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E4 - Intergrated Care (S) > Dementia COPY > Flashcards

Dementia COPY Flashcards

1
Q

What is dementia?

A

A syndrome characterised by:

  • Progressive (usually irreversible) global cognitive deficit compared to baseline
  • Significant impairment of normal functioning
  • Definite Dx: symptoms lasting 6+ months
  • Tentative Dx: symptoms lasting less than 6 months
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2
Q

What are the cognitive deficits seen in dementia?

A
  • Memory impairment
  • Impaired executive function
  • Dysphagia
  • Agnosia
  • Apraxia: loss of motor function
  • Personality disintegration
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3
Q

What is executive function?

A

A set of cognitive processes that enable planning, organising, and completion of tasks.

e.g. Problem solving, abstraction, reasoning, decision making, judgement, planning, organisation, processing

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4
Q

What are the common causes of dementia?

A
  • Alzheimer’s disease (50-60%)
  • Vascular dementia (20-25%)
  • Mixed dementia
  • Lewy body dementia (10-15%)
  • Frontal-temporal dementia (7%)
  • Other e.g. CJD, AIDS dementia, Alcohol dementia (3%)
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5
Q

What differential diagnoses must be excluded for a diagnosis of dementia?

A
  • Delirium
  • Depression
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6
Q

Name 3 reversible causes of dementia

A
  • Subdural haematoma
  • Normal pressure hydrocephalus
  • Chronic alcohol misuse
  • Metabolic
    • Vitamin B12 deficiency
    • Hypothyroidism
    • Hypoglycaemia
  • Neurosyphilis
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7
Q

What is the characteristic of fronto-temporal cortical dementia?

A

Prominent personality change, may manifest as frontal lobe syndrome

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8
Q

Describe the prevalence of dementia?

A
  • 830,000 in the UK
  • Over 65: 1 in 20
  • Over 75: 1 in 10
  • Over 85: 1 in 5
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9
Q

What is Alzheimer’s disease?

A

The commonest form of dementia. A degenerative disease of the brain with prominent cognitive and behavioural impairment. Significantly interferes with social and occupational function.

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10
Q

List 3 risk factors for Alzheimer’s disease

A
  • Increasing age
  • FHx of AD or early-onset AD
  • Down’s syndrome
  • FHx of Down’s syndrome
  • Previous head injury
  • Hypothyroidism
  • Parkinson’s disease
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11
Q

Name 4 risk factors for Dementia

A
  • Genetic: Apolipoprotein E
  • Vascular: smoking, alcohol, obesity, HTN, DM, CV disease
  • Other: Cholesterol diet, lower education, poor social network
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12
Q

Name 4 protective factors for Dementia

A
  • Diet: Vitamin E and C
  • Exercise
  • Mental and social activity
  • More complex work ➔ reduced hippocampal atrophy
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13
Q

What is the association between Alzheimer’s disease and Down’s syndrome

A

Chromosome 21:

  • AD: the gene for amyloid precursor protein ➔ amyloid plaques
  • DS: trisomy 21 People with Down’s syndrome have an extra Chromosome 21 ➔ accelerated production of amyloid plaques ➔ earlier dementia
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14
Q

What are the 3 symptomatic domains of Alzheimer’s disease?

A
  • Cognitive
  • Functional: ADLs
  • Neuropsychiatric
    • Mood/affect disturbances
    • Aggression
    • Anxiety
    • Psychosis
    • Sleep disturbances
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15
Q

Describe the memory problems in Alzheimer’s disease

A
  • Early impairment of immediate and short-term memory, due to atrophy of the hippocampus.
  • Long-term (remote) memory declines with progression
  • Common to also have disorientation of time and place
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16
Q

List 4 early symptoms of Alzheimer’s disease

A
  • Impaired immediate and short-term memory
  • Disorientation of time and place
  • Muddled efficacy with ADLs
  • Spatial dysfunction
  • Behavioural: Wandering, irritability
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17
Q

List 3 middle symptoms of Alzheimer’s disease

A
  • Intellectual and personality deterioration
  • Aphasia
  • Apraxia
  • Agnosia (inability to process sensory information)
  • Impaired executive function
  • Impaired visuospatial skills: getting lost, impaired driving
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18
Q

List 3 late symptoms of Alzheimer’s disease

A
  • Fully dependent
  • Physical deterioration
  • Incontinence
  • Gait abnormalities
  • Spasticity Seizures (3%)
  • Tremors
  • Extrapyramidal signs
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19
Q

What psychotic symptoms may appear in Alzheimer’s disease?

A

Delusions (15%) - usually paranoid Hallucinations (10-15%) - auditory or visual

20
Q

Name 3 behavioural disturbances present in Alzheimer’s disease?

A

Aggression Wandering Explosive temper Sexual disinhibition Incontinence

21
Q

How does early-onset Alzheimer’s disease differ from typical AD?

A

More aphasia and apraxia Rapid course with severe intellectual decline Poor survival rate

22
Q

List 3 factors associated with a poorer prognosis of Alzheimer’s disease

A

Greater severity at presentation Male Early-onset (<65) Parietal lobe damage Prominent behavioural problems Severe focal cognitive deficits - apraxia, aphasia Observed depression Absence of delusional misidentification syndrome

23
Q

How can Alzheimer’s disease be assessed?

