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ICB > dementia > Flashcards

dementia Flashcards

1
Q

define dementia

A

progressive chronic global decline in cognitive function, which effects memory (especially short term memory), orientation, ability to perform daily tasks (such as shopping, paying the bills, dressing) and problem solving skills.

chronic deficit in thinking, memory and/or personality

Problems with the processing of incoming information - problems with maintaining and directing attention

Clear consciousness

Above syndrome present for >= 6 months

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2
Q

signs seen in normal aging

A

Not being able to remember details of a conversation or event that took place a year ago

Not being able to remember the name of an acquaintance

Forgetting things and events occasionally
Occasionally have difficulty finding words
Family members generally not worried about their memory

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3
Q

what is mild cognitive impairment

A

May affect memory, problem-solving, planning, language, visuospatial awareness
Does not interfere significantly with daily life

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4
Q

why do we want to diagnose dementia early

A

Optimising medical management

Relief gained

Maximising decision making autonomy

Access to care and services

Risk reduction

Clinical and cost effectiveness

A human right?

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5
Q

what cognitive assessment screen can GPs do

A 
6-item Cognitive Impairment Test (6-CIT)*
Mini-Cog*
10-CS*
GPCOG
MMSE
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6
Q

if you suspect rapidly progressive dementia refer where

A

refer to neurology

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7
Q

suspect memory issue where do u refer

what happens there

A

Dementia and sub-type diagnosis

Reviews after diagnosis

Care co-ordination

Interventions to promote cognition, independence and wellbeing

Pharmacological interventions

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8
Q

what do we need to specifically know in the history/collateral history in dementia

A

Decline of cognitive, behavioural and psychological symptoms

Impact on daily living (functionality)

Risk factors

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9
Q

what physical examination would you conduct in a dementia patient

A

Neurological exam

CVS exam

Check new physical finding if prompted by Hx

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10
Q

what would you assess in the mental state examination

A

Appearance and behaviour

Speech

Mood (subjective/objective)

Thought (form/content)

Perception

Cognition

Insight

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11
Q

What Ix would you do in memory clinic

A

Bloods

ECG
Establish absolute / relative contraindications

CT head / MRI brain scan:
Assist in diagnosing dementia sub-type

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12
Q

what specific Ix can you do if ur not sure or if it will change management

Alzheimers or frontotemporal

dementia with lewy bodies

vascular

A

FDG-PET or perfusion SPECT

MRI

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13
Q

risk assessment of dementia

A

to self

to others

from others

Behavioural and psychological symptoms of dementia

  • Aggression / agitation
  • Restlessness
  • Psychotic symptoms
  • Depressive symptoms
  • Anxiety symptoms
  • Sexual disinhibition
  • Sleep disturbance
  • Wandering

no routine obligation to inform the DVLA

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14
Q

how can dementia affect carers

A

Changing relationships

Financial difficulties

Social isolation

Psychological and physical strain

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15
Q

management of dementia initially

A

For all patients

1) Information and explanation
- carer support
- referral should be made to a community service organisation
- - alzheimers association

2) environmental control measures
3) Psychological support - maintaining a positive outlook and remaining engaged in life
3) Practical advice to cope with cognitive problems +/- assistive technologies
4) Carer support

For some types of dementia
- cholinesterase inhibitor
- antidepressant
- antipsychotics
- Mx of insomnia
- Mx of behavioural and psychological symptoms 
switch to or add memantine
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16
Q

drug options for patients with mild/moderate alzheimers disease

MOA

A

a. Donepezil
b. rivastigmine
c. galantamine

Acetylcholinesterase inhibitors

The cholinergic hypothesis suggests that a dysfunction of neurones in the brain
containing the neurotransmitter acetylcholine significantly contributes to the
cognitive decline seen in those with advanced age and AD. This premise serves
as the basis for the development of the majority of treatment strategies.
2. AChEi –inhibit the enzyme acetylcholinesterase from breaking down
acetylcholine into choline and acetate, thereby increasing both the level and
duration of action of the acetylcholine

SECOND LINE FOR MODERATE ALZHEIMERS Memantine (NMDA receptor antagonist)

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17
Q

what medications do we not prescribe with dementia pts and why

A

1) Avoid anticholinergic drugs
- Cognitive deterioration
- Hallucinosis and other psychotic symptoms may arise

