Dementia

Question 1

Alzheimers epidemiology?

Answer 1

Slightly more common in females

The most common cause of dementia in the UK accounting for about half of all dementia diagnoses.

Question 2

Alzheimers PPx?

Answer 2

Amyloid plaques develop between neurons.
Neurofibrillary tangles made of tau protein develop within within neurons

The accumulation of these leads reduction in transmission of information, and eventually to the death of brain cells

Question 3

Vascular dementia epidemiology?

Answer 3

More common in males
second most common type of dementia.
Increased prevalence in those who have had a stroke (9x higher than the general population).

Question 4

Vascular dementia types?

Answer 4

Stroke-related VD – multi-infarct or single-infarct dementia
Subcortical VD – caused by small vessel disease
Mixed dementia – the presence of both VD and Alzheimer’s disease

Question 5

Vascular dementia features?

Answer 5

Single infarct vascular disease: classically cognitive impairment (acutely or subacutely) following the event.
Functional deficits are often seen before memory impairment
Mood disturbances and mood disorders are common in vascular dementia.

Psychosis, delusions, hallucinations and paranoia can often be seen, especially in later stages.

Patients should be screened for depression and for signs of psychomotor retardation (often a more common feature than positive signs of depression).

Emotional lability can be prominent.

Question 6

Vascular dementia progression?

Answer 6

‘Stepwise’ – often shows a period of stability at one level of functioning, before an acute decline progression, followed by another period of stability.

Question 7

Lewy-body dementia epidemiology?

Answer 7

Appears to affect slightly more men than women.

Mostly affects those over the age of 50.

Question 8

LBD PPx?

Answer 8

Spherical “Lewy Body” proteins are deposited in the brain (alpha-synuclein)

These Lewy Bodies are also present in Parkinson’s disease – the difference being that in Parkinson’s they are mainly deposited in the substantia nigra, whereas they are more widespread in Lewy-Body dementia.

Question 9

Features of lewy body and progression?

Answer 9

Often involves visual hallucinations and Parkinson-like symptoms.

If physical symptoms precede cognitive decline by more than a year, the diagnosis is often Parkinson’s, with superimposed cognitive decline.
Fluctuation in cognitive ability is common.
At presentation, problems multitasking and performing complex cognitive actions are more likely to the primary issue (rather than memory).
Sleep disorders are a common manifestation.

Fairly rapidly progressive, with death most commonly in the first 7 years post-diagnosis.

Question 10

Mixed dementia dx?

Answer 10

diagnosed when patients have evidence of more than one type of dementia (often Alzheimer’s and vascular dementia) based upon clinical or neuroimaging evidence.

Question 11

Frontotemporal dementia epidemiology?

Answer 11

Much less common type, but responsible for a significant number of diagnoses of dementia in under 65s.
Tends to affect both sexes equally.

Question 12

PPx of frontotemporal dementia?

Answer 12

Neuron damage and death in the frontal and temporal lobes.

The atrophy is due to deposition of abnormal proteins (often tau protein) within the lobes.

Question 13

Features of Frontotemporal dementia?

Answer 13

Behavioural presentation: Altered emotional responsiveness, apathy, disinhibition, impulsivity; Progressive decline noted in interpersonal skills.; Changes in food preference, more childlike amusements.
Obsessions and rituals may also be noted.

Semantic presentation: Progressive decline in the understanding of word meanings;
Speech may still be fluent, but there is difficulty in name-retrieval and use of less precise terms;
Unable to determine the meanings of common words when asked.
This tends to develop into the inability to recognise objects, or familiar faces (prosopagnosia).

Non-fluent presentation: Progressive breakdown in the output of language.
Generally display speech apraxia (poor articulation) or disorders of speech sound.
impaired comprehension of sentences and an impact on literacy skills.

Over time, all three initial presentations tend to emerge and worsen.

Question 14

Dementia differentials?

Answer 14

Prion Protein Diseases (eg. Creutzfeldt-Jakob Disease)
HIV-related Cognitive Impairment/Dementia
Normal Pressure Hydrocephalus
Severe Depression
Mild Cognitive Impairment

Question 15

Cause of variant CJD? What’s the other type called? Features of disease?

Answer 15

eating meat infected by bovine spongiform encephalopathy

Sporadic CJD - affects those over the age of 40

To begin with, it may present as minor memory lapses, mood disturbance and loss of interest.
followed by (over weeks) unsteadiness, physical clumisiness

Progression then involves stiffness, jerking movements, incontinence and aphasia.

Question 16

Normal pressure hydrocephalus PPx? Epidemiology? RFs?

