Dementia

Question 1

How is dementia defined?

Answer 1

Acquired decline in memory, thinking and other cognitive functions. Information processing and problems with maintaining and directing attention

In an alert person (non-delirious)

Clear consciousness

Sufficiently severe to impair daily life

Above syndrome present for more than 6 months

Question 2

What symptoms are seen in dementia pts?

Answer 2

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 - loss of motivation/interest

Question 3

How should dementia be investigated?

Answer 3

Bloods = FBC, TFT, B12 and folate def, glucose, HIV, CRP

CXR

ECG

CT head - lesions, bleed

MRI = suspicion of posterior circulation pathology

EEG - frontotemporal dementia, CJD, seizures

Lumber puncture = CNS infection, CJD, vasculitis

Cognitive testing = MMSE, MOCA, mini-COG, 6-CIT, ACE III

Question 4

How is dementia assessed?

Answer 4

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

Question 5

Describe Alzheimer’s and its management

Answer 5

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

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

Question 6

Describe vascular dementia and how it should be managed?

Answer 6

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

Step-wise decline

Imaging may show large areas of infarcts

CVS risk management

Question 7

What are the possible complications of dementia?

Answer 7

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

Question 8

What is lewy body dementia?

Answer 8

Typically fluctuating cognitive impairment

Detailed visual hallucinations, later parkinsonism

Lewy bodies in brainstem and neocortex

Question 9

How does fronto-temporal dementia present?

Answer 9

Behavioural/personality changes, disinhibition, emotional unconcern

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

May forget to chew or hold food in their mouth

Question 12

What are the key priorities in managing a dementia patient?

Answer 12

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

Question 13

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

Answer 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

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?

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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?

Question 19

What is an MMSE test?

Answer 19

Mini mental state exam

Gives score out of 24

Mild, moderate, severe impairment

Assess cognitive base

Repeat to monitor progression of decline

Question 20

How can you differentiate between delirium vs dementia?

Answer 20

Confusion assessment method – CAM score

Acute change or fluctuating mental status

Hypoactive or hyperactive

Inattention

Disorganised thinking

Each factor is indicate of delirium

Question 21

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

Answer 21

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

DAT scan = dementia with lewy body

MRI brain = vascular dementia

Question 22

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

Answer 22

Rivastigmine

Question 23

When should anti-dementia medication not be used?

Answer 23

Vascular dementia

Frontotemporal dementia

Cognitive impairment sec to multiple sclerosis

Question 24

Define cognitive impairment

Answer 24

Disturbance of higher cortical functions including memory, thinking, judgement, language, perception and awareness

It is not an illness

Question 25

What is the inverse care law?

Answer 25

Those who are most dependent and vulnerable often have the least awareness of their illness. When they are struggling they cannot call for help

Question 26

What are the most common causes of dementia in >65?

Answer 26

Alzheimer’s

Vascular

Question 27

What are the most common causes of dementia in <65?

Answer 27

Alzheimer’s
Vascular 
Fronto-temporal 
Alcoholic 
Lewy body dementia
Huntington’s