Dementia Flashcards
What is dementia
A neurodegenerative syndrome with progressive decline in several cognitive domains
What is the initial presentation of dementia
Memory loss over months/years
What is a diagnosis of dementia made by?
History - from patient and collateral narrative
Cognitive testing
Examination - identify and physical cause or risk factors also mental state examination
Medication review - important to exclude drug induced cognitive impairment
List some non-cognitive symptoms of dementia which indicate late disease
Agitation
Aggression
Apathy
What tool is used for cognitive testing
AMTS
What investigations should be carried out when diagnosing dementia
FBC B12/folate Thiamine Ca2+ MSU ESR U&E LFT glucose MRI - vascular or structural pathology Functional imaging - help delineate subtypes Consider EEG in suspected delirium, frontotemporal dementia, CJD or seizure disorder
List the subtypes of dementia
Alzheimer's disease Lewy body dementia Vascular dementia Fronto-temporal dementia Picks disease
Describe vascular dementia
Cumulative effect of many small strokes
Sudden onset and stepwise deterioration is characteristic
Look for evidence of arteriopathy (increased BP, focal CNS signs, past strokes)
Which drugs should you not use for treating vascular dementia
Acetylcholinesterase inhibitors and memantine
Describe Lewy body dementia
Fluctuating cognitive impairment
Detailed visual hallucinations
Later - parkinsonism
Describe histology in Lewy body dementia
Lewy bodies - eosinophilic intracytoplasmic inclusion bodies
Where are Lewy bodies found?
Brainstem and neocortex
Which drugs should be avoided in Lewy body dementia
Antipsychotics
Why should antipsychotics be avoided in Lewy body dementia?
Increased risk of side effects
Describe frontotemporal dementia
Frontal and temporal atrophy with loss of >70% of spindle neurons
Patients display executive impairment, behavioural/personality change, disinhibition, hyperorality, stereotyped behaviour and emotional unconcern
Episodic memory and spatial orientation are preserved until later stages
Describe picks disease
Few fronto-temporal patients who have pick inclusion bodies on histology
What are pick inclusions?
Spherical clusters of tau-laden neurons
How is dementia managed?
Referral to integrated memory services for further assessment and management
Medication - avoid drugs that impair cognition - neuroleptics, tricyclics and sedatives
Non-pharmacological - non cognitive symptoms may respond to aromatherapy, multisensory stimulation, music and animal assisted therapy
What other co-morbidities occur with dementia
Depression
Capacity
Describe the management of depression with dementia
Try SSRI or if severe then try mirtazapine
CBT
Describe Alzheimer’s disease and its presentation
Leading cause of dementia
Adults >40yo with persisting, progressive and global cognitive impairment: visuospatial skill, memory, verbal abilities and executive function (planning) are all affected, unlike other dementias in which specific domains are affected
Anosognosia - lack of insight into the problems endangered by the disease
Later on there may be irritability, mood disturbance and behavioural change, psychosis, agnosia
No standard history
Cognitive impairment is progressive but non-cognitive symptoms may come and go over months
Eventually patients become sedentary and do not take interest in things
Which dementia sometimes coexists with Alzheimer’s disease
Vascular dementia (95% of cases)
Describe the pathophysiology of Alzheimer’s disease
Beta amyloid peptide accumulation which results in progressive neuronal damage, neurofibrillary tangles, increased amyloid plaques and the loss of the neurotransmitter acetylcholine.
What is beta amyloid
Degradation product of amyloid precursor proteins
Where is the neuronal loss in Alzheimer’s disease selective for
Hippocampus, amygdala, temporal neocortex and subcortical nuclei
What are the risk factors for Alzheimer’s disease
1st degree relative with AD Downs syndrome - AD is inevitable <40yo Homozygosity for apolipoprotein E (APoE) E4 allele PICALM CL1 and CLU variants Vascular risk factors Decreased physical/cognitive activity Depression Loneliness Smoking
How is Alzheimer’s disease managed
Refer to memory service
Acetylcholinesterase inhibitors
BP control
What is the mean survival of Alzheimer’s?
7 years from USy
Which drug may be given in both Alzheimer’s, Lewy body dementia and Parkinson’s disease
Rivastigmine
Name some acetylcholinesterase inhibitors
Donepezil
Rivastigmine
Galantamine
What are the side effects of acetylcholinesterase inhibitors
Exacerbate peptic ulcer disease and heart block
Name some antiglutamatergic drugs
Memantine
When is memantine suggested for use in patients with Alzheimer’s disease
Late stage AD
Recommended for those intolerable of anticholinesterase inhibitors
What are the side effects of memantine
Hallucinations
Confusion
Hypertonia
Hypersexuality
What is the mechanism of action of memantine
NMDA antagonist
When are antipsychotics used in the treatment of dementia
Severe, non-cognitive symptoms only - psychosis and extreme agitation
Describe what antipsychotics increase the risk of
Stroke/TIA
What complication might occur when antipsychotics are given to those with Lewy body dementia
Neuroleptic sensitivity reactions
Which vitamin supplement is the best for management of dementia
Vitamin E
On which chromosome is the APOE4 allele found?
Chromosome 19