2) Benzodiazepines
Use sparingly due to risk of falls, cognitive decline etc

3) Antipsychotic tranquilisers
Avoid where possible due to risks of stroke, falls, movement disorders and cognitive deterioration

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18
Q

in which pts can we not use antidementia medication

A

Vascular dementia – unless mixed dementia suspected

Frontotemporal dementia

Cognitive impairment secondary to multiple sclerosis

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19
Q

SEs of AChE inhibitors

A

Worsen pulmonary disease

Increase gastric acid increasing risk of peptic ulceration

Cause syncope, bradycardia and seizures (rare but life-threatening)

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20
Q

SEs of memantine

A

Cause seizures (rare but life-threatening)

21
Q

common causes of dementia

A
  • Alzheimer’s most common
  • Vascular dementia second most common
  • Lewy body dementia, Dementia in PD
  • Frontotemporal dementia
22
Q

other causes of dementia

A 
Others
Alcohol (ARBI, Korsakoffs)
Huntingtons Disease
HIV associated 
MSA, CBD, PSP
Prion disease
MS
NPH
Wilsons
23
Q

risk factors of dementia

A
  • Age and Sex (?Female > Male)
  • Education, Occupation, Socioeconomic status
  • Genetics – APOE e4 Allele, (PS1,PS2, APP)
  • Smoking, alcohol, obesity, cholesterol, hypertension, DM, cerebrovascular disease.
  • Psychosocial factors, physical activity, depression
24
Q

what qs to ask in history

A

Attention and concentration ability.

Orientation - time, place, person.

Memory - both short- and long-term.

increasingly rigid daily routines

day-night reversal
Praxis - whether they can get dressed, lay a table, etc.

Language function (usually evident during questioning).

Executive function - problem-solving, etc.

Psychiatric features - depression, anxiety, psychotic symptoms.

med review

25
Q

diagnostic criteria of dementia

A

1) Affect ability to function in normal activities.
2) Represent a decline from a previous level of function.
3) Cannot be explained by delirium or other major psychiatric disorder.
4) Have been established by history-taking from patient and informant, and formal cognitive assessment.

5) Involve impairment of at least two of the following domains:
- Ability to acquire and remember new information.
- Judgement, ability to reason or handle complex tasks.
- Visuospatial ability.
- Language functions.
- Personality and behaviour.

26
Q

name of resource pack created by NHS for dementia

A

well pathway for dementia

27
Q

non pharmacological treatment for dementia

A
  • Cognitive stimulation programmes
  • Multisensory stimulation
  • Music therapy
  • Art therapy
  • Dancing
  • Massage
  • Aromatherapy
  • Structured exercise programmes
  • Animal-assisted therapy
28
Q

what risk factors might exacerbate their violent or aggressive behavior

A 
Overcrowding.
Lack of privacy.
Boredom or lack of activity.
Poor communication.
Conflict.
Weak clinical leadership in care home settings.
29
Q

Palliative end of life care treatment

A

hysical, psychological, social and spiritual support should be offered

PEG if dyspahgia

30
Q

post diagnostic care options

A

1) Alzheimers sociatey, Age UK – social groups, carer support.

2) Psychological interventions
- Cognitive stimulation therapy
- cognitive rehab, reminiscence
- life story work

31
Q

comorbidities associated with dementia

A

Vascular risk modification

Avoid polypharmacy (e.g reduce anticholinergics – oxybutinin, TCAs, antihistamines, opiates)

BPSD, including depression

32
Q

what is BPSD

A

BPSD, also known as neuropsychiatric symptoms, refers to the non-cognitive manifestations of dementia, including aggression, depression, apathy, psychosis and agitation.

33
Q

features of early stages of dementia

A

Forgetfulness and other memory symptoms, the most prominent cognitive abnormality, especially in AD

– There may be subtle changes in mood and
behaviour e.g. loss of motivation/interest

– There may be minimal intrusion into day to day
activities if these are not too demanding

34
Q

features of Mid stage dementia

A

Memory problems become more prominent and
other cognitive difficulties may start to emerge e.g.
difficulty with language and executive function

– Changes in behaviour will usually be more marked

– Disability starts to become more obvious: simple
personal ADLs may be OK but complex activities e.g.
finance, planning activities, dealing with unexpected
events becomes a problem. People usually require
frequent but not continuous support and assistance

