Dementia In Primary Care Flashcards
Definitions of dementia and delirium
Dementia (major cognitive impairment)
- progressive/chronic decline in intellectual function severe enough to compromise social and/or occupational functioning
Mild cognitive impairment
- essentially major but DOES NOT compromise social or occupational functioning yet
- it will progress to dementia in due time though
Delirium
- acute/abrupt confusional state
- often has an identifiable trigger/event for onset
- often waxes and wanes (NOT seen in dementia)
Most prominent Risk factors for dementia
Increasing age > 60
- Strongest risk factor
Vascular diseases in any capacity
- 2nd strongest risk factor
Trauma/degenerative comorbidity/disorder
- 3rd strongest risk factor
Chronic intoxication
- especially alcohol
What are less common causes of dementia
Vitamin deficiencies
Endocrine/organ dysfunctions/failures
Chronic infections
TBI
TIA/CVA
Neoplastic syndrome
Toxic disorders
Psychiatric conditions
High yield differentiation of the major dementias based on general complaining clinical symptoms
Alzheimer’s disease = memory loss (especially short term)
- also difficulty doing daily tasks
Frontotemporal dementia (picks disease) = apathy/poor judgement, hyperorality and dishibition
- also speech fluency and Parkinsonism may be present
- MEMORY is spared
Lewy body dementia = visual hallucinations, REM sleep disorders, delirium, Parkinsonism symptoms
- also capgras syndrome (delusion of familiar person is replaced by an imposter)
- also may present with inability to understand words or inability to speak (usually not both at the same time)
Vascular dementia = gait disturbances, trauma/falling, apathy, local weaknesses
- can present with STD’s (HIV/syphilis)
High yield Clinical physical neuro exam findings to help differentiate major dementia types
Alzheimer’s disease = NORMAL
- other than memory disorders
FTD = alien hand, axial rigidity, dystonia, vertical gaze palsy
Lewy body = Parkinsonism usually first
CJD = myoclonus and General rigidity
Vascular = psychomotor Retardation and general spasticity
Screening tools for cognitive examination
Mini-mental state examination (MMSE)
- simple 30 question test that checks for cognitive impairment
Cognistat
- short-term for neurobehavioral and psychological exam
- # 1 for neuropsychological exams
Montreal Cognitive Assessment (MOCA)
High yield clinical mental study findings for major dementias
Alzheimer’s disease = episodic memory loss is profound
FTD = frontal/executive loss, (+/-) language loss.
- SPARES DRAWING
Lewy body = drawing and frontal/executive are lost
- SPARES MEMORY
- very prone to delirium episodes
CJD = varies a lot but frontal and executive planning are the most common
Vascular = frontal/executive loss w/ cognitive slowing
- often SPARES MEMORY
What are the domains for diagnosis of dementia?
at least 2 of the 5 must show abnormalities and be impaired to the point where it affects daily living
Memory = acquiring/remembering new info
Executive function = reasoning is intact and can perform complex tasks
Perception = visuospatial orientation is in tact
Language = comprehension is intact and can speak appropriate language (both in social context and in grammar context)
Behavior = behaves normally and appropriately based on social and cultural norms
High yield neuropsychiatric findings in the major dementias
Alzheimer’s disease = irritability, depression
FTD = severe apathy, disinhibition, overeating/hyperorality, compulsivity
Lewy body = visual hallucinations, sleep disorders, delusions, depression
CJD = depression, psychosis, anxiety
Vascular = delusions anxiety, mild apathy
High-yield Imaging results in the major dementias
Alzheimer’s disease = hippocampus, temporal and entorhinal cortex atrophy
FTD = contralaterally, insular, temporal atrophy
- spares parietal lobes
Lewy body = partial lobe atrophy
- spares hippocampus
CJD = basal ganglia and thalamus hyper- intensity and cortical ribboning
Vascular = cortical and/or subcortical infarction
Treatment in dementia
major goal is to slow progression and treat any reversible symptoms
Often need to first try to reverse environmental causes or metabolic causes
- DONT jump to drugs/medications off the bat
If using medications, use ones tailored to the patients and for specific symptoms
What medications can be used in dementia patients
Benzos or phenothiazines
- chlorpromazine and lorazepam
2nd gen antipsychotics
- quetiapine, olanzapine, clozapine
Cholinesterase inhibitors
- donepezil, rivastigmine, galantamine
NMDA receptors antagonists
- memantine
