Dementia & Delirium Flashcards
1
Q
The most common cause of dementia in the UK is
A
Alzheimer’s disease
2
Q
Vascular dementia makes up ___% of dementia cases in the UK?
A
20%
3
Q
Lewy Body dementia makes up __% of dementias in the UK?
A
10-15%
4
Q
Alzheimer’s makes up __% of dementias in the UK?
A
60-70%
5
Q
MMSE stands for
A
mini-mental state examination
6
Q
A MMSE score of ____ or less out of 30 suggests dementia
A
24
7
Q
GPCOG test for cognition stands for
A
General practitioner assessment of cognition
8
Q
AMTS test for dementia stand for
A
abbreviated mental test score
9
Q
The AMT-4 test for dementia stands for
A
Abbreviated Mental Test- 4 questions
10
Q
The 6CIT test for cognition stands for
A
Six-item Cognitive Impairment Test (6CIT)
11
Q
The IQCODE test for dementia stands for
A
Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
12
Q
Blood screen tests in primary care to rule out reversible causes of dementia
A
NICE recommend the following tests:
* FBC,
* U&E,
* LFTs,
* calcium,
* glucose,
* ESR/CRP,
* TFTs,
* vitamin B12 and folate levels. Patients are now commonly also referred on to old-age psychiatrists (sometimes working in ‘memory clinics’).
13
Q
Reversible causes of dementia
A
- Alcohol (thiamine def)
- Drug abuse (barbituates)
- Vitamin B12/ folate deficiency
- Hypothyroidism
- Addison’s
- Infections such as HIV, Syphillis and UTIs
- Tumors or haematomas that place pressure on the brain
- Depression
14
Q
In secondary care, it is essential to carry out _____ to rule out any other causes of reversible dementia and provide information of aetiology
A
Neuroimaging
15
Q
Reversible causes of dementia that may be picked up on neuroimaging
A
- Subdural haematoma,
- normal pressure hydrocephalus
- Tumour
16
Q
Multi-infarct dementia is that which is caused by
A
Cerebrovascular disease (stroke)
17
Q
Dementia secondary to stroke makes up ____% of strokes
A
10-20%
18
Q
Rare causes of dementia (5%)
A
- Huntington’s
- CJD
- Pick’s disease (atrophy of frontal and temporal lobes)
- HIV (50% of AIDS patients)
19
Q
Frontotemporal dementia is also known as
A
Pick’s disease
20
Q
Risk factors for Alzheimer’s Disease
A
- Increasing age
- family history
- Caucasian ethnicity
Down’s syndrome - 5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form - apoprotein E allele E4 - encodes a cholesterol transport protein
21
Q
Macroscopic changes in Alzheimer’s (physical visual brain changes)
A
widespread cerebral atrophy, particularly involving the cortex and hippocampus
22
Q
Microscopic changes in Alzheimer’s
A
- Cortical plaques due to deposition of type A-Beta-amyloid protein and
- **intraneuronal neurofibrillary tangles ** caused by abnormal aggregation of the tau protein
hyperphosphorylation of the tau protein has been linked to AD
23
Q
Biochemical changes in Alzheimer’s
A
there is a deficit of acetylcholine from damage to an ascending forebrain projection
24
Q
Describe what neurofibrillary tangles are:
A
They are paired helical filaments are partly made from a protein called tau
tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules
in AD are tau proteins are excessively phosphorylated, impairing its function
25
Non-Pharmacological management of Alzheimer's
* NICE recommend offering 'a range of activities to promote wellbeing that are tailored to the person's preference'
* NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia
* other options to consider include group reminiscence therapy and cognitive rehabilitation
26
1st line pharmacological management of Alzheimer's
the three **acetylcholinesterase inhibitors** :
**donepezil
galantamine** and **rivastigmine**
to managing mild to moderate Alzheimer's disease
27
2nd line pharmacological management of Alzheimer's
**memantine (an NMDA receptor antagonist) **
28
Memantine, the 2nd line treatment of Alzheimer's is recommended by NICE to be used in which circumstances?
* **moderate Alzheimer's** who are **intolerant** of, or have a **contraindication** to, acetylcholinesterase inhibitors
* as an **add-on drug** to acetylcholinesterase inhibitors for patients with **moderate or severe Alzheimer's**
* monotherapy in **severe Alzheimer's**
29
NICE does not recommend ___
for mild to moderate depression in patients with dementia
Antidepressants
30
antipsychotics should only be used for dementias patients when:
They are at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
31
Donezepil is contraindicated in
* bradycardia
32
Adverse effect of Donezepil
Insomnia
33
____ is the third most common type of cortical dementia after Alzheimer's and Lewy body dementia.
Frontotemporal lobar degeneration (FTLD)
34
There are three recognised types of FTLD
(Frontotemporal Lobar Dementia)
* Frontotemporal dementia (Pick's disease)
* Progressive non fluent aphasia (chronic progressive aphasia, CPA)
* Semantic dementia
35
The onset of frontotemporal lobar dementia is usually
before 65
36
The nature of the onset of frontotemporal lobar dementia is an ____ one
insidious
37
In frontotemporal lobar dementias, memory is relatively ____
preserved
38
A classic feature of frontotemporal lobar dementia is
Personality change and social conduct problems
39
The most common type of frontotemporal lobar dementia is
Pick's Disease
40
Pick's Disease is characterised by:
personality change and impaired social conduct
41
Features of Pick's disease
* personality change
* impaired social conduct
* hyperorality,
* disinhibition,
* increased appetite,
* and perseveration behaviours.
