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Dementia |X Flashcards

1
Q

What is the definition of dementia?

A

Severe impairment or loss of intellectual capacity and personality integration, due to the loss of or damage to neurons in the brain

or

Dementia is a loss of cognitive ability in a previously unimpaired person beyond what might be expected from normal ageing

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2
Q

According to NICE, what are the 4 elements of the diagnostic process of dementia?

A
  1. History
  2. Cognitive and mental state examination e.g. MMSE, AMT, MOCA
  3. Physical examination and confusion bloods
  4. Review of medications to identify any that may impair cognitive function
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3
Q

According to the ICD-10, what are the 4 elements needed for a diagnosis of dementia?

A
  1. A decline in memory
    - most evident in learning new info and verified from history plus a decline in cognitive abilities enough to impact on daily living and functioning. This is characterised by a deterioration in:
    - Judgement
    - Thinking
    - Planning
    - Organising
  2. Consciousness not impacted
  3. Decline in emotional control, motivation or social behaviour such as:
    - Emotional lability
    - Irritability
    - Apathy
    - Coarsening of social behaviour
  4. Present for at least 6 months
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4
Q

What is the definition of mild cognitive impairment (MCI)?

A

Evidence of early memory decline on formal memory tests (e.g. MMSE) without clinical evidence of the other features of dementia
-needs to be objective evidence of memory problems

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5
Q

What can mild memory problems indicate (2)?

A
  1. The early stages of dementia

2. May be due to problems with depression, anxiety, stress or a physical problem

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6
Q

What fraction of people with dementia are F and M?

A

F = 2/3

M = 1/3

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7
Q

What is the % prevalence of dementia in:

  1. > 65
  2. > 80
A
  1. 7%

2. 17%

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8
Q

What is primary dementia?

A

Dementias that are not due to an alternative cause

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9
Q

What is secondary dementia?

A

Dementias that occur as a result of physical disease or injury

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10
Q

What is progressive dementia?

A

Dementias that deteriorate over time

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11
Q

What is cortical dementia?

A

Dementia causing problems with memory, language, thinking and social skills

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12
Q

What is subcortical dementia?

A

Dementia causing problems with emotions, movements and memory problems

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13
Q

What are 5 classifications of dementias?

A
  1. Primary
  2. Secondary
  3. Progressive
  4. Cortical
  5. Subcortical
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14
Q

What classifications of dementia does Alzheimer’s disease fit into?

A

Primary, progressive, cortical dementia

dementias often fit into several classifications

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15
Q

What are the categories of causes of dementia (9)?

A
  1. Degenerative
  2. Vascular
  3. Trauma
  4. Intracranial malignancy
  5. Hydrostatic causes
  6. Infections
  7. Toxic, endocrine and metabolic
  8. Anoxic
  9. Genetics -> most dementias result from a combo of multiple genetic contributors
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16
Q

What are 6 degenerative causes of dementia?

A
  1. Alzheimer’s Disease
  2. Frontotemporal dementia
  3. Lewy Body Dementia
  4. Parkinson’s Disease
  5. Huntington’s disease
  6. Progressive supranuclear palsy
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17
Q

What are 5 vascular causes of dementia?

A
  1. Multi-infarct dementia
  2. Cerebral infarcts
  3. Binswanger’s disease
  4. Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL)
  5. Vasculitis e.g. lupus
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18
Q

What are 2 trauma causes of dementia?

A
  1. Major head injury

2. Boxing

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19
Q

What are 2 hydrostatic causes of dementia?

A
  1. Hydrocephalus

2. Normal pressure hydrocephalus

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20
Q

What are 6 infectious causes of dementia?

A
  1. Syphilis
  2. Cryptococcus
  3. Sclerosing panencephalitis (SPE)
  4. Progressive multifocal leukoencephalopathy (PML)
  5. HIV
  6. Creutzfeld-Jakob disease (CJD)
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21
Q

What are 7 toxic, endocrine and metabolic causes of dementia?

A
  1. Alcohol-related
  2. Heavy metals
  3. Drug intoxication
  4. Hypothyroidism
  5. B12 and folate deficiencies
  6. Paraneoplastic
  7. Inherited metabolic disorders e.g. Wilson’s disease
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22
Q

What is an anoxic cause of dementia?

A

Post cardiac arrest

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23
Q

What are 7 types of dementia (there are more), in order of most common?

