Dementia and Delirium Flashcards
Dementia
Permanent impairment of intellectual capacity and personality integration, due to the loss of or damage to neurons in the brain.
cognitive impairment + functional disability
Delirium
Temporary cognitive impairment due to an acute illness
describe the epidemiology of dementia
total prevalence over 65 10.3 per 100
65-74 3 per 100
75-84 18.7 per 100
85 and above 47.2 per 100
how is the diagnosis of a patient’s cognitive function conducted
Patient history
Collateral history (essential)
Patient examination (incl. mental state examination)
Blood tests
Neuroimaging
how is the mini mental state exam conducted
orientation -
a(5) date/month/year/day/season
b(5) city/country/county/building/ floor
registration (3)- test their memory - name 3 objects e.g ball, car, man. repeat the objects repeat 6 times
attention (5)- from 100 subtract 7 5 times (93, 86, 79, 72, 65)
spell WORLD backwards
recall (3) - list the 3 words I said earlier
Language(2) - name these objects (pen, watch), repeat (1)”no ifs, ands, or buts”
Reading (1) - show card write CLOSE YOUR EYES. tell them to do what it says.
writing (1) - write a short sentence
three stage command (3) - take this paper in your left hand fold it in half and put it on the floor
construction (1) - copy this drawing
scored out of 30
what is neuropsychological testing
Used to test specific cognitive domains
Verbal memory, recent memory, remote memory
Orientation, language, motor skills, perception
executive function
how is diagnosing a dementia subtype conducted
History
Time course
Examination
Vascular or neurological signs
Blood tests
Glucose / B12 / Folic acid / TFT’s / Syphilis
Blood tests usually normal though
Imaging
CT / MRI / SPECT/PET
Lumbar puncture for CSF amyloid and tau measurement
how is the structural integrity of the cerebrum assessed and what is its purpose in diagnosis of dementia
purpose -To exclude structural causes of dementia
To assess degree of grey and white ischaemia
Brain tumours, Normal Pressure Hydrocephalus
To assess degree and distribution of atrophy
what is the purpose of of conducting a SPECT/PET for dementia
To assess hypoperfusion in brain regions
what patients are typically indications for scanning to assess dementia
Recent onset of cognitive impairment
< 2 years
Atypical history for AD
Rapid deterioration over weeks
Unexplained neurological symptoms or signs
Known cancer
Gait balance problems/ incontinence early in course of dementia
what neuroimaging is available for the diagnosis of dementia
CT Brain (widely available)
MRI Brain (fairly available)
PET scan brain (pretty unavailable)
SPECT scan brain (rarely done anymore)
list the dementia subtype
alzheimer’s disease - 50%
vascular dementia - 15%
‘Mixed’ dementia - 15%
Dementia with Lewy bodies - 10%
Frontotemporal dementia - 8%
Other -2%
describe mild cognitive impairment
a subtype of cognitive impairmentAbnormal tests but normal function
Amnestic / non amnestic
Single domain / multi-domain
what is the expected clinical presentation of a patient with dementia
abnormal tests and abnormal function
Performance must be below 5th centile in 2 or more cognitive domains
Functional disability must be as a result of cognitive impairment
describe the early investigation conducted for dementia
initial assessment - basic cognitive assessment e.g. mini mental state exam, check for function impairment e.g. paying bills, shopping, check for mood disorder e.g. anger, depression
neurogimaging - CT, MRI, PET, SPECT
Indications for neuroimaging - short duration of symptoms (<2 yrs), unexplained CNS symptoms (headaches, seizures), unexplained CNS signs (hemiparesis), cancer hx
neuropsychological testing - for MMSE >24
Common differential diagnosis - mild cognitive impairments, early dementia
describe the classification of AD (Alzheimer’s Disease
Very mild AD = MMSE > 24
Mild AD = MMSE 20-23
Moderate AD = MMSE 16-19
Severe MMSE < 15
What is the management strategy for very mild AD (Alzheimer’s Disease)
establish diagnosis
consider enduring power of attorney
consider driving assessment
consider a cholinesterase inhibitor if function impaired
What is the management strategy for mild AD (Alzheimer’s Disease)
establish diagnosis
consider enduring power of attorney
consider driving assessment
consider a cholinesterase inhibitor if function impaired
What is the management strategy for moderate AD (Alzheimer’s Disease)
establish diagnosis
consider enduring power of attorney
consider cognitive enhancer/combination therapy of memantine with cholinesterase inhibitor
check for behaviour disturbances and treat
check for carer stress
What is the management strategy for severe AD (Alzheimer’s Disease)
consider cognitive enhancer
consider for behavioural and psychological symptoms of dementia
consider social support for carer stress
what drugs should be avoided for alzheimer’s disease
opioids
drugs with anticholinergic action
benzodiasepines
what sedatives are typically given for behavioural and psychological symptoms of dementia (BPSD)
trazodone
quetiapine
haloperidol
lorazepam
what non pharmacological intervention is available for BPSD (behavioural and psychological symptoms of dementia)
Behaviour management
avoid overstimulation
music therapy
staff training
what assessment is conducted for AD in the nursing home
assess personal ADL, e.g. toileting, dressing, mobility
assess appetite, nutritional state and food refusal
assess for anxiety and depression and BPSD
Initiate palliative care planning and discuss resuscitation status
