Dementia and depression Flashcards
What are the effects of normal ageing on the brain?
The weight and volume of the brain decreases.
Ventricle size increases.
Decreased grey matter.
Nerve cell loss in the cortex, hippocampus, cerebellum and fewer cell connections.
New deposits: protein tangles, plaques (amyloid), lewy bodies (intracellular inclusions).
IQ peaks at 25, plateaus until 60 then declines (performance > verbal).
Working memory declines with age.
Problem solving deteriorates due to declining abstract ability and difficulty applying information to new situations.
Social: fear of death; bereavement; limited income; physical illness/disability; social isolation- living alone; loss of independence- homes.
What is delirium?
Acute confusional state/ organic brain syndrome.
Disturbance of consciousness and change in cognition that develops over a short period of time.
Reduced clarity of awareness of the environment/ reduced ability to focus, sustain, or shift attention.
Change in cognition/ memory deficit, disorientation, language disturbance.
Development of a perceptual disturbance.
Disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
How is the cause of an acute confusional state/ delirium diagnosed?
Evidence from the history, physical examination, and laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
CURB-65 score, dementia screen, puerperal period.
Symptoms developed during substance intoxication, or during or shortly after a withdrawal syndrome.
What is the epidemiology of delirium?
Prevalence in hospitalised medically ill patients ranges from 10-31%.
Most delirium occurs in the first 7-10 days of admission or within days of surgery.
Up to 50% of postoperative patients develop delirium, with patients at increased risk of they have had cardiac surgery, hip surgery, or transplantation.
Delirium is also commonly reported to occur in nursing homes, but is uncommon n community populations.
How is delirium managed?
Assessment.
Treatment of underlying condition.
Environmental management.
Tranquillisation? only if absolutely necessary.
How is dementia diagnosed?
Dementia triad: cognitive impairment/ memory loss; irreversibility; functional impairment.
Specific symptoms or signs can help guide specific subtypes, e.g.:
- pick/ frontotemporal: disinhibition/ dysexecutive
- vascular: stepwise and vascular risk factors
- Lewy body: Parkinson’s/ visual hallucinations
- Alzheimer’s disease: gradual onset.
ICD-10 criteria.
What are the ICD-10 criteria for dementia diagnosis?
Chronic/progressive brain syndrome.
Disturbed higher cortical functions including memory, thinking, orientation, comprehension, calculation, learning, language and judgement.
Consciousness is not clouded.
Commonly accompanied by deterioration in emotional control, social behaviour or motivation.
Ddx: pseudo dementia, LD, poor education, delirium, medication side effects.
What factors are assessed in the global assessment of dementia?
Memory Orientation Judgement/ problem solving Outside home At home Personal care
How is cognition/consciousness assessed?
Glasgow Coma Scale GCS /15: motor (obeys commands); verbal (oriented, converses); eyes (spontaneously open).
Orientation: TPP /3.
Abbreviated mental state /10: time, year, place, age, DOB, recall, people, WW1, PM, countdown; screening test for confusion.
Mini mental state examination /30, or MOCA.
Full cognitive assessment.
What questions are asked in a mini mental state examination (MMSE), cognitive assessment?
5 time + 5 place 5 7s 6 registration + recall 6 read, repeat, write, draw, name 3 step process Draw clock Frontal lobe: proverbs, vocabulary, executive thinking, sequencing. No prompting.
What are the biomedical treatments for dementia?
For cognitive symptoms and maintenance of function in dementia.
Cholinergic hypothesis- widespread loss of ACh in cerebral cortex due to atrophy of cells.
Symptomatic treatment: does not alter disease process- delays progression by 6 months.
Consider acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine (patch) for mild or moderate Alzheimer’s disease (MMSE <26pts).
Should be started by a specialist (e.g. memory clinic/psychiatrist).
Can improve overall state, preserve ADLs, reduce carer burden.
SE: GI upset, headache, dizziness.
Review effectiveness (MMSE) 6 monthly by GP.
Can be stopped quickly if adverse reaction.
What are BPSD (behavioural and psychological symptoms of dementia)?
Core features of dementia.
BPSD increases distress, carer burden, mortality.
Drug treatment last resort.
Behavioural: apathy, agitation, wandering, restlessness, eating agitation, disinhibition, pacing, screaming, night crying, mannerisms.
Psychological: depression, anxiety, insomnia, delusions, hallucinations, misidentification.
Physical, activity related, intrinsic to dementia, depression and delusions?
How are BPSD (behavioural and psychological symptoms of dementia) treated?
Reality orientation. Memory enhancement. Cognitive stimulation. Psychological therapies, e.g. CBT. Occupational therapy. Social services care. Day hospitals. Respite care/ support for carers- Admiral.
What are biomedical treatments for behaviour that challenges in dementia?
Antipsychotics given over 3-16 weeks modestly better than placebo for behaviour.
Risperidone and olanzapine beneficial for aggression.
Risk of stroke ? all antipsychotics.
? hasten cognitive decline.
Consider medication only if there is severe distress or an immediate risk of harm to the person with dementia or others.
Do not use in Lewy body dementia because of risk of severe adverse reactions.
Consider risk of CVA/ death.
Low dose, review regularly (6 weeks).
Depression/anxiety: antidepressants.
Agitation: avoid antipsychotics, antiCh, benzodiazepines, mood stabilisers.
Delusions/hallucinations: antipsychotics.
What is diagnostic of a depressive episode?
5 or more of the following symptoms during the same 2 week period representing a change in functioning. At least 1 of the symptoms myst be depressed mood or loss of interest or pleasure:
- depressed mood most of the day every day
- anhedonia
- weight change
- sleep change
- psychomotor disturbance
- anergia
- feelings of worthlessness/guilt
- impaired concentration/indecisiveness
- thoughts of death/ suicidality.