A
  1. Alzheimer’s
  2. Vascular
  3. Mixed (combo of Alzheimer’s and vascular)
  4. Lewy body
  5. Frontotemporal
  6. Parkinson’s
  7. Other
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24
Q

What is the genetics behind early onset AD?

What are 3 genes affected?

A

Autosomal dominant

The 3 genes are:

  1. Amyloid precursor protein (APP) (chromosome 21)
  2. Presenilin gene 1 (PSEN-1) (chromosome 14)
  3. Presenilin gene 2 (PSEN-2). (chromosome 1)
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25
Q

What are the genetics linked to late onset AD?

A

Linked to the apolipoprotein E gene (APO-E).
There are 3 types: APO-E2, APO-E3 and APO-E4. Everyone has two copies of the gene and these may be of the same type or different.

  1. APO-E4 and E3 associated with higher risk of Alzheimer’s
  2. APO-E2 is mildly protective against Alzheimer’s
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26
Q

What are the genetics behind vascular dementia?

A

Single-gene defects are responsible for rare variants of the disease.

  1. The Notch3 gene is linked with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
  2. A variation in the APP gene causes heritable cerebral haemorrhage with amyloidosis (HCHWA).
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27
Q

What are the genetics for Down’s syndrome?

A

Patients with Down’s have three copies of chromosome 21

Approximately 50% will develop Alzheimer’s by their sixth decade.

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28
Q

What are the genetics for Huntington’s disease?

A

Autosomal dominant

Defect in Huntingtin gene

Dementia can occur at any stage but often presents quite young.

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29
Q

What are the genetics behind frontotemporal dementia?

A

These are strongly heritable.

A number of faults on the tau gene have been implicated

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30
Q

What are 3 non-modifiable risk factors for dementia?

A
  1. Mild cognitive impairment
  2. Genetics
  3. Age
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31
Q

What are 4 modifiable risk factors for dementia?

A
  1. Smoking
  2. Alcohol
  3. Atherosclerosis
  4. Hypercholesterolaemia
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32
Q

What % of dementias are Alzheimer’s disease?

A

62%

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33
Q

What is the mean life expectancy following diagnosis of Alzheimer’s disease?

A

7 years

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34
Q

What is the prevalence of Alzheimer’s in over 65s?

A

1 in 14

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35
Q

What are the 3 forms of Alzheimer’s (AD)?

A
  1. Early onset (rare) – fewer than 10% of Alzheimer’s patients. Associated with the development of myoclonus
  2. Late onset (most common) - symptoms begin after 65
  3. Familial (rare) –entirely inherited. Fewer than 5% cases and very early onset usually in 40’s
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36
Q

What are 3 phases of AD?

A
  1. Early
  2. Middle
  3. Late
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37
Q

What are aspects of the early stage of AD (3)?

A
  1. Minor changes in abilities or behaviour; often only realised in hindsight
  2. Loss of recent memory, repetition of questions, slow at grasping ideas, occasional confusion, mislaying items and blaming others
  3. Unwilling to embrace change and difficulty dealing with money
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38
Q

What are aspects of the middle stage of AD (8)?

A
  1. Changes seen in phase one become more marked and more support is needed with day-to-day tasks.
  2. Prompting required; increasingly forgetful.
  3. Increasingly repetitive due to the decline in short term memory.
  4. Failure to recognise friends/family.
  5. Frustration may lead to aggression or loss of self confidence.
  6. Disorientation to time, place and person.
  7. Development of hallucinations
  8. Memory for the distant past often remains good
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39
Q

What are aspects of the late stage of AD (7)?

A
  1. Increasing dependence on others for care
  2. Inability to recognise familiar objects or even relatives.
  3. Increasing frailty; eventually confined to bed or wheelchair.
  4. Poor appetite, dysphagia and weight loss.
  5. Deteriorating speech and understanding.
  6. Incontinence
  7. Restlessness, agitation, distress or aggressive behaviour
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40
Q

How long do the early stages of AD usually last for?

A

3-4 years

41
Q

How long do the end stages of AD usually last for?

A

Last 1-2 years of life

42
Q

How do patients of AD usually die?

A

From infection such as pneumonia.

Malnutrition is common and contributes to risk of developing infection

43
Q

What is the pathophysiology of AD (2)?

