Dementia/Delirium Flashcards
An 80-year-old man is diagnosed with Alzheimer’s dementia in the memory clinic after extensive clinical evaluation, cognitive examination and MRI brain scan. His past medical history includes chronic diarrhoea, hypertension, heart failure and urinary urge incontinence. His ECG shows evidence of QT prolongation which appears to be longstanding. Which of the following is the most appropriate first line management of his Alzheimer’s?
A. Risperidone
B. Cognitive stimulation therapy
C. Donepezil
D. Riluzole
E. Rivastigmine
B. CBT
The fact this patient has evidence of QT prolongation makes the prescription of anti-cholinesterase inhibitors unsafe. Also, they might make his diarrhoea and urge incontinence worse. The learning point here is that you should always check a patient’s ECG before starting anti-cholinesterase inhibitors. Contra-indications include prolonged QT, second or third degree heart block in an unpaced patient and sinus bradycardia <50 bpm. Along with Cognitive stimulation and of equal consideration are the “Bio-psycho-social” aspects of holistic management for a patient which may include a carer referral, information giving, support groups, psychoeducation, and Advance Care Planning
Egs of pharmacological management:
Donepezil, Rivastigmine and galantamine
Histological finding of Pick’s disease? what type of dementia?
One specific cause of Frontotemporal Dementia is Pick’s disease.
This is diagnosed on post-mortem where “Pick’s bodies” (accumulations of TAU protein that stain with silver) are found in the neurons.
These are histologically distinct from those TAU protein collections seen in Alzheimer’s as they stain differently and are found preferentially in other areas of the brain (preferentially damaging the frontal and temporal lobes).
what is part of confusion bloods workup:
FBC,U&Es, LFTs, coagulation/INR, haematinics (B12/folate, TFTs, bone profile, calcium, glucose and blood/urine cultures, neurosyphilis/HIV screening
tetrad of Wernicke’s encephalopathy:
ataxia, opthalmoplegia, nystagmus and acute confusional state (thiamine deficiency: and is associated with lesions in the mamillary bodies)
how does frontotemporal dementia present? Subtype:
Aetiology
Frontotemporal dementia is caused by atrophy of the frontal and temporal lobes.
Clinical features
1. Classically presents at a younger age than other forms of dementia
2. Patients exhibit early personality change and frequently become disinhibited
3. Language can also be affected early on
4. Often misdiagnosed, and neuroimaging may need to be used. Genetic tests can also be used if an inherited form is suspected (i.e. a strong family history)
5. Hyperorality:carbohydrate cravings, particularly for sweet foods, and binge eating, often to the extreme point in which patients completely fill their mouth with food and are not able to chew completely
Pick’s disease
One specific cause of Frontotemporal Dementia is Pick’s disease.
This is diagnosed on post-mortem where “Pick’s bodies” (accumulations of TAU protein that stain with silver) are found in the neurons.
These are histologically distinct from those TAU protein collections seen in Alzheimer’s as they stain differently and are found preferentially in other areas of the brain (preferentially damaging the frontal and temporal lobes).
what’s the term for an inability to recognise people, objects or places that were once known to a person.
Agnosia
4As of Alzheimer’s disease:
- Amnesia (recent memories lost first)
- Aphasia (word-finding problems, speech muddled and disjointed)
- Agnosia (recognition problems)
- Apraxia (inability to carry out skilled tasks despite normal motor function)
what are the 3 core features of lewy body dementia:
- fluctuating cognition
- parkinsonism
- visual hallucinations
clinical features of LBD:
- Accounts for around 20% of cases of dementia
- Characterised by alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
- Associated with Parkinson’s disease - patients are also highly sensitive to neuroleptics, which causes a deterioration in parkinsonism
- Three core features: fluctuating cognition, parkinsonism and visual hallucinations
- Progressive cognitive impairment seen
- Diagnosis is usually clinical but dopamine uptake scanning may be used
normal pressure hydrocephalus triad (mnemonic):
`Wet, wobbly and weird
-gait disturbance, urinary or fecal incontinence, and memory impairment.
Normal pressure hydrocephalus CT brain findings:
Enlarged ventricles and absent sulci seen on CT brain scan
This man is is presenting with the triad of “Wet, Wobbly & Weird”. This is typical of Normal Pressure Hydrocephalus, which is caused by an abnormal increase in cerebrospinal fluid (CSF) in the ventricles. The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase. The fact that he has not had headaches, nausea nor vomiting helps to point away from any causes of raised intracranial pressure
what is fluctuating course? seen in…
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline?
-seen in delirium
