Dementia and Delirium

Question 1

Dementia signs and symptoms

Answer 1

Question 2

Dementia symptoms timeline over the years

Answer 2

Question 3

Alzheimer’s risk factors

Answer 3

Question 4

Alzheimer’s pathophysiology

Answer 4

macroscopic:
widespread cerebral atrophy, particularly involving the cortex and hippocampus

biochemical
there is a deficit of acetylcholine from damage to an ascending forebrain projection

Question 5

• Alzheimer’s symptoms

Answer 5

A useful mnemonic to remember the features of Alzheimer’s is the ‘4As’:
Amnesia (recent memories lost first)
Aphasia (word-finding problems, speech muddled and disjointed)
Agnosia (recognition problems)
Apraxia (inability to carry out skilled tasks despite normal motor function)

Question 6

Vascular dementia cause

Answer 6

• Second most common cause of dementia
• Caused by impaired blood flow to areas of the brain due to vascular damage i.e. lots of micro-infarcts in someone with cardiovascular disease risk factors
• Can have a ‘step-wise’ progression due to progressive infarcts over time
• Usually a clinical diagnosis. Neuro-imaging can show evidence of significant small vessel disease

Question 7

Vascular dementia risk factors and prominent symptoms

Answer 7

• Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
• The difficulty with attention and concentration
• Seizures
• Memory disturbance
• Gait disturbance
• Speech disturbance
• Emotional disturbance
• Executive dysfunction

Question 8

• Lewy body dementia cause

Answer 8

In Lewy Body Dementia, abnormal protein deposits called Lewy Bodies cause cognitive decline associated with parkinsonism (rigidity, tremor, bradykinesia). Lewy bodies (alpha synuclein) deposits within cells as inclusions. This is also seen in Parkinson’s disease.

Question 9

Lewy body dementia: core symptoms and suggetsive symptoms

Answer 9

Core symptoms
* visual hallucinations, classically of small creatures/children/figures (Lilliputian bodies.)
* parkinsonism (rigidity, tremor, bradykinesia)
* Fluctutating cognition

Suggestive symptoms
* REM sleep disturbance
* sensitivity to antipsychotics

Question 10

Lewy body dementia management

Answer 10

• Neuroleptics which may be given to manage agitation/hallucination (i.e. dopamine blocking medication) can trigger rigidity and Parkinsonism, whilst dopaminergic agents that may be given to help with the rigidity may worsen the hallucinations, therefore the management can be difficult.

Question 11

There are three recognised types of FTLD

Answer 11

• Frontotemporal dementia (Pick’s disease)
• Progressive non fluent aphasia (chronic progressive aphasia, CPA)
• Semantic dementia

Question 12

Fronto-temporal dementia prominent features

Answer 12

Fronto-temporal dementia presents with cognitive impairment, personality change, repetitive checking behaviour, disinhibition, in keeping with the frontal area of the brain which is affected.
Atrophy of the frontal and temporal lobes is seen.
Constructional apraxia i.e. failure to draw interlocking pentagons may be a key feature in the early stages. Memory loss is a late feature.

Question 13

Pick’s disease:pathophysiology, prominent features and management

Answer 13

Question 14

CPA features

Answer 14

fronto temporal dementia
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.

Question 15

Semantic dementia features

Answer 15

Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.

Question 16

Dementia diagnosis/investigations

Answer 16

Diagnosis of dementia requires:

Functional history (which may require a collateral history, risk assessment)
Cognitive assessments
Brain imaging

• Assess cognitive decline using an approved scoring tool such as MMSE, MOCA, 10-point Cognitive Screener (10-CS), 6-item Cognitive Impairment Test (6-CIT), 6-item Screener, Memory Impairment Screen (MIS), Mini-Cog, Test Your Memory (TYM). This is usually done in primary care.
• in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’).
• in secondary care, neuroimaging (CT head) is performed to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management
• Once reversible causes are ruled out and a diagnosis of dementia is still suspected, refer to a specialist dementia diagnostic service (such as a memory clinic or community old age psychiatry service. Here, a full functional assessment is carried out and the patient will be referred for neuroimaging, such as CT or MRI.

Question 17

Alzheimer’s pharmacological management

Answer 17

Question 18

Alzheimer’s non-pharmacological management

Answer 18

• NICE recommend offering ‘a range of activities to promote wellbeing that are tailored to the person’s preference’
• NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia
• other options to consider include group reminiscence therapy and cognitive rehabilitation

Question 19

Dementia management

Answer 19

Question 20

Delirium definition and subtypes

Answer 20

Question 21

Delirium Predisposing factors include:

Answer 21

age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy

Question 22

Delirium precipitating events

Answer 22

• infection: particularly urinary tract infections
• metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
• change of environment
• any significant cardiovascular, respiratory, neurological or endocrine condition
• severe pain
• alcohol withdrawal
• constipation

Question 23

Delirium signs and symptoms

Answer 23

• memory disturbances (loss of short term > long term)
• may be very agitated or withdrawn
• disorientation
• mood change or personality change
• visual hallucinations
• disturbed sleep cycle
• poor attention
• Sundowning is agitation and confusion worsening in the late afternoon or evening.

Question 24

Delirium differentials

Answer 24

Question 25

Delirium investigations

Answer 25

Question 26

Delirium management

Answer 26

management can be challenging in patients with Parkinson’s disease, as antipsychotics can often worsen Parkinsonian symptoms
* careful reduction of the Parkinson medication may be helpful
* if symptoms require urgent treatment then the atypical antipsychotics quetiapine and clozapine are preferred

Question 27

Typical front-temporal dementia patient

Answer 27

Impulsivity,
Aggressive
relatively young age and lack of movement abnormalities
memory changes
Personlaity changes

Question 28

Different types of dementias comparison table

Answer 28