A
  1. Characterised by loss of neurons and synapses from the cerebral cortex and certain subcortical regions
  2. This loss results in gross atrophy of the affected regions, including degeneration in the temporal lobe (hippocampus and amygdala), parietal lobe, parts of the frontal cortex and cingulate gyrus
  3. There is an excess of plaques and tangles
44
Q

If we compare a normal brain to one of AD, what could be seen (3)?

A
  1. The cortex is atrophic; damaged areas are involved in thinking, planning and remembering.
  2. The hippocampus is severely atrophic; this area plays a key role in memories and is affected early
  3. The ventricles of the brain are enlarged
  4. Amygdala later damaged - controls emotions
45
Q

What are plaques made up of and how do they contribute to the development of AD (3)?

A
  1. Made up of deposits of a protein fragment called beta-amyloid
  2. These proteins are sticky and clump together and form plaques that build up within the spaces between cells.
  3. Plaques are thought to block cell-to-cell signaling or activate immune system responses that trigger inflammation and cell death within the brain.
46
Q

What are tangles made up of and how do they contribute to the development of AD (3)?

A
  1. Neurofibrillary Tangles are thought to destroy the cell transport system which is made from a protein called tau.
  2. Tau usually helps the strands of the transport system link together.
  3. Tangles are twisted fibres of tau that are no longer able to link the transport system of the cell and thus this falls apart and the cell dies.
47
Q

The standard diagnostic criteria for AD is DSM-IV, what are the 6 diagnostic criteria?

A
  1. Memory deficit that can be demonstrated objectively by cognitive tests
  2. Plus at least one other cognitive deficit (aphasia, apraxia, agnosia or impairment with executive functioning)
  3. Reduced ability to perform activities of daily living (ADLs)
  4. A gradual onset and progressive course
  5. A decline from a previous level of functioning
  6. No evidence of other medical or neurological condition
48
Q

What is the 2nd most common form of dementia?

A

Vascular dementia

49
Q

What is the pathological process leading to vascular dementia?

A

A problem with the blood supply to the brain

-like most vascular problems it is potentially preventable

50
Q

Is vascular dementia more prevalent in men or women?

A

Men

51
Q

What are the different sub-types of vascular dementia?

A
  1. Post-stroke dementia
  2. Multi-infarct dementia
    - a series of small strokes in the cerebral cortex (cortical vascular dementia)
  3. Subcortical vascular dementia
    - affects inner parts of brain
  4. Mixed cortical and subcortical dementia
52
Q

Which patients tend to get subcortical vascular dementia?

A

People with HTN

53
Q

What are the risk factors for vascular dementia (9)?

A

Same as for vascular disease

  1. Hypertension
  2. Hypercholesterolaemia
  3. Diet high in saturated fats
  4. Lack of physical activity
  5. Smoking
  6. Family history of stroke or vascular dementia
  7. Cardiovascular Disease
  8. Diabetes
  9. Excess alcohol
54
Q

What are some specific features of VaD (12)?

A
  1. Memory problems (may be less apparent earlier on)
    - Problems planning, organising, making decisions etc
  2. ‘Step wise’ progression with stable disease and then sudden deteriorations
  3. Difficulty with concentration and communication, and following steps
  4. Seizures
  5. Depression
  6. Symptoms and signs of stroke disease
  7. Incontinence
  8. Emotional lability
  9. Changes in behaviour
  10. Visual problems and perceptual difficulties
  11. Early gait disturbance, unsteadiness and falls
  12. Slower speed of thought
55
Q

The standard criteria used for VaD is the NINDS-AIREN, what are the 3 diagnostic criteria?

A
  1. Dementia defined by cognitive decline manifesting as memory impairment and impairment in a further cognitive domain (as for AD).
  2. Deficits should be causing limitation with ADLs not due to the physical effects of stroke alone.
  3. Evidence of cerebrovascular disease on clinical examination and imaging.
56
Q

What is the prevalence of Lewy body dementia (LBD)?

A

4%

57
Q

Is LBD more common in men or women?

A

Slightly more common in men

58
Q

What is the pathophysiology of LBD? 4

A
  1. Presence of Lewy bodies, made up of protein alpha synuclein
  2. Their presence disrupts the brain’s functioning by interrupting the action of acetylcholine and dopamine.
  3. Areas affected in Lewy Body dementia include:
    - The substantia nigra. Lewy bodies seen here are called classical Lewy bodies - as seen in Parkinson’s disease
    - Degeneration in the cortex. Lewy bodies here are called cortical Lewy bodies
  4. Shrinkage of the brain affects mainly the parietal and temporal lobes and the cingulate gyrus.
59
Q

What are 4 core features and 4 supportive features of LBD?

