Dementia + Alzheimer's

Question 1

differentials for dementia - different dementias

Answer 1

1 - alzheimer’s
2 - vascular dementia
3 - lewy body dementia
4 - fronto-temporal dementia

Question 2

differentials for dementia - non-dementia

Answer 2

delirium
drugs - medication, intoxication, withdrawal, alcohol-related
brain - infection, tumour, injury
neuro - huntington’s, parkinson’s

Question 3

dementia - behaviour

Answer 3

restless, repetitive, purposeless activity
sexual + social disinhibition
rigid routine
no initiative

Question 4

dementia - speech

Answer 4

speech errors
dysphasia
mutism

Question 5

dementia - thoughts

Answer 5

slow, poor memory, muddled
delusions
no insight

Question 6

dementia - perceptual abnormalities

Answer 6

illusions + hallucinations - often visual

Question 7

dementia - mood

Answer 7

irritable
depressed
blunt affect
emotional incontinence eg of crying, laughing

Question 8

vascular dementia - what is it? feature? investigations?

Answer 8

cumulative effects of many small strokes - sudden onset + stepwise deterioration
expressive aphasia (broca’s - stroke)
look for vascular pathology - BP, strokes, focal CNS signs

Question 9

lewy body dementia - features, later features + management

Answer 9

fluctuating cognitive impairment
visual hallucinations
later - parkinsonism, falls, mobility problems
management - rivastigmine for behavioural symptoms

Question 10

fronto-temporal dementia - features

Answer 10

behaviour + personality change
hyperorality + hyperphagia

early on, episodic memory + spatial orientation preserved
executive impairment
disinhibition + impulsivity
emotional unconcern/loss of sympathy

Question 11

episodic memory

Answer 11

collection of past personal experiences that occurred at a particular time and place

Question 12

dementia - history of memory/cognitive decline

Answer 12

2 re memory:
first thing noticed + timeline
hardest thing to remember

2 re out and about:
lost in familiar place?
ADL effects - shopping, tasks

2 re changes to normal traits:
mobility
aggression

Question 13

dementia - symptoms to ask about in history

Answer 13

4 mood, behaviour + attitude:
depression + anxiety 
aggression + agitation
apathy
drowsiness 

4 dementia specific:
repetitive speech
hallucinations 
sleep disorder 
wandering

Question 14

dementia - clinical tests

Answer 14

glucose
urine dip/CXR - infection
full bloods - FBC, U+E, LFT, calcium, TFT
B12 + folate - alcoholism
CT/MRI - vascular damage, tumour, subdural haematoma, NPH
volumetric MRI - subtype the dementia

Question 15

volumetric MRI - how does each type of dementia look?

Answer 15

alzheimer’s - medial temporal + hippocampal atrophy
frontotemporal - inferior temporal atrophy; asymmetry
lewy body - medial temporal lobe fairly spared

Question 16

drugs for alzheimer’s + lewy body dementia - types + examples

Answer 16

acetylcholinesterase inhibitors - slow disease progress:
donepezil, galantamine, rivastigmine
memantine (NMDA receptor blocker) - helps symptoms + slows disease

Question 17

management of dementia - social

Answer 17

safety:
risk assess
e-tagging

mobility:
home adaptations - fire-safe, alarms, stairs, bathroom
walking frames

conservative medical:
catheters
nutritional supplements

legal:
LPA/advanced directive
DVLA

Question 18

management of agitation in dementia

Answer 18

rule out pain + infection
music, muscle, massage (MMM)
risperidone oral if no response
beware benzos - falls risk

Question 19

dementia - advice for relatives + carers

Answer 19

practical - lock unused rooms + important drawers
support - groups, helplines, alzheimer’s society - contact with others in same situ
specific - respite care, financial support

Question 20

alzheimer’s dementia - presenting symptoms

Answer 20

global cognitive impairment (unlike in other dementias)
visuo-spatial impairment (gets lost)
speech problems
executive function (planning) problems

Question 21

alzheimer’s dementia - later symptoms

Answer 21

mood - irritable, anxious, aggressive, depressed, elated
wandering
disinhibition
hallucinations/delusions
agnosia - doesn't recognise self/family
reading/writing troubles
tasks - forgets how to do

Question 22

SEs of acetylcholinesterase inhibitors

Answer 22

headache + dizziness
insomnia
GI - tummy upset, appetite + weight loss
incontinence

Question 23

acetylcholinesterase inhibitors - checks before starting + contraindications + cautions

Answer 23

caut - exacerbates PUD + heart block
CI - bradycardia, LBBB, prolonged QTc
ECG - HR, conduction abnormalities, QTc

Question 24

memantine - class, SEs, preceding checks

Answer 24

antiglutamergic - NMDA receptor agonist

hallucinations + confusion
hypertonia
hypersexuality
dizziness

check U+Es - risk AKI

Question 25

non-drug management of BPSDs

Answer 25

treat cause:
routine
orientation - clocks, calendars

activities:
music/dancing, massage
exercise

therapy:
CBT - may involve carers
reminiscence therapy, aromatherapy
animal-assisted therapy

Question 26

non-drug management of BPSDs for when in hospital

Answer 26

familiar staff
red trays for food to alert help needed
individual rooms
safe space to wander

Question 27

management of depression in dementia - which drug? what monitoring? what risks?

Answer 27

citalopram
monitor QTc
risks - falls, GI bleeding

trazodone - good for sleep regulation

Question 28

lewy body vs frontotemporal

Answer 28

lewy - visual hallucinations + parkinsonism

frontotemporal - personality change + hyperorality

Question 29

alzheimer’s - drug management (updated 2018)

Answer 29

mild-mod
1° - rivastigmine / donepezil / galantamine
2° - memantine

mod-severe - 1° + 2°
severe - monotherapy

antidepressants - only if mod-severe depression
antipsychotics - only if risk to self/others, or much distress

donepezil, galantamine, rivastigmine = AChE inhibitors
memantime = NMDA antagonist