memantine = NMDA receptor blocker
  • BP control
  • Refer to specialist memory service
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6
Q

Describe vascular dementia and how it should be managed?

A

Risk factors = DM, IHD, stroke, HTN, smoking

Step-wise decline

Imaging may show large areas of infarcts

CVS risk management, treat HTN/high cholesterol

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7
Q

What are the possible complications of dementia?

A

Dysphagia = when a dementia pt can no longer swallow they are at the end stage of their disease do not put a feeding tube in

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8
Q

What is lewy body dementia and how does it present?

A

Lewy bodies (protein) in brainstem, cortex, substantia nigra = parkinsons Sx

S+S

  • Typically fluctuating cognitive impairment
  • Visual hallucinations (people, animals)
  • Later parkinsonism

***avoid antipsychotics due to adverse reactions/increased mortality

TRIAD = dementia, visual hallucinations, Parkinsonism

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9
Q

How does fronto-temporal dementia present?

A

Behavioural/personality changes, disinhibition (taking of clothes), emotional unconcern, aggression, gambling

Speech falls eventually to a state of mutism

Common in pts <65y, onset at younger age

Often family Hx

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10
Q

How would you establish baseline and trajectory in function over the last 12 months?

A

Establish what the pt used to be able to do and what they can no longer do

Talk to the family/friends about the patients decline - 6 months

Sudden or gradual decline

PMH - stroke, TIA, MI

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11
Q

What are the likely causes of poor oral intake in a dementia patient?

A

Struggling to coordinate swallow correctly = dysphagia, chocking
- Motor and sensory difficulties

May forget to chew or hold food in their mouth

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12
Q

What are the key priorities in managing a dementia patient?

A

Referral to speech and language therapist to help with swallowing difficulties

Make sure they are eating/drinking enough

Establish the cause to put a treatment plan in place and understand the prognosis

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13
Q

What alternative feeding methods are available and what evidence is there on the use of enteral (NG/PEG) feeding in patients with dementia?

A

NG = nasogastric tube
PEG = percutaneous endoscopic gastrostomy
Nasoduodenal/nasojejunal tube

Presently available guidelines make a single recommendation against tube feeding for all patients - studies suggest pts with dementia who are given feeding tubes dont liver longer or gain weight with those who are carefully hand fed

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14
Q

What does the term “Feed at risk” mean? What information would be important to give with the family/next of kin when discussing this?

A

Feed at risk = if your swallow is unsafe and a feeding tube is not suitable, you may continue to eat and drink by mouth even though there is a high risk of choking/aspiration

Risk associated with still eating and drinking by mouth, what foods/textures should be eaten to minimise risk

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15
Q

What is mental capacity, why is it important to assess for cases like this and how is this determined?

A

Mental capacity = can understand, retain and weigh the necessary information

Capacity needs to be assessed for the pt to be rightfully involved in the planning of their treatment

Assessing capacity = assumed present until proven otherwise, understanding? Retain? Use info in making a decision? Communicate decision?

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16
Q

What is a best interests decision? When is this made?

A

When a decision is made for the patient not by the patient, which is in their best interest.

This kind of decision is made when the patient doesnt have mental capacity.

17
Q

What is an advanced care plan? Who completes this and what is taken in consideration when completing this?

A

Voluntary process of discussion about future care between a patient and their care providers, for when the patient is no longer able to communicate their preferences (no longer has capacity)

Includes = wishes for types of care, personal values, clarify broad goals of care, aims to decrease family member burden, preparing for the difficulties they may face at the end of life

18
Q

What does a Do Not Attempt Resuscitation (DNAR) order mean and what do you understand about the discussions that should be held about this?

A

DNAR = cardiopulmonary resuscitation will not be performed

Discussions to be had

  • Is CPR likely to be successful?
  • Does the patient want CPR?
  • Is CPR in the patients best interest?
19
Q

What is an MMSE test?

A

Mini mental state exam

Gives score out of 24

Mild, moderate, severe impairment

Assess cognitive base

Repeat to monitor progression of decline

20
Q

How can you differentiate between delirium vs dementia?

A

Confusion assessment method – CAM score

Acute change or fluctuating mental status

Hypoactive or hyperactive

Inattention

Disorganised thinking

Each factor is indicate of delirium

21
Q

If the subtype of dementia remains unclear what tests can be ordered?

A

FDG-PET/SPECT = Alzheimer’s, FT dementia

DAT scan = dementia with lewy body

MRI brain = vascular dementia

22
Q

What medication should be given to a patient with Parkinson’s disease dementia?

A

Rivastigmine

23
Q

When should anti-dementia medication not be used?

A

Vascular dementia

Frontotemporal dementia

Cognitive impairment sec to multiple sclerosis

24
Q

What tests make up a confusion screen?

A

Obs: BP, HR, RR, O2, temp, GCS

CT head

Bloods: FBC, U+Es, LFTs, coag/INR, TFT, Ca, B12 + folate/haematinics, glucose, blood cultures

CXR

Urine dipstick

25
Q

Outline the progression of cognitive decline in dementia

A

Vascular = step by step

Alzheimers = gradual

Lew body = fluctuating, short periods of improvement