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.
Comma sign on DAT scan is seen in which type of dementia?
Lewy body/PD
Shows reduction in dopamine
