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Yr 3 psychiatry > dementia > Flashcards

dementia Flashcards

1
Q

definition of dementia

A

Neurodegenerative condition with progressive decline

Significant impairment of memory and one/more other cognitive (language, visuospatial skills and praxis) in a setting of clear consciousness, and interfering with work, social activities or relationships

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2
Q

subtypes of dementia

A

alzheimer’s

vascular

lewy body

fronto-temporal

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3
Q

vascular dementia

A

25%

Cumulative effect of many small strokes

sudden onset and stepwise deterioration is characteristic

look for evidence of arteriopathy (raised BP, past strokes, focal CNS signs)

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4
Q

lewy body dementia

A

15-25%

Fluctuating cognitive impairment

Detailed visual hallucinations

Parkinsonism

Histology is characterised by lewy bodies (eosinophilic intracytoplasmic inclusion bodies) in brainstem and neocortex

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5
Q

fronto-temporal dementia

A

Frontal and temporal atrophy with loss of >70% spindle neurons

Executive impairment

Behavioural/personality change

Disinhibition

Hyperorality

Stereotyped behaviour

Emotional unconcern

Episodic memory and spatial orientation are preserved until later stages

Pick’s disease – fronto-temporal dementia with Pick inclusion bodies on histology (spherical clusters of tau laden neurons)

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6
Q

epidemiology of dementia

A
  • Prevalence increases with age, 20% >80yrs have it – only ½ cases diagnosed
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7
Q

aetiology of dementia

A
  • Alzheimer’s disease
  • Vascular – multiple infarctions
  • Infection – HIV, syphilis, Whipple’s disease
  • Inflammation – vasculitis, SLE, sarcoid, MS
  • Trauma – heads injury, subdural haemorrhage
  • Tumour – frontal tumour, posterior fossa (causing hydrocephalus), brain met, paraneoplastic
  • Toxic – alcohol, lead, barbiturates, drugs
  • Metabolic – myxoedema, vit b12 def, repeated hypoglycaemia
  • Inherited – Wilson’s disease, Huntington’s chorea, cerebellar ataxias
  • Degenerative – Parkinson’s and other akinetic-rigid syndromes, Pick’s disease, prion disease, lewy body dementia
  • Pellagra
  • CJD
  • Cryptococcus
  • Familial autosomal dominant Alzheimer’s
  • CADASIL
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8
Q

sx of dementia

A

Memory loss over several years/mo

Ask about timeline of decline and the domains affected

Non-cog symptoms: agitation, aggression, apathy – indicate late disease

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9
Q

signs of dementia

A
  • Cognitive testing
    • Validated dementia screen eg AMTS or similar
    • Tests of executive function or language
    • Mental state examination to identify anxiety, depression or hallucinations
  • Examination – may reveal physical cause, RF (eg for vascular dementia) or parkinsonism
  • Medication review – exclude drug induced cognitive impairment
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10
Q

Ix for dementia

A
  • Look for reversible/organic causes
    • High TSH
    • Low B12
    • Low folate
    • Low thiamine eg from alcohol
    • Low Ca
  • MSU
  • FBC
  • ESR
  • UE
  • LFT
  • Glucose
  • MRI
  • functional imaging – FDG, PET, SPECT may delineate subtypes when diagnosis is not clear
  • consider EEG
  • If clinically indicated – checkautoAb, syphilis, HIV, CJD,
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11
Q

MRI for dementia

A
  • identify reversible pathologies eg subdural haematoma, normal pressure hydrocephalus
  • underlying vascular damage
  • structural pathology
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12
Q

when would you do an EEG for dementia

A
  • suspected delirium,
  • frontotemporal dementia
  • CJD
  • Seizure disorder
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13
Q

definition of alzheimer’s

A
  • Primary chronic progressive neurodegenerative dementia
  • Characterised by extracellular deposition of B amyloid protein and intracellular neurofibrillary tangles
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14
Q

definition of mild cognitive impairment

A

impairment of some cognitive domains, insufficient to qualify for dementia diagnosis, or interfere with QOL

