dementia Flashcards
define dementia
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
signs seen in normal aging
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
what is mild cognitive impairment
May affect memory, problem-solving, planning, language, visuospatial awareness
Does not interfere significantly with daily life
why do we want to diagnose dementia early
Optimising medical management
Relief gained
Maximising decision making autonomy
Access to care and services
Risk reduction
Clinical and cost effectiveness
A human right?
what cognitive assessment screen can GPs do
6-item Cognitive Impairment Test (6-CIT)* Mini-Cog* 10-CS* GPCOG MMSE
if you suspect rapidly progressive dementia refer where
refer to neurology
suspect memory issue where do u refer
what happens there
Dementia and sub-type diagnosis
Reviews after diagnosis
Care co-ordination
Interventions to promote cognition, independence and wellbeing
Pharmacological interventions
what do we need to specifically know in the history/collateral history in dementia
Decline of cognitive, behavioural and psychological symptoms
Impact on daily living (functionality)
Risk factors
what physical examination would you conduct in a dementia patient
Neurological exam
CVS exam
Check new physical finding if prompted by Hx
what would you assess in the mental state examination
Appearance and behaviour
Speech
Mood (subjective/objective)
Thought (form/content)
Perception
Cognition
Insight
What Ix would you do in memory clinic
Bloods
ECG
Establish absolute / relative contraindications
CT head / MRI brain scan:
Assist in diagnosing dementia sub-type
what specific Ix can you do if ur not sure or if it will change management
Alzheimers or frontotemporal
dementia with lewy bodies
vascular
FDG-PET or perfusion SPECT
MRI
risk assessment of dementia
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
how can dementia affect carers
Changing relationships
Financial difficulties
Social isolation
Psychological and physical strain
management of dementia initially
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
drug options for patients with mild/moderate alzheimers disease
MOA
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)
what medications do we not prescribe with dementia pts and why
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
in which pts can we not use antidementia medication
Vascular dementia – unless mixed dementia suspected
Frontotemporal dementia
Cognitive impairment secondary to multiple sclerosis
SEs of AChE inhibitors
Worsen pulmonary disease
Increase gastric acid increasing risk of peptic ulceration
Cause syncope, bradycardia and seizures (rare but life-threatening)
SEs of memantine
Cause seizures (rare but life-threatening)
common causes of dementia
- Alzheimer’s most common
- Vascular dementia second most common
- Lewy body dementia, Dementia in PD
- Frontotemporal dementia
other causes of dementia
Others Alcohol (ARBI, Korsakoffs) Huntingtons Disease HIV associated MSA, CBD, PSP Prion disease MS NPH Wilsons
risk factors of dementia
- 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
what qs to ask in history
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
diagnostic criteria of dementia
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.
name of resource pack created by NHS for dementia
well pathway for dementia
non pharmacological treatment for dementia
- Cognitive stimulation programmes
- Multisensory stimulation
- Music therapy
- Art therapy
- Dancing
- Massage
- Aromatherapy
- Structured exercise programmes
- Animal-assisted therapy
what risk factors might exacerbate their violent or aggressive behavior
Overcrowding. Lack of privacy. Boredom or lack of activity. Poor communication. Conflict. Weak clinical leadership in care home settings.
Palliative end of life care treatment
hysical, psychological, social and spiritual support should be offered
PEG if dyspahgia
post diagnostic care options
1) Alzheimers sociatey, Age UK – social groups, carer support.
2) Psychological interventions
- Cognitive stimulation therapy
- cognitive rehab, reminiscence
- life story work
comorbidities associated with dementia
Vascular risk modification
Avoid polypharmacy (e.g reduce anticholinergics – oxybutinin, TCAs, antihistamines, opiates)
BPSD, including depression
what is BPSD
BPSD, also known as neuropsychiatric symptoms, refers to the non-cognitive manifestations of dementia, including aggression, depression, apathy, psychosis and agitation.
features of early stages of dementia
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
features of Mid stage dementia
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
features of late stage dementia
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
most commonest form of dementia
alzheimers
what is lewy body dementia
Deposition of abnormal protein
within neurons in the brain stem and neocortex.
lewy bodies are intracytoplasmic neuronal inclusion bodies
what Ix would you do for dementia
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
when do we offer antipsychotics in dementia pts
if they are at risk of harming themselves or others
experiencing agitation
how to diagnose delirium from dementia
the long confusion assessment method (CAM)
the Observational Scale of Level of Arousal (OSLA).
what simple measure can be taken to reduce agitation delusions and hallucinations
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.
what environmental control measures
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
why should acetylcholinesterase inhibitors stopped quickly
may experience rebound worsening of cognition.
Mx of insomnia
trazodone
Sleep hygiene measures, including daytime activity, avoidance of naps, daily walking, and bright light therapy, have been shown to improve sleep quality
what factors can confound bedside testing
- 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
moderate AD who are e intolerant of or have a contraindication to AChEi or severe AD.
memantine
glutamate receptor antagonist
Mx of BPSD
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
what is advanced care planning
- 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.