A

Mental state examination Cognitive testing: Clock drawing test, MMSE Bloods: FBC, LFT, U&Es, TSH, Vit B12, HIV etc. CT head: cortical atrophy esp in medial temporal lobes (hippocampus), ventricular enlargement

24
Q

What is the pharmacological management of mild-moderate Alzheimer’s disease?

A

AChEIs: Donepezil, Rivastigmine, Galantine Use one with lowest acquisition cost

25
Q

What is the indication for Memantine?

A

Moderate Alzheimer’s disease where AChEIs are contraindicated or not tolerated. Severe Alzheimer’s disease

26
Q

What is the mechanism of action of Memantine?

A
  • NMDA-receptor partial antagonist
  • NMDA binds to glutamate (excitatory) in the CNS: role in long-term memory and learning.
27
Q

Name 3 risk factors for Vascular dementia

A

Male Family or personal Hx of cardiovascular disease CV risk: smoking, diabetes, HTN, hyperlipidaemia

28
Q

Which features are suggestive of Vascular dementia?

A
  • Sudden onset
  • Stepwise deterioration
  • Cardiovascular risk factors
29
Q

How can the presentation of vascular dementia be categorised?

A
  • Cognitive deficits following a single stroke
    • Deficits depend on site of infarct
  • Multi-infarct dementia
    • Stepwise deterioration in cognitive function
    • Relative stability between strokes
  • Binwangers disease: progressive small-vessel disease
    • Gradual intellectual decline
    • Generalised slowing
    • Motor problems
30
Q

Describe the presentation of Vascular dementia

A

Onset may follow a stroke More acute onset than Alzheimer’s disease Early: emotional and personality changes Cognitive deficits - fluctuate Behavioural slowing and anxiety Common: depression with affective lability and confusion, especially at night. Physical signs of arteriovascular disease and neurological impairment.

31
Q

What is included in the routine dementia screen?

A
  • TFTs
  • Vit B12
  • FBC, ESR and CRP: anaemia and vasculitis
  • LFTs and U&Es
  • Glucose
  • CT head
32
Q

Outline the management of Vascular dementia

A

Manage risk factors: Diet, exercise, smoking cessation, less alcohol

Medication: Aspirin, clopidogrel, statins, ACEi, Diabetes medication.

33
Q

When would a CXR be done when investigating dementia?

A

Indication of malignancy, especially of small-cell lung cancer due to its paraneoplastic syndromes resembling neurological deficits in dementia.

34
Q

Name 1 infectious causes of reversible dementia

A
  • HIV
  • Syphilis
  • TB
  • Meningitis
35
Q

What personality and behavioural changes can occur in dementia?

A

Introverted and socially withdrawn Aggression Irritable Disinhibited Restless Wandering

36
Q

Outline the pathophysiology of Alzheimer’s disease

A

Accumulation of amyloid plaques and neurofibrillary tangles of tau proteins (Tau deposits in hippocampus/medial temporal lobes).

37
Q

Outline the pathophysiology of Vascular dementia

A

Thromboembolic or hypertensive infarctions of small/medium-sized vessels. Patients may present well depending on location of infarcts. They would have difficulties with other cognitive functions such as orientation.

38
Q

Outline pathophysiology of Lewy body dementia

A

Accumulation of Lewy bodies (alpha-synuclein and ubiquitin) in the cerebrum and substantia nigra.

39
Q

What are the characteristic clinical features of Lewy body dementia?

A
  • Fluctuating cognitive impairment
  • Spontaneous parkinsonism
  • Vivid visual hallucinations
  • Additional: REM sleep disturbance - treated with clonazepam
40
Q

Why should antipsychotics be avoided in Lewy body dementia?

A

Antipsychotics can precipitate irreversible parkinsonism, autonomic dysregulation (similar to neuroleptic malignant syndrome), reduce consciousness, and increases mortality rates 2-3 fold.

41
Q

Outline primary prevention of dementia

A
  • Vascular and lifestyle factor modifications
    • HTN, obesity, diabetes, heart failure, smoking, alcohol
  • Intellectually stimulating activities
  • Participation in social, physical, and intellectual activities
  • Extensive social network
42
Q

Outline secondary prevention of dementia

A

Identify any mild cognitive impairment (MCI) Biochemical marks in serum and CSF for amyloid and tau proteins PET scan - amyloid deposits Volumetric MRI - medial temporal lobe atrophy

43
Q

Outline tertiary prevention of dementia

A

Cognitive training Psychosocial support for patient and carer AChE inhibitors (donepezil, rivastigmine, galantamine) NMDA antagonist (memantine) Antidepressants

44
Q

Define mild cognitive impairment

A

Focal cognitive impairment that is not severe enough to interfere with daily life and function.

45
Q

What percentage of people with Mild cognitive impairment progress to dementia?

A

10-15%

46
Q

Differentiate dementia from delirium

A

Delirium has altered consciousness and attention. Dementia: Gradual onset, duration months to years, progressive deterioration, normal consciousness, perceptional disturbances occur later, normal sleep-wake cycle. Delirium: Acute onset, duration hours to weeks, fluctuating course, impaired consciousness, perceptional disturbances are common, disrupted sleep-wake cycle.

47
Q

What is the indication for Memantine?

A

Severe dementia: typically MMSE <10

E4 - Intergrated Care (S) (18 decks)

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