Dementia and Delirium Flashcards
Dementia is a chronic, progressive syndrome of insidious onset.
List 4 cognitive symptoms and the associated brain lobe
- Impaired memory, Temporal
- Impaired orientation, Temporal
- Impaired learning capacity, Temporal
- Impaired judgment, Frontal
List 4 types of non-cognitive symptoms of Dementia
- Behavioural (Agitation, Aggression, Wandering, Sexual disinhibition)
- Depression + Anxiety
- Psychotic features (V+A Hallucinations, Delusions)
- Sleep symptoms (Insomnia, daytime drowsiness)
Describe the diagnosis of Dementia by exclusion
What features do you look for?
- Exclude delirium
- Exclude organic causes of cognitive decline
- Progressive cognitive decline
- Impairment of activities of daily living
- Normal consciousness level
List 4 organic causes of cognitive decline
- Hypothyroidism
- Hypercalcaemia
- B12 deficiency
- Normal pressure hydrocephalus (Abnormal gait, Incontinence, Confusion)
List 5 types of Dementia
- Alzheimer’s (50-70%)
- Vascular dementia (25%)
- Dementia with Lewy bodies (15%)
- Frontotemporal dementia
- AIDS dementia complex
List the Macroscopic pathological features of Alzheimer’s
- Global cortical atrophy
- Widening of Sulci
- Enlarged ventricles (mainly Lateral and 3rd)
List the Microscopic pathological features of Alzheimer’s
- Amyloid beta plaques
- Neurofibrillary Tangles (Intracellular hyperphosphorylated tau filaments)
These 2 features kill neurones, mainly;
- Cholinergic
- Noradrenergic
- Serotonergic
- Those expressing Somatostatin
Is Alzheimer’s more common in Women or Men?
Women
Describe the pharmacological management of Alzheimer’s
- Cholinesterase inhibitors (slow it down)
- Antidepressants
- Antipsychotics (controversial)
(Non-pharmacological: Occupational Therapy, Community services, ID bracelets)
In vascular dementia, cognitive impairment is caused by CVD (many small strokes)
List some risk factors (same as for Alzheimer’s and any vascular disease)
- Smoking
- Diabetes
- Hypertension
- Hypercholesterolaemia
- Previous stroke/ MI
Describe the management of Vascular dementia
To reduce risk of further sclerotic/ embolitic effects
- Antiplatelets/ anticoagulants
- Lifestyle changes
- Statins
- BP control
- Glycaemic control
- Carotid endarterectomy if carotid stenosis> 70%
- Cholinesterase inhibitors if Alzheimer’s also present
Describe the link between Dementia with Lewy Bodies and Parkinson’s
- Essentially same disease
- Parkinson’s: Movement disorder BEFORE dementia
- DwLB: Dementia BEFORE movement disorder
Describe the pathology of Dementia with Lewy Bodies
Common to have co-existing Alzheimer’s
- Accumulation of Lewy bodies (which are aggregates of the protein Alpha Synuclein)
Main deposits found in;
- Substantia Nigra
- Cingulate gyrus
- Temporal lobe
- Frontal lobe
The greatest risk factor for Dementia with Lewy Bodies is old age
How does it present?
- Fluctuating cognition and alertness
- Vivid visual hallucinations
- Parkinsonian features (falls, motor symptoms)
- Loss of Atonia during REM seep
Describe the management of Dementia with Lewy Bodies
- Carbidopa + Levidopa if motor symptoms present and severe
Similar to Alzheimer’s;
- Cholinesterase inhibitors
- Antidepressants
Why can’t you give Antipsychotics to patients with Dementia with Lewy Bodies?
Antipsychotics are Dopamine Antagonists, can cause Neuroleptic Malignant Syndrome (a psychiatric emergency)
How does Neuroleptic Malignant Syndrome present?
- Fever
- Encephalopathy (confusion)
- Instable vital signs (Raised RR, HR, fluctuating BP)
- Elevated CPK
- Rigidity (due to dopamine antagonism)
Frontotemporal dementia is the 2nd most common cause of early onset dementia.
Describe the pathology
Atrophy of Frontal and Temporal lobes
Cellular inclusions: FTD-Tau and FTD-U
(Possible element of family history)
How does Frontotemporal dementia present?
Most symptoms related to Frontal lobe
- Behavioural disinhibition
- Inappropriate social behaviour
- Loss of motivation without depression
- Repetitive behaviours
- Expressive dysphasia
What are the 3 behavioural presentations of Frontotemporal dementia
- Apathetic
- Disinhibited
- Stereotyping
(Can overlap)
How is Frontotemporal dementia managed?
- SSRIs (to treat compulsive behaviours e.g gambling)
- Home assistance
- Anxiolytics (e.g Benzodiazepines)
As patients with HIV live longer, their chance of developing AIDS associated Dementia increases.
Describe the pathology
- HIV-infected macrophages enter the brain and directly damage neurones
- Insidious onset, but rapid progression
Describe the clinical features of AIDS-Dementia Complex
Related to global damage, but also some Cerebellar involvement
- Cognitive impairment
- Psychomotor retardation (slow thoughts and movements)
- Tremor
- Ataxia
- Dysarthria
- Incontinence
Describe the investigations for Dementia
Investigations to rule out other possible causes
- Mini Mental State Exam
- Dementia screen (FBC for Anaemia, TSH, B12, U&E for Na, Ca, Glucose)
- Urine drug screen
- CT head
- MRI brain
- ECG in Vascular Dementia
- Syphilis testing if history is suggestive
