Dementia and Delirium

Question 1

Definition of Dementia

Answer 1

A global, chronic and progressive impairment of cognitive function without related systemic disease or specific cause

Question 2

Prevalence of Dementia

Answer 2

1 in 3 people over 65yrs - 800,000 in the UK - 1% of pop
Only 40-50% are diagnosed - 60% have Alzhiemer’s
2/3 are female and 1/3 live alone - 25% of inpatients

Question 3

Reversible causes of Dementia

Answer 3

Up to 10% of dementia in younger (<60yrs) patients
Chronic alcohol abuse/ B12 or thiamine deficiencies
Normal pressure hydrocephalus. Frontal Brain tumours or Tertiary syphilis. Depression or pseudodementia. Always remember delirium

Question 4

Pseudodementia

Answer 4

Depression in older people which presents as dementia or can mask it - presents like subcortical dementia with apathy and low concentration

Question 5

Types of Dementia

Answer 5

60% - Alzheimer’s Vascular - 17%
Mixed Dementia - 10% Lewy Body - 4%
Other - 10% (AIDs dementia, CJD or vCJD, Parkinson’s/huntington’s etc, Pick’s disease)

Question 6

Pick’s Disease

Answer 6

Frontotemporal Dementia - 20% of young onset dementia

Significant personality and speech problems

Question 7

Differentiating between Dementias

Answer 7

AD - Gradual progressive course and steady global deterioration
VD - Step-wise sudden progression and personality & insight maintained for longer
LBD - Marked fluctuation and with more prominent psychiatric symptoms

Question 8

Early stage of AD (2-4yrs in duration)

Answer 8

Starts with frequent forgetfulness of recent memories
Problems with speech and reasoning develop - increasing repetition, inflexibility and decision making (driving)
Insight is retained and leads to depression or denial

Question 9

Middle stage of AD (2-10yrs duration)

Answer 9

Disorientation in space and time - sig. persistent amnesia
Risk of wandering and major personality changes
Psychotic symptoms, self neglect and dis-inhibition
Restriction of speech and ADLs

Question 10

Late Stage of Ad (1-3yrs duration)

Answer 10

Severe memory problems - progressive dys-phagia/phasia
Increased aggression, wandering and distress
General physical deterioration and autonomic dysfunction
Increased risk of falls and frailty

Question 11

Histopathology of AD

Answer 11

Extracellular B-amyloid plaques
Intraneuronal neurofibrillary tangles of Tau protein
Atrophy and gliosis of the hippocampi

Question 12

Histopathology of Vascular Dementia

Answer 12

Arteriosclerosis of vessels and cell death from occlusion
Patchy areas of leucoaraiosis
Multiple large cerebral infarcts.
Can effect the frontal lobes causing avolutional states.

Question 13

Non-drug management of Dementia

Answer 13

Explain diagnosis and prognosis - promote and protect function - music, dance, multi-sensory rooms. Behavioral or cognitive stimulation therapy & social help. Support groups and carers. End of life planning and signpost to other services

Question 14

Drug treatment of AD

Answer 14

Anticholinesterases - Donepezil, Rivastigmine, Galantamine

NMDA receptor antagonists - Memantine

Question 15

Anticholinesterases in AD - drugs and side effects

Answer 15

Donepezil, Rivastigmine,Galantamine - licensed for AD
Generic so all cheap (£2/month) - address a deficit in ACh
SEs –> >10% have D&V, nausea, insomnia, <10% have headache, vomiting, cramping, fatigue, anorexia

Question 16

Contraindications of Anticholinesterases

Answer 16

Bradycardia
Asthma or COPD
GI bleeding or ulceration so care must be taken with NSAIDs

Question 17

NMDA receptor antagonists in AD (Memantine)

Answer 17

Blocks NMDA reducing cell death due to Ca influx
Used in severe AD and those who cannot tolerate ACHEIs
SEs (<10%) - headache, dizziness, confusion, constipation
A bit more expensive (£70/month)

Question 18

Contraindications of NMDA receptor antagonists

Answer 18

Epilepsy

Severe Renal or hepatic impairment

Question 19

When To use of Anticholinesterases in AD

Answer 19

Mild to moderate AD and started in memory clinics - should have full Hx, bloods, brain imaging, behavioral, functional and cognitive scales
Start with low dose and reassess at 2-4wks, then 3mths,
Discontinue in non-responders

Question 20

Rivastigmine

Answer 20

Used for mild/moderate AD

Also licensed for parkinson’s dementia and LBD

Question 21

Mild Cognitive Impairment

Answer 21

Common and increasing - memory impairment only (no diagnosed dementia)
15-50% may progress to dementia - need periodic monitoring

Question 22

BPSD

Answer 22

Behavioural and psychological symptoms of dementia - the distressing non-cognitive symptoms of dementia including agitation & aggression - 50-80% prevalence with moderate dementia and 80% of patients in care home settings - 50% self limiting and changes with environment

Question 23

Symptoms in BPSD

Answer 23

49% - anxiety Psychosis - 37%
46% - aggression Sleep disturbance - 45%
46% - apathy Depression - 25% or up to 60% in care

Question 24

Assessment of Dementia

Answer 24

Informant Hx and physical exam (signs of infection)
ABC - Antecendent/triggering event, Behaviour, Consequences
Cognitive tests - AMTs, SMMSE

Question 25

Causes of BPSD

Answer 25

Can be a central feature of dementia syndrome or a reaction to the environment arising from cognitive deficit
Can be due to unrelated pain, concurrent physical problems or due to medication

Question 26

Management of BPSD

Answer 26

Similar to dementia - focus on environment and relationships
Benzos can be useful in the short term
Antipsychotics are useful but hasten cognitive decline and increase CVA risk

Question 27

Dementia Screening

Answer 27

Should screen all emergency admissions over 75yrs

‘Have you/patient been more forgetful in the past 12months to the extent it has significantly affected daily life?’

Question 28

Subtypes of AD

Answer 28

Early - (before 65) - genetic
Late - (after 65) - 1. gradual progressive decline, 2. rapid decline with marked aphasia & apraxia with poor survival, 3. EPSEs, functional impairment and psychosis, 4. Benign group with little progression.