Dementia, Delirium and Cognitive Impairment Tools Flashcards
Give 4 risk factors for Alzheimer’s Disease?
Increased age 1st degree Family History CV disease Vascular risk factors- smoking, hypertension, hypercholesterolaemia, diabetes, obesity Depression Loneliness Down's Syndrome Severe head injury
What is the pathophysiology of Alzheimer’s Disease?
Accumulation of beta-amyloid peptide (which forms amyloid plaques) and accumulation of tau protein (which forms neurofibrillary tangles). Results in progressive neuronal damage and loss of acetylcholine
Give 4 clinical features of early stage Alzheimer’s Disease
Forget recent events Forget names of objects Misplace items Increased anxiety Ask questions repeatedly Show poor judgement Hesitant to try new things Periods of confusion
Give 4 clinical features of middle stage Alzheimer’s Disease
Increased disorientation Repetitive behaviour Disturbed sleep Difficulty judging distance Delusions Aphasia Frequent mood swings Hallucinations
Give 4 clinical features of late stage Alzheimer’s Disease
Dysphagia Incontinence Weight loss Increased severity of pervious symptoms Violent behaviour Loss of speech Poor mobility
How is Alzheimer’s disease managed?
Memory assessment
CT/MRI Head
Rule out depression
Acetylcholinesterase inhibitors- Donepezil, Rivastigmine, Galantamine
Antiglutamatergic drugs- Memantine (NMDA antagonist)
Vitamin E supplements
What is the pathophysiology of vascular dementia and some of the subtypes?
A cognitive impairment due to reduced blood supply to the brain due to diseased vessels
Causes/Types:
- Stroke
- Post-stroke = symptoms appear 6 month after a major stroke
- Single-infarct= 1 small infarct
- Multi-infarct = several small infarcts
- Subcortical
- Mixed= both vascular and Alzheimer’s dementia
Give 4 clinical features of early stage Vascular dementia
Difficulty planning Difficulty following instructions Slower speed of thoughts Visual Spatial issues Poor concentration Mild memory issues Less fluent speech Rapid mood swings
Give 4 clinical features of late stage Vascular Dementia
Severe confusion Loss of independent ADLs Social inhibition Aggressive/irritable Delusions/hallucinations
How is the progression of Vascular dementia often described?
Stepwise decline –> sudden decrease in cognitive function followed by period of plateau followed by another sudden decrease in cognitive function thought to be due to when additional mini strokes occur in the brain.
What is subcortical vascular dementia?
Small vessel disease of blood vessels deep in the brain . Can also damage white matter nerve fibres in the brain.
How does subcortical vascular dementia present?
Not stepwise! Gradual decline as more white matter is damaged.
- Early loss of bladder control
- Mild unilateral weakness so more prone to falls
- Clumsiness
- Lack of facial expression
- Problems pronouncing words
Give 4 predisposing factors for vascular dementia
Hypercholesterolaemia Hypertension Family history Obesity Diabetes Depression CV disease Stroke/TIA Sleep apnoea
How is vascular dementia investigated?
Full Hx and Examination
CT/MRI head
Memory testing
How is vascular dementia managed?
Control of CV risk factors Stop smoking CBT- psychological help with coming to terms with diagnosis Regular routine Pill box Stay active
What is the pathophysiology of Lewy Body dementia?
Lewy bodies are eosinophilic intracytoplasmic inclusion bodies which are very small deposits of the protein alpha-synuclein. When they build up it results in less ACh and dopamine and a loss of connections between nerve cells. The LEwy bodies are found in the brainstem and neocortex so movement and cognitive abilities are affected
Give 5 clinical features of Lewy Body dementia
Fluctuating cognitive impairment Vacant episodes Episodes of disorganised speech Trouble judging distance and 3D space Poor planning Depression Sleep disturbance- violent movements in bed Anosmia Hallucinations- visual and auditory Delusions- persecutory, strangers living in the house, family member is an imposter, spouse is having an affair. Urinary incontinence Parkinsonism
How is Lewy Body dementia managed?
Do not give antipsychotics!- can increase stroke risk and can have severe reactions.
Do not give Levodopa- can make psych symptoms worse
Cognitive stimulation Social interaction Structured routine Reassurance of hallucinations Exercise PT Manage low mood Sleep tablets/good sleep hygiene SALT support
What is the pathophysiology of frontotemporal dementia?
Accumulation of TDP-43 and tau proteins. The tau proteins form Pick’s bodies. The protein accumulation in the frontal and temporal lobes results in nerve cells dying and reduction in neurotransmitter release. Over time the tissue in the frontotemporal lobes shrinks and causes the symptoms of FTD.
