Dementia and major neurocognitive disorders Flashcards
What is a major neurocognitive disorder?
Dementia - new name
Gender more affected by dementia and maybe why
- Females more than males
- Females are more likely to be carers for those with dementia = depression and isolated = risk factor for dementia (visicous cycle)
What is dementia?
- Substantial cognitive decline from previous level in 1 or more domains
- Sufficient enough to interfere with daily function
- Cognitive deficits do not exclusively occur in context of delirium
- Not another cause from mental disorder eg depression, scizophrenia
Neurocognitive domains
- Perceptual-motor function
- Language
- Learning and memory
- Social cognition
- Complex attention
- Executive function
Tests for executive function
- Category fluency - name all animals, all words beginning with A
- Tap test - tests for inhibition, if I tap once tap, if i tap twice don’t tap
- Conceptualisation - what is similar between apple and orange
- Clock drawing - how detailed?
- Abstract thinking - what does ‘fought like a lion mean’
- Judgement - if you see a smoking house what do you do?
Tests for visualspatial awareness
- Hemineglect - draw clock
- Test praxis - tell me how to use a hammer, comb, scissors
- Intersecting pentagon draw
Perceptual motor test
- Copy designs
- Show movement and copy movement
Language tests
- Impaired word finding?
- Impaired fluency?
- Hesitant speech?
4 most common types, in order, of dementia
- Alzheimers 50-75%
- Vascular 20-30%
- Dementia with Lewy bodies 10-25%
- Frontotemporal 10-15%
What is lewy body dementia sometimes meaning?
- Dementia with Lewy Bodies OR
- Parkinsons dementia
RF for dementia
- Physical inactivity
- Smoking
- Excessive alcohol consumption
- Air pollution
- Head injury - eg ex boxers
- Infrequent social contact
- Low eduction
- HTN
- Obesity
- Diabetes
- Depression
- Hearing impairement
Pathophysiology of Alzheimers
- Extracellular amyloid plaques
- Formed by amyloid beta
- Intracellular neurofibrillary tangles - from tau proteins
Normal role of tau
- Stabilise microtubules in neurones
- Microtubules help nutrients travel around neurone
Amyoid plaques and contribution to disease
Removing them does not reduce clinical progression
Are they waste product of already damaged thing?
Subtypes of amyloid beta
40
42
38
What happens in alzheimers?
- Apoptosis of neurones = widespread cortical atrophy
- Increase in some neurotransmitters
- Decrease in others eg Ach
Symptoms of Alzheimers
- confusion with time and location
- Poor judgement
- Withdrawal from social activities
- Difficulty with words
- Problem solving difficulty
- Difficult to complete regular tasks
- Misplacing items
- General memory loss
- Difficulty with words
- Random emotions
- Trouble with images and spaces
Biomarkers of Alzheimers
- CSF - Decreased amyloid beta 42, decreased 42:40 ratio, increased P and T tau, increased neurofilament light chain
- Plasma - increased T tau, increased neurofilament light chain
Imaging for biomarkers of Alzheimers
- Amyloid and Tau PET scan
- FDG PET scan for neuroinflammation (hypometabolism)
- MRI brain - atrophy
Vascular dementia RF
- Diabetes
- HTN
- Previous stroke?
- Atherosclerosis?
- MI
Imaging for vascular dementia
CT or MRI head - show areas of ischaemia
Signs/symptoms of vascular dementia
- Gait (scizzoring, shuffling, parkinson like) and bladder problems - frontal lobe affected
- Fluctuating
- Emotional fluctuations but personality ok
- Stepwise decline - ok for a while then drop off
Dementia with lewy body - who
Males affected more than females (unlike others)
Pathophysiology of DLB
- Alpha synuclein accumulates
Symptoms specific to DLB
- REM sleep disorder - act out dreams
- Anosmia - years
- Constipation
- Visual hallucinations and delusions
- Fluctuations in day - risk accidentally diagnosing delirium
- VERY sensitive to neuroleptics
- Autonomic dysfunction - urination problems, postural hypotension
Difference between DLB and parkinson dementia
- For parkinson dementia, have parkinson symptoms for 1 year before get dementia like symptoms
- DLB - cognitive decline is first
DLB sensitive to neuroleptics consequence
- If give haloperidol if agitated if suspect extreme delirium = neuroleptic malignant syndrome = BAD
- As already deficient in dopamine
Neuroleptic malignant syndrome signs
- fever
- Altered mental state
- Rigidity
- Autonomic dysfunction
Parkinsonism features of DLB
- Rigidity
- Bradykinesia
- Tremors
- Freezing
Diagnosis aid for DLB
- DAT scan - dopamine active transporter scan, nuclear scan showing dopamine transport in specific areas of brain
Frontotemporal dementia can affect
- Frontl lobe
- Temporal lobe
- Both
behavioural varient FTD symptoms
- Changes to social behaviour
- Loss empathy
- Apathy
- Disinhibition
- Lack insigns
Semantic FTD
- Loss ability to remember meaning of words, faces and objects
- Impaired object naming
- But fluent speech
Progressive non fluent aphasia dementia
- Difficult speech, takes more effort
- Can understand objects and words fine
3 types of FTD
- Behavioural variant
- Semantic
- Progressive non fluent aphasia
What is FTD associated with?
- Younger age onset
- Genetic components unlike others (+sporadic mutations too)
- Motor neurone disease + amyotrophic lateral sclerosis
Proteins in FTD
- Tau
- TDP (TAR DNA binding protein)
- FUS (fused in sarcoma)
What are TDP and FUS involved in?
Intranuclear - involved in RNA metabolism
More familial componement to FTD
Management of dementia
- Donepezil
- Rivastigmine
- Galantamine
- Memantine
Ach esterase inhibitors
Management of dementia depends on…
Reisberg stage of disease - end stage need to think about DNACPR and advanced care planning
How much dementia preventable?
40% other 60 is non-modifiable RF
What do we need to rule out in agitated, aggressive pt?
- Pain
- Constipation
- Retention
- Emotional distress
- Sleep deprivation
- Medication induced?
Management for aggressive pt with dementia - non pharm
- Music and aroma therapy
- Physical therapy
- Lighting
Pharmacological management for dementia aggressive pt (only LAST resort)
- Benzodiazepines eg Lorazepam
- Mood stabilisers
- Antipsychotics - haloperidol, risperidone (BUT these can make things worse so be careful)
