Dementia General

Question 1

Defin

Answer 1

Progressive irrev global cognitive deficits-
Memory imapirment to dysphasia, agnosia, apraxia, impaired executive function, personality disintegration.
Must be sig impairment of normal function and other dx eg depression and delerium excluded.

Question 2

Causes and prevalence

Answer 2

Alzheimers 60%
Vascular 20%
Mixed 10%
Lewy body 5-10%
Fronto temporal 2%
Other 3% eg CJD, AIDS. 
Reversible 15% eg subdural haematoma, NPH, b12 defic, metabolic causes, hypothyroid. 
Dementia rates- 1/20 over 65s, 1/10 over 75s, 1/5 over 85s.

Question 3

Aetiology

Answer 3

-bio
Parenchymal or degenerative- AD, VD, FTD, MND, MS, parkinsons, HD, LBD, wilsons.
Intracranial- tum, CVA, haematoma
Infection- CJD, syphillis, TB.
Endocrine- hypothyr, hyper PTH, cushings, addisons.
Metabolic- uraemia, hypoglyc, Ca, Mg, electrolyte.
B12
Toxins eg alc
genetic eg apoE4
vascular RFs eg smok, alc, obesity, chol, HTN, DM, CVS dis.
Nutrit- high sat fat and chol.
-social-
Low educ
Poor soc network

Question 4

Px

Answer 4

Short then LT memory impair. 
Personality change- withdrawal, labile affect, disinhib, silly, apathy, reduced func. 
Psychosis
Anx and dep
Seizures and other neuro signs
Catastrophic reaction
Pathological emot
Sundowner synd
5 As cog impairment- amnesia, aphasia, agnosia, apathy, apraxia.

Question 5

Diffs

Answer 5

Other dementias
Delerium
Dep- pseudodementia
Amnestic disorders
Learning disability
Psychotic disorders
Normal aging

Question 6

Investigation

Answer 6

FBC, LFT, UE, gluc, ESR, TFT, Ca, Mg, P, HIV, B12 and folate, CRP, blood culture.
Test for syphillis, HIV, heavy metals. 
EEG
CXR
ECG
CT
MRI hippo atrophy, WM changes etc. 
SPECT or DAT
MMSE, AMTS in AE setting. Other eg DEMTECT. ACE, MoCA. 
Psych hx and MSE
Vasc RFs
Check for reversib causes

Question 7

Mx

Answer 7

-AchEI eg tacrine, donepezil, rivastigmine, galantamine for mild to mod.
N methyl D aspartate R antag eg memantine for mod to sev.
Above if MMSE 10-20.
NA valproate often given as mood stabiliser as antiP can incr CVEs in dementia.
Antioxidants eg selegiline, vitE
?horms eg oestrogen, HRT
Consider antiP for behav- risks eg s/e, CVE.
SSRI
Hypnotics
Other health probs eg GI constipat etc, UTI comm, sleep probs.
Remove or restrict tx for mod to sev dis- MMSE under 10.
-Psych support incl carer
Cog training
Func mx eg maximise mobil, encour indep self care, assist communic.
Cog stim therapy- encour brain plasticity.
Memory mx for mild dementia- encour use of prompts. Psychologist assessment.
Reality orientat, reminiscence, validat, mem aids.
-Social eg suitable accomm for indiv needs, activities, finance, legal. ADL. Support. Risk eg driving, vulnerability to expoltation, wandering etc. MCA or MHA if agress/active. MCA can give covert meds. Advanced directives. Speech and lang. dietician inv. physio. Family education.

Some forms reversible if tx early eg normal press hydrocephaly, endoc causes, chronic alc abuse, defic eg thiamine and T4, infec eg syphillis, meta and endoc distrub, frontal lobe tum.

Question 8

Clinical syndromes of dementia

Answer 8

-cortical dementias-
FTD eg picks dis. Personality change. Comm early onset. Language impairment reduced content. FT atrophy (ct) and alt metab (spect).
Posterior parietal ag AD. Early mem loss and focal cog deficits. Personality change later, word finding diffic. CT thinning medial temporal cortex.
-subcortical-
Parkinsons, HD, wilsons, HIV. Psychomotor slowing, dep, mild amnesia, personality change.
-cortical sub cortical-
LBD.
-multifocal-
CJD. Rapid onset and course.

Question 9

Less common types

Answer 9

-alcohol related-
Often yng, risk withdrawal. Wernicke korsakoff.
Cause- alc damage directly and thiamine deficiency.
Tx vitamins, abstin, motiv interview etc.
-parkinsons disease dementia.
-prion disease.

Question 10

Capacity issues

Answer 10

Consider mental disorder and ability to make decisions.

Mental disrder very broad defin- any mind or brain impairment. Incl incompl dev and psychopathic.

Question 11

Defin

Answer 11

-multiple domain cog impair eg mem, calc, lang, personality.
Must be more than one.
-change from baseline (assesm tools)
-interfs with ADLs
-ICD10- these symps for 6mnths means definate diag.
Clinical diag predomianntly based on hx. Scans are supportive only.
Need collateral.

Question 12

Reversible

Answer 12

Chronic alc abuse
Defic eg B12, thiamine, T4
Norm press hydrocephalus
Infec eg syphillis
Metab and endoc
Neoplastic eg frontal lobe tum

Question 13

ICD10

Answer 13

6 mnth or more of-
Decline in mem and other cog abil
Preserved awareness of env- no clouding of conciousness.
Decline emot control or motiv, or changes in soc behav.