What cortical functions does the frontal lobe control?
Behaviour Problem solving Planning Emotional control Speech (Broca's area)
What cortical functions does the left temporal lobe control?
Meaning of words
Names of objects
hat cortical functions does the right temporal lobe control?
Recognising faces and familiar objects
Describe the clinical features seen in behavioural variant frontotemporal dementia
Lose inhibitions Apathy Poor planning Decreased sensitivity to pain, sounds and temperature Repetitive, compulsive behaviours Crave fatty foods Poor table manners Lose empathy
Describe the clinical features seen in progressive non-fluent frontotemporal dementia
Slow hesitant speech
Errors in grammar
Impaired understanding on complex sentences
Describe the clinical features seen in sematic frontotemporal dementia
Ask meaning of familiar words
Trouble finding the right word
Difficulty recognising familiar people and objects
Give 3 examples of motor disorders commonly seen alongside frontotemporal dementia
Motor neurone disease
Progressive supranuclear palsy
Corticobasal degeneration
What is the definition of delirium?
Common clinical syndrome characterised by disturbed consciousness, cognitive function or perception which has an acute onset and fluctuating course. Usually develops over 1-2 days
Give 5 potential symptoms of delirium
Fluctuating course- may be worse at night
Increased confusion Lack of concentration Disorientation Rambling speech Behavioural change Disturbed sleep Hallucinations Paranoid delusions
What is hypoactive delirium?
Abnormally withdrawn and sleepy
What is hyperactive delirium?
Abnormally alert, restless, aggressive, intense hallucinations
Give 4 risk factors for delirium
Dementia >65 years old Frail Several comorbidities Poor hearing or poor vision Polypharmacy
Give 3 common underlying causes of delirium
UTI URTI Pneumonia Surgery recovery Dehydration Constipation Poor nutrition Change in medication
What tools are used to diagnose delirium?
4AT
CAM
How is delirium managed?
Treat underlying cause
Supportive environment- 24hr clock, wear hearing aids and glasses, avoid excess noise, not moving patient excessively between wards
Family and staff reassurance
Avoid using sedative drugs
Describe the Confusion Assessment Method (CAM) tool?
Standardised evidenced based tool to identify delirium quickly and accurately
1 Acute onset or fluctuating course
2 Inattention
3 Disorganised thinking
3 Altered level of consciousness
Delirium if 1 + 2 present, worse if 3 + 4
What is involved in the 4AT delirium screen?
4 As Test
Alertness- if abnormal +4
AMT- abbreviated mental test- need to recall age, place, year, DOB. 1 mistake = +1, >2 mistakes= +2
Attention- list months starting in reverse from december. Too unwell +2, <7 months +1
Acute change or fluctuations- if yes +4
If score >4 then strong chance of delirium
Describe the 6CIT score
Scoring tool for Dementia, score /28
What year is it? What month is it? Give address to remember with 5 components What time is it? Count down from 20 to 1 Say months in reverse order Repeat address
Describe the GPCOG score
Used in primary care to assess cognitive function Patient --> Repeat back example name and address What date is it? Clock drawing- number and time showing 11:10 Recent news event Recall original name and address (Score out of 9)
Carer= reduction in memory, trouble recalling recent conversations, trouble finding the right words to use, able to manage financial affairs, able to manage their own medication, need assistance with transport. (Score out of 6)
Explain the Mini-cog test
Repeat 3 unrelated words
Dram clock face and specific time
Recall previous 3 words
3 words recalled = no dementia
2/1 words recalled + normal clock face= no dementia
2/1 words recalled + abnormal clock face= dementia
0 words recalled = dementia
What is the Addenbrooke’s Cognitive Examination III (ACEIII)?
Scoring test done in memory clinic. Score out of 100 and tests memory, language, fluency, visuospatial and attention
What is the Montreal Cognitive Assessment (MoCA) tool?
10 minute, 30 point cognitive test with areas tested including executive functioning, attention, language, memory and visuospatial skills. Accurate in Parkinson’s dementia
What is the Abbey Pain score?
Assesses pain in dementia patients
- Vocalising (whimpering/crying)
- Facial expression (tense, frowning)
- Body language (fidgeting, rocking, guarding)
- Physiological changes (fever, hypertension, flushing)
- Physical changes (wound, pressure sores, arthritis)
Score out of 15, >14= severe pain, >8= moderate pain, >3= mild pain
