Dementia and Delirium

Question 1

What is dementia?

Answer 1

Syndrome of generalised decline of memory, intellect and personality without impairment of consciousness

Leads to functional impairment

Question 2

What are the risk factors for vascular dementia?

Answer 2

Stroke/TIA
HTN
AF
DM
Smoker
Hyperlipidaemia

Question 3

What are the two classifications of vascular dementia?

Answer 3

Stroke related: as a result of cerebrovascular disease

Small vessel related: due to arteriosclerosis

Question 4

How does vascular dementia present?

What criteria is used for diagnosis?

Answer 4

Usually within 3 months of a stroke
There is a stepwise decline 
- Emotional changes
- Focal neurology
- Poor concentration
- Abnormal gait
- Abnormal speech 

NINDS-AIREN criteria

Question 5

What is lewy body dementia?

Answer 5

Abnormal protein (Lewy bodies) deposition in the substantia nigra and neocortex leading to cholinergic and dopaminergic neurone loss

Question 6

How and when does Lewy Body dementia present?

Answer 6

Occurs BEFORE parkinsonism features
Fluctuating course
- first difficulties are usually executive functioning and attention (not memory like other dementias)
- Visual hallucinations

Question 7

How is Lewy Body dementia investigated and then managed?

What drugs must be avoided?

Answer 7

DaTscan

1. rivastigmine or donepezil
2. galantamine
3. memantine

Avoid neuroleptics as can induce parkinsonism

Question 8

What are the types of fronto-temporal dementia? What features are common to all 3?

Answer 8

Picks disease
Chronic progressive aphasia (CPA)
Semantic

All have a gradual onset
Memory is often preserved
Personality changes
No insight

Question 9

What causes Picks disease and how does it present?

Answer 9

Picks bodies and fronto-temporal atrophy

• disinhibition
• impaired social conduct
• increased appetite

Question 10

How does a) CPA and b) Semantic depression present?

Answer 10

CPA: speech as agrammatic and consists of short utterances that are non-fluent

Semantic: speech is fluent however is empty and meaningless. Memory is better for recent events compared to past

Question 11

What screening/ investigations would you do in primary care for ?dementia

Answer 11

6 item cognitive impairment screen
10 point cognitive screener

TFTs (hypothyroid)
B12, folate, thiamine
Glucose
Calcium

Question 12

What investigation would you do in secondary care for ? dementia and why?

Answer 12

Neuroimaging to rule out

• normal pressure hydrocephalus
• chronic subdural haematoma
• SOL

Question 13

What are some differentials for dementia?

Answer 13

Huntingtons 
Parkinsons 
CJD
HIV
Chronic alcohol or barbiturate abuse 
Depression 
Hypothyroidism
Normal pressure hydrocephalus 
Chronic subdural haematoma

Question 14

What is important in the non-pharmacological management of dementia?

Answer 14

Group cognitive stimulation therapy
Group reminiscent therapy
Art, music, pet therapy 
DVLA
Home safety 
Power of attorney and future care planning

Question 15

What causes Alzheimer’s?

Answer 15

ACh deficiency
Neurofibrillary tangles (Tau tangles)
Beta amyloid plaques
Cortical and hippocampal atrophy

Question 16

How does alzheimers progress? Timing and symptoms at each stage

Answer 16

Gradual decline

Early

• Problems remembering names and places
• Problem finding words

Moderate

• Global aphasia
• Apraxia (can’t carry out previously learned activities)
• Executive functioning (planning, problem solving)

Late/severe

• Agitation
• Incontinence
• Disorientation

Question 17

What is the stepwise management of Alzheimer’s?

Answer 17

1. donepezil or rivastigmine or galantamine
2. memantine
3. combination

Question 18

What are the side effects of the acetylcholinesterase inhibitors?

How can one of these be managed?

Answer 18

Insomnia - manage with trazodone
Reduced appetite
Nausea, vomiting, diarrhoea
dizziness

Question 19

What are the side effects of memantine?

Answer 19

Constipation
Dizziness
HTN

Question 20

What is delirium?

Answer 20

Acute transient global organic disorder of CNS leading to impaired consciousness and attention

Question 21

What are the types of delirium and how to they differ?

Answer 21

Hypoactive:

• Lethargic
• Decreased motor activity
• Apathy
• Sleepiness

Hyperactive:

• Agitated
• Irritable
• Aggressive
• Hallucinations/delusions

Question 22

What are the key pre-disposing risk factors for delirium?

Answer 22

> 65yo
polypharmacy
significant injury
frailty

Question 23

What are some causes for delirium?

Answer 23

Hypoxia - MI, PE, Cardiac failure

Endocrine - hypercalcaemia, hyper/hypoglycaemia

Infection - pneumonia, UTI, Meningitis

Intracranial - stroke, raised pressure, space-occupying lesion

Social - alcohol, drugs (could be same dose but lost weight = OD)

Abdo - Faecal impaction, malnutrition, urinary retention

Other - severe pain, sleep deprivation, anaesthetic, opioid

Nutrition - Thiamine, B12, nicotinic acid deficiency

Question 24

How does delirium present?

Answer 24

D - disordered thinking (rambling and irrational)
E - emotional (euphoric, fearful, angry)
L - language (repetition, rambling)
I - illusions and delirium (persecutory, tactile, visual)
R - reversal of sleep (sleep in day)
I - inattention (can't focus)
U - unaware (to time, place and person)
M - memory deficits

• It FLUCTUATES throughout the day
• There is impaired CONSCIOUSNESS (including hyperalert, drowsy, coma)

Question 25

How is delirium managed?

Answer 25

• Treat underlying cause
• Reassurance and re-orientation
• Low dose haloperidol (not in Lewy-Body)

Question 26

What is the difference between dementia and delirium?

Answer 26

Factor - Dementia vs Delirium
Onset - Gradual vs Fast
Duration - Months to years vs hours to weeks
Course - slow progression vs fluctuations
Consciousness - Intact vs Impaired
Hallucinations - No vs Yes
Delusions - Complex vs Fleeting
Sleep - Normal vs Disrupted
Attention - Normal vs Reduced
Autonomics - Normal vs Disrupted

Question 27

How is depression differentiated from dementia?

Answer 27

Depression has:

• rapid onset
• biological symptoms (Weight loss/sleep disturbance)
• mini mental state test can be variable
• global memory loss (vs dementia more recent)