Dementia Flashcards
How is dementia defined?
Acquired decline in memory and other cognitive functions
In an alert person (non-delirious)
Sufficiently severe to impair daily life
What symptoms are seen in dementia pts?
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
How should dementia be investigated?
- 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
How is dementia assessed?
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
Describe Alzheimer’s and its management
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
Describe vascular dementia and how it should be managed?
Risk factors = DM, IHD, stroke, HTN, smoking
Step-wise decline
Imaging may show large areas of infarcts
CVS risk management, treat HTN/high cholesterol
What are the possible complications of dementia?
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
What is lewy body dementia and how does it present?
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
How does fronto-temporal dementia present?
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
How would you establish baseline and trajectory in function over the last 12 months?
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
What are the likely causes of poor oral intake in a dementia patient?
Struggling to coordinate swallow correctly = dysphagia, chocking
- Motor and sensory difficulties
May forget to chew or hold food in their mouth
What are the key priorities in managing a dementia patient?
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
What alternative feeding methods are available and what evidence is there on the use of enteral (NG/PEG) feeding in patients with dementia?
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
What does the term “Feed at risk” mean? What information would be important to give with the family/next of kin when discussing this?
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
What is mental capacity, why is it important to assess for cases like this and how is this determined?
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?
What is a best interests decision? When is this made?
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.
What is an advanced care plan? Who completes this and what is taken in consideration when completing this?
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
What does a Do Not Attempt Resuscitation (DNAR) order mean and what do you understand about the discussions that should be held about this?
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?
What is an MMSE test?
Mini mental state exam
Gives score out of 24
Mild, moderate, severe impairment
Assess cognitive base
Repeat to monitor progression of decline
How can you differentiate between delirium vs dementia?
Confusion assessment method – CAM score
Acute change or fluctuating mental status
Hypoactive or hyperactive
Inattention
Disorganised thinking
Each factor is indicate of delirium
If the subtype of dementia remains unclear what tests can be ordered?
FDG-PET/SPECT = Alzheimer’s, FT dementia
DAT scan = dementia with lewy body
MRI brain = vascular dementia
What medication should be given to a patient with Parkinson’s disease dementia?
Rivastigmine
When should anti-dementia medication not be used?
Vascular dementia
Frontotemporal dementia
Cognitive impairment sec to multiple sclerosis
What tests make up a confusion screen?
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
Outline the progression of cognitive decline in dementia
Vascular = step by step
Alzheimers = gradual
Lew body = fluctuating, short periods of improvement
