Dementia (and MCI) Flashcards
What is the NICE guidelines for non-pharmacological and pharmacological management of dementia?
Diagnosis and initiation by clinician with necessary knowledge & skills
Pharmacological
-
Alzheimer’s –
- AChEI
- +/- Memantine for mild to moderate; Memantine for moderate if intolerant to AChEI or 1st line for severe
-
Dementia with Lewy Bodies
- AChEI
-
Vascular-
- None
- AChEI only if co-morbid Alzheimer’s or DLB
Do not stop AChE inhibitors because of disease severity alone
Non-pharmacological
- Social services
- OT
- Telecare
- Neuropsychology
What is the management of BPSD?
Non-pharmacological:
- educating carers,
- improving communication,
- activities etc
Medication:
- Only if severely distressed or there is an immediate risk of harm to the person or others.
- Often not needed long-term - review efficacy, stop if not helping but also consider withdrawal once symptoms have improved
- x3 increased CVA risk with Rosperidone and Olanzapine but Rosperidone has a short term license in dementia for aggression
Define dementia.
Dementia is a progressive, irreversible clinical syndrome with a range of cognitive and behavioural symptoms causing a reduction in the person’s ability to carry out ADLs.
Decline in cognition is extensive, often affecting multiple domains of intellectual functioning + is not entirely attributable to normal ageing.
How long do symptoms need to be present for a diagnosis of dementia?
Symptoms should be present for at least 6 months in clear consciousness.
What are the clinical features of dementia?
- Cognitive decline - especially recent memory but all other cortical areas affected:
- Language
- Visuo-spatial skills
- Abstract thinking
- Judgement
- Behavioural & psychological symptoms of dementia:
- Mood changes - anxiety and depression may develop early
- Abnormal behaviour
- Hallucinations and delusions
- Hx of gradual memory loss
- Reduced repertoire of activities
- Less able to manage finances
- Revert to native language
- Getting lost/disorientated
- Symptoms worsen on holiday
- Lack of insight (especially in Alzheimer’s)
What criteria must be met for diagnosis of dementia? (NICE CKS)
For a diagnosis of dementia to be made, the person must have impairment:
- In at least two of the following cognitive domains: (1)memory, (2)language, (3)behaviour, (4)visuospatial or (5)executive function.
- …which causes a significant functional decline in usual activities or work.
- …which cannot be explained by delirium or other major psychiatric disorder.
Give some examples of ADLs.
- Financial management
- Using the toilet
- Washing
- Dressing
- Grooming
- Shopping
- Cooking
- Housework
- Mobilizing/transfers/stairs
What are some BPSDs that can occur in dementia?
(*Behavioural and Psychological Symptoms of Dementia)
- motor disturbance e.g. wandering or repetitiveness
- sleep disturbance/day-night reversal
- delusions
- hallucinations
- calling out, shouting, screaming, swearing
- social or sexual disinhibition
- agitation
- emotional lability, depression, anxiety, apathy
These usually occur later.
.
What are the different conditions under the umbrella term dementia?
- Alzheimer’s - 60-80%
- Lewy body dementia - 5-10%
- Vascular dementia - 5-10%
- Frontotemporal dementia - 5-10%
- Mixed dementia
- Parkinson’s, Huntington’s and others
How common is dementia?
- 5-10% of >65s
- 20% of >80s
- Female>male
- Increasing incidence
What mood disorder can mimic dementia?
Depression - “depressive pseudodementia” is not very clear cut though. Important to ask about mood in suspected delirium
What is the most common type of dementia?
Alzheimer’s disease
What is the aetiology of Alzheimer’s disease?/What are the risk factors?
- Age - MAIN, more common in F
- Genetics - familial early-onset AD is usually de to autosomal dominant gene mutations causing increased beta-amyloid e.g. presenilin 1 or 2 (chr 14 and 1 respectively), beta-amyloid precursor protein (APP) gene (chr21). Late onset is associated with Apolipoprotein E4 allele (chr9) which probably increases arteriosclerosis.
- Vascular risk factors e.g. HTN
- Low IQ/poor educational level
- Head injury
Why are patients with Down syndrome more at risk of AD by middle age?
They have an extra copy of the APP gene which is on Chr21
What is the pathophsyiology of Alzheimer’s disease?
(1) Amyloid plaques + (2) neurofibrillary tangles + (3) cell loss/atrophy –> loss of cholinergic neuronal function
Macroscopically this results in atrophy, widened sulci and dilated ventricles. MRI/CT shows hippocampal atrophy (medial temporal lobe atrophy)
Where does atrophy most occur in AD? What is the result?
Hippocampus –> loss of new learning and visuospatial skills
Then temporal and parietal lobes affected later.
How do plaques form in AD?
- APP is abnormally cleaced into beta-amyloid which aggregates into insoluble lumps
- These then get surroundded by dystrophic neurites filled with hyperphosphorylated tau protein
How do neurofibrullary tangles form in AD?
Hyperphosphorylated tau protein (which is abnormal) usually holds microtubules together within a neurom but when phosphorylated it cannot attach to microtubules so accumulates as as insoluble paired helical filaments.
These become tangles which fill up the neuron and kill it. The severity of dementia is most closely linked with number of NFTs.
What are the 4 A’s of AD?
- Amnesia - forget recent memories and become disorientated
- Aphasia - word-finding problems occur e.g. muffled speech
- Agnosia - recognition problems e.g. faces (prosopagnosia)
- Apraxia - can’t carry out skilled tasks
What are the features of vascular dementia?
