Dementia and Delirium Flashcards
Dementia signs and symptoms
Dementia symptoms timeline over the years
Alzheimer’s risk factors
Alzheimer’s pathophysiology
macroscopic:
widespread cerebral atrophy, particularly involving the cortex and hippocampus
biochemical
there is a deficit of acetylcholine from damage to an ascending forebrain projection
- Alzheimer’s symptoms
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)
Vascular dementia cause
- 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
Vascular dementia risk factors and prominent symptoms
- 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
- Lewy body dementia cause
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.
Lewy body dementia: core symptoms and suggetsive symptoms
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
Lewy body dementia management
- 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.
There are three recognised types of FTLD
- Frontotemporal dementia (Pick’s disease)
- Progressive non fluent aphasia (chronic progressive aphasia, CPA)
- Semantic dementia
Fronto-temporal dementia prominent features
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.
Pick’s disease:pathophysiology, prominent features and management
CPA features
fronto temporal dementia
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
Semantic dementia features
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.
Dementia diagnosis/investigations
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.
Alzheimer’s pharmacological management
Alzheimer’s non-pharmacological management
- 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
Dementia management
Delirium definition and subtypes
Delirium Predisposing factors include:
age > 65 years
background of dementia
significant injury e.g. hip fracture
frailty or multimorbidity
polypharmacy
Delirium precipitating events
- 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
Delirium signs and symptoms
- 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.
Delirium differentials
Delirium investigations
Delirium management
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
Typical front-temporal dementia patient
Impulsivity,
Aggressive
relatively young age and lack of movement abnormalities
memory changes
Personlaity changes
Different types of dementias comparison table
