dementia and delerium2 Flashcards
What is dementia?
A chronic progressive syndrome of insidious onset, chronic with cognitive and behavioural symptoms, cognitive and non cognitive symptoms
What are the cognitive symptoma of dementia
Impaired memory (temporal lobe involvement)
Impaired orientation (temporal lobe involvement)
Impaired learning capacity ((temporal lobe involvement)
Impaired judgement (frontal lobe involvement
What are the non-cognitive symptoms of demenia
Non-cognitive symptoms Behavioural symptoms •Agitation •Aggression (frontal lobe involvement) •Wandering •Sexual disinhibition (frontal lobe involvement)
Depression and anxiety
Psychotic features
•Visual and auditory hallucinations (hallucinations=false perceptions)
•Persecutory delusions (delusions=false beliefs)
Sleep symptoms
•Insomnia
•Daytime drowsiness (decreased cortical activity)
How is dementia diagnosed?
Diagnosis By exclusion •Exclude organic causes of cognitive decline oHypothyroidism oHypercalcaemia oB12 deficiency oNormal pressure hydrocephalus - Abnormal gait - Incontinence - Confusion
•Exclude delirium (see later)
Look for features of progressive cognitive decline, impairment of activities of daily living in a patient with a normal conscious level(cf. delirium where conscious level is diminished with acute cognitive decline)
What are types of dementia?
Alzheimers disease, vascular dementia, DLB,
Frontotemporal dementia and ADC (less commin)
What are the macroscpoic changes in alzheimers
oMacroscopic
- Global cortical atrophy
- Sulcal widening
- Enlarged ventricles (primarily lateral and third affected)
What are the microscopic changes in alzheimers
Microscopic
Plaques - Composed of amyloid beta
Tangles - Hyperphosphorylated tau
It is believed that plaques and tangles kill neurones. Since neurogenesis is limited in the CNS any neurones that die are unlikely to be replaced
What are the predominant neurones affected by plaques and tangles
•Predominant neurones affected oCholinergic (treatments target this) oNoradrenergic oSerotonergic oThose expressing somatostatin
What is vascular dementia
Vascular dementia
•Cognitive impairment caused by cerebrovascular disease (multiple small strokes
Presentation
oStepwise, maybe with focal neurological features
What are the risk factor for VD
•Risk factors same as for any vascular disease (and indeed same as for Alzheimer’s) oPrevious stroke / MI etc oHypertension oHypercholesterolaemia oDiabetes oSmoking
What is DLB
Dementia with Lewy bodies
•Essentially the same disease as Parkinson’s. If movement disorder followed by dementia then we call this Parkinson’s disease. If dementia precedes movement disorder we call it dementia with Lewy bodies
Describr the pathology of DLB
oAggregation of alpha synuclein
Forms spherical intracytoplasmic inclusions
Main deposits found across the brain
•Substantia nigra
•Temporal lobe
•Frontal lobe
•Cingulate gyrus (found just above the corpus callosum)
Can label alpha synuclein in the brain using advanced imaging techniques
Descrbe the presentation of DLB
Presentation oFluctuating cognition and alertness oVivid visual hallucinations oParkinsonian features May cause repeated falls
In which disease should antipsychotics not be given and why?
Do not give antipsychotics (dopamine antagonists) as can cause neuroleptic malignant syndrome, a psychiatric emergency
Fever
Encephalopathy (confusion)
Vital signs instability (tachycardia, tachypnoea (v.sensitive sign), fluctuating BP)
Elevated creatine phosphokinase
Rigidity (caused by dopamine antagonism)
What is frontotemporal dementia and what are the symptoms?
Frontotemporal dementia •Second most common cause of early onset dementia
•Frontal and temporal lobe atrophy
•Symptoms mostly related to frontal lobe dysfunction
oBehavioural disinhibition
oInappropriate social behaviour
oLoss of motivation without depression (caused by damage to anterior cingulate cortex)
oRepetitive/ritualistic behaviours
oNon fluent (Broca type) aphasia
What is ADC?
AIDS dementia complex•As patients with HIV infection live longer thanks to modern treatments, their chance of developing AIDs associated dementia is increasing
Insidious onset but rapid progression once established
Describe the pathology of ADC
Entry of HIV infected macrophages into the brain is thought to lead to indirect damage to neurone
What are the clinical features of ADC
Clinical features (related to global damage but also some manifestations of cerebellar involvement)
oCognitive impairment
oPsychomotor retardation (slow thoughts and movements, also seen in depression)
oTremor
oAtaxia
oDysarthria
oIncontinenc
What are the biological managements for dementia? (drugs)
Biological
•Drugs
oAcetylcholinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine)
- Modest efficacy for mild to moderate Alzheimer’s disease
oNMDA antagonists (e.g. memantine)
- Useful for treating agitation
- NMDA antagonist
what are teh psychological managemnrts for adc
Few psychological treatments are available for dementia due to its progressive nature
Describe the social managemnt of dementia?
Social
Mainstay of management
Key themes
oExplain the diagnosis sensitively
oTalk about problems that will arise and how they will be managed
oGive results of any special investigations (e.g. scans)
oDriving – often a difficult topic to deal with as patients frequently desperate to retain their independence
oFinances
Will
Power of attorney
oDay care and respite care (mainly to allow carers to rest and provide supportive environment for patients)
oResidential/nursing home placemen
What is delerium
oSometimes called ‘acute confusional state’
oOften reversible, due to organic cause
oAssociated with a variety of insults to the brain which may cause neuronal damage and inflammation
oDementia can predispose to episodes of delirium
What are the features of dementia
- Rapid onset of confusion
- Clouded consciousness (may be drowsy)
- Fluctuating course
- Maybe transient visual hallucinations
- Often exaggerated emotional responses (e.g. aggression)
What are the types of delerium
Hypoactive
•Withdrawn
•Quiet
•Sleepy
•Consequently more likely to be missed / confused with something else
Hyperactive
•Restless
•Agitated
•Aggressive
Mood may rapidly fluctuate
Persecutory delusions (narrative of elusion often not coherent)
Symptoms worse at start and end of day
•Maybe related to changes in endogenous cortisol levels
What are causes of delerium
•Multifarious (use a surgical sieve approach)
oNutritional
- Vitamin deficiencies
oIntracranial
- Strokes, TIAs, epilepsy, infection etc.
oExtracranial infections
- UTI, pneumonia
oIatrogenic
- Infections
- Drugs
oAlcohol
- Intoxication
- Withdrawal (including delirium tremens, caused by changes in GABA and NMDA receptors induced by long term alcohol consumption)
oEndocrine
- Thyroid
- Pancreas
oMetabolic
- Hypoxia
- Renal (e.g. electrolyte disturbances)
- Hepatic
Descrbe the management of delerium
Management Find and treat the underlying cause Prognosis •Increases risk of dementia •Associated with mortality •These patients often have lengthy hospital stays and have a high risk of re-admission
