dementia and delerium2

Question 1

What is dementia?

Answer 1

A chronic progressive syndrome of insidious onset, chronic with cognitive and behavioural symptoms, cognitive and non cognitive symptoms

Question 2

What are the cognitive symptoma of dementia

Answer 2

 Impaired memory (temporal lobe involvement)
 Impaired orientation (temporal lobe involvement)
 Impaired learning capacity ((temporal lobe involvement)
 Impaired judgement (frontal lobe involvement

Question 3

What are the non-cognitive symptoms of demenia

Answer 3

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)

Question 4

How is dementia diagnosed?

Answer 4

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)

Question 5

What are types of dementia?

Answer 5

Alzheimers disease, vascular dementia, DLB,

Frontotemporal dementia and ADC (less commin)

Question 6

What are the macroscpoic changes in alzheimers

Answer 6

oMacroscopic

• Global cortical atrophy
• Sulcal widening
• Enlarged ventricles (primarily lateral and third affected)

Question 7

What are the microscopic changes in alzheimers

Answer 7

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

Question 8

What are the predominant neurones affected by plaques and tangles

Answer 8

•Predominant neurones affected
oCholinergic (treatments target this)
oNoradrenergic
oSerotonergic
oThose expressing somatostatin

Question 9

What is vascular dementia

Answer 9

Vascular dementia
•Cognitive impairment caused by cerebrovascular disease (multiple small strokes
Presentation
oStepwise, maybe with focal neurological features

Question 10

What are the risk factor for VD

Answer 10

•Risk factors same as for any vascular disease (and indeed same as for Alzheimer’s) 
oPrevious stroke / MI etc
oHypertension
oHypercholesterolaemia
oDiabetes
oSmoking

Question 11

What is DLB

Answer 11

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

Question 12

Describr the pathology of DLB

Answer 12

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

Question 13

Descrbe the presentation of DLB

Answer 13

Presentation
oFluctuating cognition and alertness
oVivid visual hallucinations
oParkinsonian features
    May cause repeated falls

Question 14

In which disease should antipsychotics not be given and why?

Answer 14

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)

Question 15

What is frontotemporal dementia and what are the symptoms?

Answer 15

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

Question 16

What is ADC?

Answer 16

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

Question 17

Describe the pathology of ADC

Answer 17

Entry of HIV infected macrophages into the brain is thought to lead to indirect damage to neurone

Question 18

What are the clinical features of ADC

Answer 18

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

Question 19

What are the biological managements for dementia? (drugs)

Answer 19

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

Question 20

what are teh psychological managemnrts for adc

Answer 20

Few psychological treatments are available for dementia due to its progressive nature

Question 21

Describe the social managemnt of dementia?

Answer 21

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

Question 22

What is delerium

Answer 22

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

Question 23

What are the features of dementia

Answer 23

• Rapid onset of confusion
• Clouded consciousness (may be drowsy)
• Fluctuating course
• Maybe transient visual hallucinations
• Often exaggerated emotional responses (e.g. aggression)

Question 24

What are the types of delerium

Answer 24

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

Question 25

What are causes of delerium

Answer 25

•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

Question 26

Descrbe the management of delerium

Answer 26

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