– Often, awareness of disability starts to diverge from reality

35
Q

features of late stage dementia

A

Severe and pervasive memory problems accompany
other major cognitive disabilities e.g. severe
disorientation, failure to recognise familiar people

– Marked (positive and negative) changes in behaviour e.g. agitation or restlessness, irritability, disinhibition, severe apathy

– Disability is severe, even basic aspects of personal
functioning are failing and people generally require
more or less continuous supervision

36
Q

most commonest form of dementia

A

alzheimers

37
Q

what is lewy body dementia

A

Deposition of abnormal protein
within neurons in the brain stem and neocortex.

lewy bodies are intracytoplasmic neuronal inclusion bodies

38
Q

what Ix would you do for dementia

A

bedside cognitive examination - MMSE
- impaired recall, nominal dysphasia, disorientation (to time, place, and eventually person), constructional dyspraxia, and impaired executive functioning

FBC - rule out anaemia

U&Es - to exclude abnormal sodium, calcium, glucose levels
- rule out recreational drug use

ESR
CXR
MSU
serum Ca
LFTs
TFTs - TSH may be low or high

syphillis seology

serum B12/Folate - may be low
autoantibody screen
blood glucose
CT/MRI

39
Q

when do we offer antipsychotics in dementia pts

A

if they are at risk of harming themselves or others

experiencing agitation

40
Q

how to diagnose delirium from dementia

A

the long confusion assessment method (CAM)

the Observational Scale of Level of Arousal (OSLA).

41
Q

what simple measure can be taken to reduce agitation delusions and hallucinations

A

Always explaining the caregiving actions in advance, such as putting clothes on or helping with showering

Giving written instructions whenever possible

Ensuring that comorbid illnesses are appropriately addressed by physician and nursing staff

Ensuring that pain is adequately addressed

Using calendars, clocks, and charts to help patients stay oriented to the time and place

Using lighting to reduce confusion and restlessness at night time

Ensuring the environment is safe and removing unnecessary furniture and items that might harm patients if they tend to wander.

Communication strategies that may foster improved communication between patients with AD and carers include: using short and simple sentences, explaining things, decreasing distractions, asking close-ended questions or providing response choices and not pushing the patient to come up with a word, name, or memory.

42
Q

what environmental control measures

A

A home safety evaluation should be undertaken, as well as an assessment of transport, driving, and self-care needs by an occupational therapist

Risk of assessment for falls and interventions to mitigate the risk

identification bracelets or installing sound and motion detectors make the environment safe for wandering patients and minimise the burden on carers

43
Q

why should acetylcholinesterase inhibitors stopped quickly

A

may experience rebound worsening of cognition.

44
Q

Mx of insomnia

A

trazodone

Sleep hygiene measures, including daytime activity, avoidance of naps, daily walking, and bright light therapy, have been shown to improve sleep quality

45
Q

what factors can confound bedside testing

A
  • Cognitive reserve and adaptability: Doctors have likely high levels of both as likely to have a higher level of intellectual functioning and are familiar with being tested so may perform well even when have early dementia.
  • Education and IQ- be cautious if patient has had problems with schooling and may have an undiagnosed specific learning disability or be poor/ no literacy skills
  • English not first language
  • Sensory impairment
46
Q

moderate AD who are e intolerant of or have a contraindication to AChEi or severe AD.

A

memantine

glutamate receptor antagonist

47
Q

Mx of BPSD

A

Non-pharmacological strategies should always be considered 1st line
• NB- ensure that thorough assessment has occurred- any evidence of deliriumUTI, LRTI/pain/constipation/iatrogenic? Treat any reversible causes.
• ABC charts- identify patterns
• Distraction/re-direction. What interests/hobbies does the patient have?
• Activity scheduling, daily structure, day centre attendance-increased socialisation
• Environmental interventions- natural light, calendar clocks to help orientation
• Compensate for sensory impairments, hearing aids/glasses
• Reminiscence therapy/ life story books

meds review for at least 6 weeks

48
Q

what is advanced care planning

A
  • the benefits of planning ahead
  • lasting power of attorney (for health and welfare decisions and property and financial affairs decisions)
  • an advance statement about their wishes, preferences, beliefs and values regarding their future care
  • advance decisions to refuse treatment
    their preferences for place of care and place of death.

ICB (30 decks)

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