- Acute onset, stepwise progression
- Hx TIA, CVA, HTN, vascular risk factors
- Emotional lability
- Personality and insight preserved to an extent
- May have focal neurological signs
What are the features of dementia with Lewy bodies?
- Rapid fluctuation in cognitive abilities
- Visual hallucination
- Falls
- Parkinsonian symptoms
- Neuroleptic sensitivity
What is the inheritance pattern of Huntington’s? When does it present in life?
Autosomal dominant
Presents 30s to 40s
What are the clinical features of Huntington’s?
Psychiatric - depression, irritability, suicide (9%)
Cognitive - flexibility, organising, impulse control, leanring new information
Movement - chorea, speech/swallowing, dystonia, gait
What is the life expectancy of Huntington’s after diagnosis?
20 years after diagnosis
What are the features of fronto-temporal dementia?
- Personality change
- Behavioural problems
- Early loss of insight
- Hyperorality
Apart from depression and delirium, what are the other differentials for dementia?
- CJD
- Alcoholic dementia
- Neurosyphilis
- Normal pressure hhydrocephalus
- HIV
- Vitamin deficiencies
- Tumours
What investigations can be used in the assessment of dementia?
- AMTS - crude (less sensitive and less specific than other tests), score <7 indicates cognitive impairment
- GP-COG, 6 CIT
- Addenbrooke’s Cognitive Examination III (ACEIII) - score less than 82 is abnormal; used in clinics and takes ~20min
- MoCA
- RUDAS
What clinical + laboratory investigations should be done for dementia?
Dementia screen:
- FBC, U&E
- TFTs
- B12, folate, Ca
- Fasting glucose and lipids
- VDRL and HIV to rule out reversible causes
Scans:
- MRI brain - alternatively CT; not all need to be scanned; preferably young patients with rapid progression and neurological symptoms
What neurotransmitter is decreased in dementia?
50% reduction in ACh
What is the MOA of medications used for dementia?
- Reversible cholinesterase inhibitors (AChEI) - Donepezil, Galantamine, Rivastigmine
- Non-competitive glutamate receptor antagonists - Memantine
How effective at AChEI in dementia?
- Placebo controlled trials showed improvement in cognition over baseline at end of 6 months
- May improve behavioural symptoms
- Delay to institutional care
- They are reversible
What are the side effects associated with AChEI?
Common 1 in 10 :
- GI upset,
- agitation,
- fatigue,
- dizziness,
- muscle cramps,
- rash,
- syncope,
- headache
Uncommon 1 in 100 :
- Bradycardia,
- duodenal/ gastric ulcers,
- G-I haemorrhage,
- seizures
Rare 1 in 10,000
- AV/sino-atrial block,
- extrapyramidal symptoms,
- hepatitis,
- bladder outflow obstruction
What are the preferred medical treatment options for these types of dementia?
- Alzheimer’s
- Lewy body
- Vascular
- Alzheimer’s –AChEI +/- Memantine for mild to moderate, Memantine for moderate if intolerant to AChEI or 1st line for severe
- Lewy Body - AChEI
- Vascular- none; AChEI only if co-morbid Alzheimer’s or DLB
Do not stop AChEI due to progression in disease severity alone.
What type of dementia are glutamate receptor antagonists recommended for?
Moderate/severe Alzheimer’s disease
or with contraindication to AChE
or can also be added to AChEI in moderate disease
What are the non-pharmacological treatment options for dementia?
Non-pharmacological
Social services
OT
Telecare
Neuropsychology
What is the best medication for aggression in dementia?
Risperidone (only one with a short term license for treating BPSEs in Alzheimer’s disease)
- Increasing concerns about high prescribing of anti-psychotics and benzodiazepines in care homes for people with dementia*
- However, Quetiapine can also be used as it is milder than Rosperidone.*
What are the risks of olanzapine and risperidone use in those with dementia?
3x increased risk of CVA
Should not be used routinely
What is mild cognitive impairment?
Dementia-like syndrome
with early stage memory loss or other cognitive ability loss
but still able to independently perform most activities of daily living.
What % of those with MCI will progress to dementia?
30% in 3 years will develop dementia
What is the aim of memory clinics?
- MDT run by old age psychiatrists, neurologists or geriatricians
- Assess and diagnose dementia
- Advise on managing BPSD
- Manage medication
- Provide support post-diagnosis
- Research trials
Can patients with dementia drive?
Do not have to stop driving (1/3 still drive) but must inform DVLA and insurers (patient does this)
License is renewed annually
How do you assess capacity in dementia (and elsewhere)? What planning is necessary?
- Understand
- Retain
- Use or weigh information
- Communicate decision
- Assume capacity, decision specific, facilitate optimum environment*
- Encouraged to appoint LPA to manage health and finances*
What are the causes of a low MMSE?
- Dementia
- Delirium
- Psychiatric illness in general including psychosis, depression, anxiety
- Learning disability
- Sensory impairment
- Language barrier
- Feeling unwell, tired, irritable
How should you manage psychosis in dementia? (old age teaching day)
- AChEi
- Clozapine (small doses divided over course of the day) - works mainly on D3 and D4 receptors.
Comma sign on DAT scan is seen in which type of dementia?
Lewy body/PD
Shows reduction in dopamine
How do social services help with dementia?
- Asked to help with washing, cooking etc.
- The council will come to assess and allocate some carers to come in
NB: OT would do the initial assessment e.g. movement, fire alarms etc. but these responsibilities are later passed on to social services.