Answer 16

Abnormal build-up of cerebrospinal fluid in the ventricles causes pressure to increase in the brain tissue, producing symptoms of cognitive impairment.
Can occur at any age, but more common in the elderly.
head trauma, infection or inflammation in the brain, tumour and subarachnoid haemorrhage.

Question 17

Symptoms of Normal pressure hydrocephalus?

Answer 17

Progressively worsening memory lapses
Personality and mood disturbances
Difficulties with walking
Dementia
Urinary incontinence

Question 18

Mx of normal pressure hydrocephalus?

Answer 18

a shunt is surgically placed to drain excess CSF into the abdomen, relieving pressure on the brain.

Question 19

Define mild cognitive impairment? Causes?

Answer 19

people with memory problems or higher cortical thinking, not severe enough to interfere with everyday life. - 10-15% will go on to develop a form of clinical dementia.

dementia, stroke, depression, stress, physical illness and drug side-effects

Question 20

Diagnostic criteria for alzheimers?

Answer 20

NIA criteria:
 Insidious onset
 Clear-cut history of worsening of cognition, and most prominent cognitive deficits are amnestic or non-amnestic (language, visuospatial, or executive dysfunction)

Question 21

Mx of Alzhemers?

Answer 21

Non-pharma - activities to promote wellbeing that are tailored to the person’s preference;
 group cognitive stimulation therapy;
 group reminiscence therapy
 cognitive rehabilitation

Pharma:
Mild to moderate -  acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
 Memantine – 2nd line. Reserved for:
• moderate Alzheimers - intolerant of, or have a contraindication to, acetylcholinesterase inhibitors;
• OR as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s
• OR monotherapy in severe Alzheimer’s

Question 22

When to use antipsychotics in alzheimers?

Answer 22

antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress

Question 23

SEs of acetylcholinesterase inhibitors?

Answer 23

cholinergic crisis:
S: Salivation
L: Lacrimation
U: Urination
D: Diaphoresis
G: Gastrointestinal upset
E: Emesis

Donepazil: CI by bradycardia (relative)
can cause insomia.

Question 24

Dx criteria of vascular dementia?

Answer 24

o Presence of cognitive decline that interferes with ADL
o Cerebrovascular disease (neuro signs and/or imaging)
o A relationship between the above two disorders inferred by:
 the onset of dementia within three months following a recognised stroke
 an abrupt deterioration in cognitive functions
 fluctuating, stepwise progression of cognitive deficits

Question 25

Mx of vascular dementia?

Answer 25

o Address CVS RFs
o Non-pharma: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy

o Pharma: Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.

Question 26

Core features of LBD?

Answer 26

o Fluctuating cognition with pronounced variations in attention and alertness
o visual hallucinations
o motor features of parkinsonism

Question 27

Mx of LBD? What drugs to avoid?

Answer 27

o Mild -moderate DLB : Offer donepezil or rivastigmine (or galantamine)
o Severe DLB: Consider donepezil or rivastigmine

Avoid neuroleptics (can developp irreversible parkinsonism)

Question 28

Ix when ?dementia?

Answer 28

• Ix: FBC, U+Es, CRP, LFT, Glucose, Syphyllis, lipid profile, Vit B12, Folate, TFTs

Question 29

Cognitive tests? Including over the phone?

Answer 29

• Cognitive tests: (Note AMTS, GPCOG< and MMSE are not recommended by NICE for use in an non-specialist setting)
o the 10-point cognitive screener (10-CS)
o the 6-item cognitive impairment test (6CIT)
o the 6-item screener
o the Memory Impairment Screen (MIS)
o the Mini-Cog
o Test Your Memory (TYM).
o COVID 19 - TICS (The Telephone Interview for Cognitive Status)

Question 30

CT head features of dementia?

Answer 30

(loss of gyral volume, enlargement of cerebral sulci), ventricle dilatation

Question 31

How to differentiate between depression and dementia?

Answer 31

Depression: having mood symptoms, sudden onset, saying ‘don’t know’ in
cognitive testing, difficulties with effortful cognitive tasks (months of the year backwards, counting back from 20 to 1), remembering items with cues and asking for help

Question 32

Use of hypnotics in older people? Dangers?

Answer 32

For psychological Tx (eg. anxiety) esp. if sleep is affected

Benzodiazepines (e.g. Diazepam) have a tendency to accumulate in older people
and lead to toxicity (sedation, cognitive problems, gait disturbances, falls, delirium),
while shorter acting Benzodiazepines (e.g. Lorazepam) carry a higher risk of
dependency.