42
Features of Pick's Disease present in the frontal and temporal lobes?
Focal gyral atrophy with a knife-blade appearance
43
Macroscopic changes in Pick's Disease
Atrophy of the frontal and temporal lobes
44
Microscopic changes in Pick's Disease
* Pick bodies - spherical aggregations of tau protein (silver-staining)
* Gliosis
* Neurofibrillary tangles
* Senile plaques
45
NICE do not recommend that ____ or ____ are used in people with frontotemporal dementia (because they can make the symptoms worse)
AChE inhibitors or memantine
46
CPA stands for
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
47
Characteristics of chronic progressive aphasia
Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
48
Characteristics of Semantic Dementia
Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning.
Unlike in Alzheimer's memory is better for recent rather than remote events.
49
What actually are Lewy Bodies?
alpha-synuclein cytoplasmic inclusions
50
What is a characteristic pathological feature of Lewy Body dementia?
alpha-synuclein cytoplasmic inclusions (Lewy bodies)
51
Where are Lewy Bodies found in the brain in Lewy Body Dementia?
in the substantia nigra, paralimbic and neocortical areas.
52
Features of Lewy Body Dementia
* progressive cognitive impairment
-occurs before parkinsonism
-fluctuating cognition
-in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss
* parkinsonism
* visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
53
Difference between Lewy body dementia parkinsonism and Parkinson's with dementia?
* Lewy body dementia typically occurs before parkinsonism
* in contrast, in Parkinson's disease, the motor symptoms typically present at least one year before cognitive symptoms (dementia)
54
Diagnosis for Lewy Body dementia is usually ____
Clinical
55
single-photon emission computed tomography (SPECT) is increasingly used in the diagnosis of ________ dementia
Lewy Body
56
Drug treatment for Lewy Body Dementia
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's.
57
____ should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism
neuroleptics
58
Factors favouring delirium over dementia
* acute onset
* impairment of consciousness
* fluctuation of symptoms: worse at night, periods of normality
* abnormal perception (e.g. illusions and hallucinations)
* agitation, fear
* delusions
59
____is the second most common form of dementia after Alzheimer disease
Vascular dementia (VD)
60
61
Vascular dementia is not a single disease but ____
It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease
62
Stroke ____ the risk of developing dementia
Doubles
63
There are 3 main subtypes of Vascular Dementia:
* Stroke-related VD – multi-infarct or single-infarct dementia
* Subcortical VD – caused by small vessel disease
* Mixed dementia – the presence of both VD and Alzheimer’s disease
64
Risk Factors for Vascular Dementia
-History of stroke or TIA
-Atrial fibrillation
-Hypertension
-Diabetes mellitus
-Hyperlipidaemia
-Smoking
-Obesity
-Coronary heart disease
-A family history of stroke or cardiovascular
65
Rarely, VD can be inherited as in the case of ____
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
66
Classical presentation of Vascular Dementia
Several months or several years of a history of a sudden or **stepwise deterioration **of cognitive function.
67
Symptoms of Vascular Dementia
-Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
-The difficulty with attention and concentration
-Seizures
-Memory disturbance
-Gait disturbance
-Speech disturbance
-Emotional disturbance
68
Ways in which vascular dementia is diagnosed
* A comprehensive history and physical examination
* Formal screen for cognitive impairment
* Medical review to exclude medication cause of cognitive decline
* MRI scan – may show infarcts and extensive white matter changes
69
General management of vascular dementia
* Treatment is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers
* Important to detect and address cardiovascular risk factors – for slowing down the progression
70
Is there any specific pharmacological management of vascular dementia?
No
70
Non-pharmacological management of vascular dementia is tailored to the individual. This includes:
Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy
Managing challenging behaviours e.g. address pain, avoid overcrowding, clear communication
70
When should AChE inhibitors or memantine only be considered for people with vascular dementia?
Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.
71
Acuet confusional state is also known as:
delirium or acute organic brain syndrome.
72
Predisposing factors to delirium
* age > 65 years
* background of dementia
* significant injury e.g. hip fracture
* frailty or multimorbidity
* polypharmacy
73
Examples of possible causes of delirium
* infection: particularly UTIs
* metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
* change of environment
* any significant cardiovascular, respiratory, neurological or endocrine condition
* severe pain
* alcohol withdrawal
* constipation
74
Features of delirium
* memory disturbances (loss of short term > long term)
* may be very agitated or withdrawn
* disorientation
* mood change
* visual hallucinations
* disturbed sleep cycle
* poor attention
75
There are 2 types of delirium
1. Hyperactive
2. Hypoactive
(can also have mixed)
76
Management of delirium
* treatment of the underlying cause
* modification of the environment
* Consider drug treatment if other methods are not working
77
What is the first-line sedative for delirium if needed?
haloperidol 0.5 mg as the first-line sedative
78
When should a sedative be used to control delirium?
At a last resort, only when the patient is at risk to themselves or others
79
Why can't haloperidol be used to help with delirium in Parkinson's?
antipsychotics can often worsen Parkinsonian symptoms
80
What drug is used as a sedative against delirium in patients with Parkinson's?
atypical antipsychotics quetiapine,clozapine and olanzapine are preferred
81
What drug can't be used to sedate delirium in Parkinson's and why?
Haloperidol because it is a typical antipsychotic and that can worsen parkinsons symptoms