A

Core:

  1. Progressive memory impairment = main feature
  2. Fluctuating cognition
  3. Visual hallucinations
  4. Features of parkinsonism

Supporting

  1. Falls
  2. Syncope
  3. REM sleep behaviour
    - During periods of REM sleep, the person will move, gesture and/or speak
  4. Sensitivity to neuroleptics - treatment with this should be avoided
60
Q

What is the general rule with Parkinsonism features when diagnosing LBD?

A

If significant cogntiive decline begins within a year or the Parkinsonian features diagnosis is likely to be LBD

61
Q

What is the diagnostic criteria for LBD?

A
  • Progressive cognitive decline. Prominent memory impairment may not occur in the early stages.
  • Deficits on tests of attention and frontal-sub-cortical skills and visuospatial ability may be especially prominent.
  • Reduced ability to perform ADLs.

2 of the following are required for a probable, and one for a possible diagnosis of LBD:

  1. Fluctuating cognition with pronounced variations in attention and alertness
  2. Recurrent visual hallucinations which are typically well-formed and detailed
  3. Spontaneous motor features of parkinsonism
62
Q

At what age does frontotemporal dementia (FTD) usually present?

A

Before 65

63
Q

What is the pathophysiology of FTD?

A
  1. Abnormal protein aggregation in brain cells. The implicated protein is tau.
  2. Affects the frontal and temporal lobes, responsible for behaviour, emotional changes and language skills
64
Q

What are 4 symptoms of FTD?

A
  1. In early stages, cognition often intact
  2. It typically causes changes to behaviour and personality
    - person may be increasingly more extrovert and disinhibited.
  3. Some have a change in eating habit, overindulging or developing a sweet tooth and later may develop hyperphagia
  4. Language problems are also prominent and this may manifest initially as word finding difficulties and resultant reduction in amount of speech
65
Q

What are 2 signs of FTD?

A

As the disease progresses a number of primitive reflexes may develop (frontal release signs)

  1. Palmar grasp reflex
  2. Rooting reflex
66
Q

The standard criteria used for FTD is the Lund-Manchester criteria, what are the core components?

A
  1. Insidious onset and gradual progression
  2. Early decline in social interpersonal conduct
  3. Early impairment in regulation of personal conduct
  4. Early emotional blunting
  5. Early loss of insight
67
Q

What are the supportive features of FTD?

  1. Behavioural (5)
  2. Speech and language (4)
  3. Physical signs (5)
A
  1. Behavioural
    - Decline in personal hygiene; grooming
    - Mental rigidity & inflexibility
    - Distractibility
    - Hyperorality and dietary change
    - Utilisation behaviour
  2. Speech and language
    - Altered speech output including reduced spontaneity and economy of speech
    - Echolalia
    - Perseveration
    - Mutism
  3. Physical signs
    - Primitive reflexes
    - Incontinence
    - Akinesia
    - Tremor
    - Low BP
68
Q

What investigations can be done for FTD and their results (3)?

A
  1. Neuropsychological tests – impaired frontal lobe tests but no amnesia or perceptual deficits
  2. EEG – normal
  3. Imaging predominant frontal lobe +/- anterior temporal abnormalities
69
Q

What is the prevalence of dementia in Parkinson’s disease?

A

30%

70
Q

What are the features of Parkinson’s dementia?

A
  1. Marked forgetfulness
  2. Lethargy
  3. Loss of executive functioning
  4. Loss of emotional control
  5. Any Psychotic symptoms may be exacerbated by the anti-Parkinson’s medication and therefore the drugs may need to be reduced or withdrawn.
  6. Often neuroleptics prescribed to help with the disruptive behaviour, eg neuroleptics, make the Parkinson’s symptoms worse. Haloperidol, chlorpromazine and sulpiride should be avoided.
71
Q

What are the 2 main management principles of AD?

A
  1. Therapy aimed at cognitive enhancement

2. Treatment of behavioural and psychological symptoms of dementia (BPSD)

72
Q

What are 2 types of medication currently licensed for treatment of AD?

