Dementia and delirium

Question 1

Define dementia (3)

Answer 1

An acquired global impairment of intellect, reason and personality, without impairment of consciousness.

Question 2

Describe testing you would undergo before making the diagnosis of dementia. (6)

Answer 2

CT or MRI to test for tumour and hydrocephalus 
Hypothyroidism 
Hypercalcaemia 
Vitamin B12 deficiency 
Heavy metal poisoning 
Diabetes.

Question 3

Describe four cognitive impairments that can be seen in dementia. (4)

Answer 3

Memory
Orientation
Learning capacity
Judgement

Question 4

Describe 4 categories of non-cognitive symptoms of dementia. (8)

Answer 4

Behavioural - agitation, aggression, wandering, sexual inhibition
Psychotic - visual and auditory hallucinations, paranoia.
Sleep - insomnia leading to daytime drowsiness.
Mental health - depression and anxiety.

Question 5

Describe frontotemporal dementia.
Pathophysiology (2)
Risk factors  (1)
Symptoms (4)
Diagnosis criteria (1)
Treatment (1)

Answer 5

Build up of Tau proteins within neurones of the frontal and temporal lobes, causing Pick Bodies.
Risk factors are genetic only.
Symptoms include symtoms of frontal and temporal lobe lesions: Broca’s aphasia, incontinence, loss of inhibition, depression
Diagnosed with an MRI looking for Pick Bodies.
Treatment is only social.

Question 6

Describe Lewy Body Dementia. 
Pathophysiology (4)
Risk factors (1)
Symptoms (4)
Diagnosis criteria (1)
Treatments (2)

Answer 6

Clumps of alpha-synuclein protein are found in neurones, especially in the substantia nigra, temporal and frontal lobes, and the cingulate gyrus.
No genetic links have been found.
Parkinsonism, fluctuating cognition and alertness, visual hallucinations, increases susceptibility to neuroleptic malignant Syndrome.
Diagnosed with an MRI to find Lewy Bodies.
Treat with acetylcholineesterase inhibitors or mematine.

Question 7

Explain how you would differentiate between two patients with Lewy Bodies in the substantia nigra, one of whom had Lewy Body dementia and the other who had Parkinson’s Disease. (2)

Answer 7

History - if features of Parkinsonism appear in isolation initially a diagnosis of Parkinson’s Disease is made. If other symptoms of cognitive decline present before or along side the Parkinsonism, a diagnosis of Lewy Body dementia is made.

Question 8

Describe neuroleptic malignant Syndrome. (7)

Answer 8

Often occurs as a side effect of newly started antipsychotics or as a result of Lewy Body Dementia.
Presents with FEVER:
Fever
Encephalopathy (recent onset confusion)
Vital sign fluctuation (bp, tachycardia, tachypneoa)
Elevated creatine phosphokinase
Rigidity

Question 9

Describe Alzheimer’s Disease.

Pathophysiology (6)

Answer 9

Formation of beta amyloid plaques outside neurones (normal senile plaques) and Tau tangles within the neurones causing cell death. This causes sulcus widening and global atrophy. Affects the hippocampus first (short-long term memory), then temporal, parietal lobes or cingulate gyrus.

Question 10

Describe Alzheimer’s Disease.
Risk factors (3)
Diagnosis criteria (2)
Management (2)

Answer 10

Risk factors include old age, family history or mutations on chromosomes 1, 14 or 21 (including downs Syndrome).
Diagnosed with an MRI (atrophy seen before symtoms appear) or a lumbar puncture.
Managed with acetylcholineesterase inhibitors, and mematine.

Question 11

Describe the types of vascular dementia (3)

Answer 11

Stroke related
Subcortical (small vessel disease of not the cortex eg thalamus, basal ganglia, brainstem nuclei).
Mixed (Alzheimers + vascular)

Question 12

Describe vascular dementia 
Progression (1)
Risk factors (8)
Diagnosis (1)
Management (3)

Answer 12

Step-wise with plateaus and rapid falls
History of stroke or TIA, AF, DMII, hypertension, smoking, FH of stroke, obesity, old age
Diagnosed with a CT or MRI to visualise ischaemia.
Managed through changing modifiable risk factors, counselling, Alzheimer’s drugs useful in mixed type.

Question 13

Describe Age Dementia Complex
Incidence (1)
Pathophysiology (2)
Symptoms (6)

Answer 13

Occurs more frequently now the life expectancy of those with AIDS increases
HIV infected macrophages enter the brain and the virus causes indirect damage it neurones.
Symptoms include cognitive impairment, psychomotor retardation, tremour, ataxia, dysarthria, incontinence.

Question 14

Describe the different types of delirium (5)

Answer 14

Hyperactive - agitated, restless, stressed
Hypoactive - sleepy, withdrawn, quiet, not wanting to eat.
Mixed

Question 15

Explain why delirium can be difficult to recognise. (4)

Answer 15

Because it can present as hypoactive, which is less obvious unless you are constantly around the patient to recognise changes.
It also could be mistaken as normal for that patient if there is no collateral opinion of normal for them.

Question 16

Describe the causes of delirium. (12)

Answer 16

Infection leading to sepsis - UTI, Pneumonia
Toxic insult to the brain - acute alcohol toxicity, or withdrawal
Endocrine - hypo-/hyperglycaemia, hypo-/hypercalcaemia
Intercranial insult - epilepsy, raised ICP, trauma.

Question 17

Explain why delirium needs to be treated quickly. (5)

Answer 17

Reduced dementia risk
Reduced mortality risk
Reduced hospital admission length 
Reduced long term care admission 
Basically increase QoL and reduce costs.

Question 18

Define delirium (2)

Answer 18

A state of confusion caused by an insult to the brain (hypoxia or toxic) which leads to neuronal death.

Question 19

Describe the presentation of delirium. (3)

Answer 19

Clouded consciousness, fluctuating course, common but poorly described visual hallucinations.