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15
Q

aetiology of alzheimer’s

A
  • Unknown, most idiopathic.
  • Rare – monogenic
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16
Q

RF for alzheimer’s

A
  • age,
  • prior intellectual level
  • FH – 1st degree relative with AD
  • Downs – AD is inevitable
  • Homozygosity for apolipoprotein E E4 allele
  • PICALM
  • CL1&CLU variants
  • Vascular RF – BP, dm, dyslipidaemia, high homocysteine, AF
  • Low physical cognitive activity
  • Depression
  • Loneliness increases risk 2x
  • Smoking
17
Q

pathophysiology of alzheimer’s

A

Extracellular deposition of amyloid plaques containing B-42 peptides and intracellular accumulation of neurofibrillary tangles containing hyperphosphorylated Tau protein (microtubule protein)

B-amyloid is a degradation product of amyloid precursor protein

Causes progressive neuronal damage, neurofibullary tangles, increased number of amyloid plaques and loss of neurotransmitter Ach

Unclear which is causative pathology

Neurone count reduced in hippocampus, medial temporal and precuneate cortex

Vascular effects important

18
Q

epidemiology of alzheimer’s disease

A
  • Very common
  • 5% people >65yrs
  • Accounts for 60-80% dementias
  • Diagnosis <60 rare
  • Incidence increases exponentially with age
19
Q

sx of alzheimer’s

A

Reliable history from relative

Gradual deterioration of cog func

  • Initially antegrade amnesia, personality change, apathy, loss of concentration and disorientation. May have psychiatric manifestations – hallucinations and delusions
  • Language spared until late
  • Late stages – cog impairment in all domains: (memory, language, visuospatial), myoclonus, seizures, behavioural disturbances (irritability, mood disturbance eg depression/euphoria, behavioural change eg aggression/wandering/disinhibition, psycosis ie hallucinations/delusions, agnosia – don’t recognise self, incontinence and loss of independence

Non-cognitive symptoms come and go over months

Suspect in pts: >40, with persistent progressive and global cognitive impairment (visio-spatial skill, memory, verbal abilities, executive func)

Anosognosia – lack insight into problems caused by the disease: missed appointments, misunderstood conversations or plots of films, mishandeling of money

Eventually sedentary – little interest in anything

20
Q

signs of alzheimer’s

A

Mini-mental state exam (MMSE) screening tool (<27 = dementia)

Premorbid intellectual function needs to be considered

In amnestic alzheimers – delayed recall is impaired even with prompting

21
Q

Ix for alzheimer’s

A
  • Aimed at excluding treatable causes of dementia
  • Blood
  • CT/MRI brain
  • psychometric testing
  • EEG
  • LP
  • nuclear imaging
22
Q

bloods for alzheimer’s

A
  • FBC,
  • UE,
  • LFT,
  • ESR,
  • CRP,
  • TFT (exclude hypothyroid),
  • folate,
  • ANA,
  • ANCA,
  • vitamin B12,
  • treponemal serology.
  • Consider HIV serology
23
Q

CT/MRI for alzheimer’s

A
  • Cerebral/hippocampal atrophy
  • Exclude tumours, infarction, inflamm, subdural haematoma
24
Q

psychometric testing for alzheimer’s

A
  • Defining domains of impairment
  • Helpful for distinguishing depressive pseudo-dementia
25
Q

EEG for alzheimer’s

A
  • Not diagnostic
  • Useful to exclude non-convulsive status epilepticus as a cause
26
Q

LP for alzheimer’s

A
  • If disease is subacute/rapid onset – exclude encephalitis or prion disease
  • Tau and B-42 peptide levels can also be measured
27
Q

nuclear imaging for alzheimer’s

A
  • Primarily research tools
  • 11C-PIB PET can image amyloid distribution in brain and 99Tc-HMPAO-SPECT shows regional hypoperfusion of affected cerebral areas

Yr 3 psychiatry (3 decks)

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