A
  1. Acetylcholinesterase inhibitor
  2. NMDA receptor antagonist

(drugs are not curative but may help control symptoms or slow progression of the condition)

73
Q

What are 3 Acetylcholinesterase inhibitors available on the market?

A
  1. Donepezil (Aricept)
  2. Galantamine (Reminyl)
  3. Rivastigmine (Exelon)
74
Q

How do Acetylcholinesterase inhibitors work?

A

Inhibiting the breakdown of acetylcholine, a neurotransmitter which is important in cognitive processes.

75
Q

What NMDA receptor antagonists are there?

A

Memantine

76
Q

How do NMDA receptor antagonists work?

A

Blocks NMDA glutamate receptors.

At normal levels, glutamate aids in memory and learning, but if levels are too high, it leads to overstimulation of nerve cells resulting in degeneration.

77
Q

What test is done to determine severity of dementia?

A

MMSE

78
Q

What are the 4 severities of dementia according to the MMSE score?

A 
21-26 = mild dementia
15-20 = moderate
10-14 = moderate to severe
>10 = severe
79
Q

What severity of AD are AChE inhibitors recommended for?

A

Mild-moderate

80
Q

What are the indications for Memantine (NMDA receptor antagonist) (2)?

A
  1. Moderate AD who are unable to take AChE inhibitors

or

  1. Severe AD
81
Q

What are 3 important elements of the guidance of prescribing medication in AD?

A
  1. Only specialists in the care of patients with dementia should initiate treatment.
  2. Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioural symptoms.
  3. Patients who continue on treatment should be reviewed regularly for any changes in behaviour and cognition as well as any medication side effects.
82
Q

What are the management options for LBD (3)?

A
  1. NICE recently suggested trial of ACHEI
  2. Management mainly aimed at managing neuropsychiatric disturbances and movement disorders
  3. No cure or definitive treatment for LBD
83
Q

What are the management options for VD (1)?

A

Reducing vascular risk (bp, lipid profile, glycaemic control etc to slow progression of VD

84
Q

What is the definition of behavioural and psychological symptoms of dementia (BPSD)?

A

Symptoms of disturbed perception, thought content, mood and behaviour that frequently occur in patients with dementia

85
Q

What are 4 common psychological symptoms of BPSD and 7 behavioural symptoms?

A

Psychological

  1. Anxiety
  2. Delusions
  3. Depression
  4. Hallucinations

Behavioural

  1. Aggression
  2. Wandering
  3. Agitation
  4. Screaming
  5. Shadowing
  6. Cursing
  7. Sexual disinhibition
86
Q

Why is BPSD important to manage (5)?

A
  1. place extra burden on the carer
  2. increase the cost of care
  3. reduce quality of life for the patient and their carers
  4. increase need for hospitalisation
  5. increase need for early placement in care facilities
87
Q

What is the prevalence of BPSD? At what stage does it occur at?

A

2/3 of patients with dementia exhibit BPSD at some point

Can occur at any stage

88
Q

What is the non-pharmacological approach to investigating BPSD (5)?

A
  1. Identification of behaviour
    - Observe/obtain history from patient and carers to: a. identify circumstances under which it occurs
    b. when it started
    c. whether onset was gradual or sudden
  2. Perceptions
    -If the behaviour appears inappropriate, consider whether there is an underlying goal (e.g. exit-seeking)
    or
    misperception (e.g. misperceiving the corner of a room as a urinal)
  3. Psychiatric history
    - Review the patient’s psychiatric history, social history and premorbid personality
  4. Life events
    - Inquire about life events and the quality of the relationship between carer and patient.
  5. Mental status
    - Examine for changes in mental status.
    - Look for signs of discomfort or distress that may be a cause of agitation or aggressiveness
  6. Diagnosis
    - Always consider an alternative diagnosis
    e. g. delirium, side effects of medication or concurrent mental illness
89
Q

What is the non-pharmacological approach to managing BPSD (9)?

A
  1. Family involvement
  2. Communication
    - Speak slowly, use shorter sentences and less complex instructions.
    - Give positive non-verbal cues and use gentle touch (if patients allow)
  3. Encourage conversation
  4. Encourage and help with orientation
  5. Hallucinations
    - When the patient is hallucinating, do not rebuke or flatly contradict
  6. Senses
    - Ensure that there are no barriers to their vision or hearing
  7. Familiarity
    - Stimulation on the ward, e.g. family pictures or music that patients can relate to.
    - Help the person feel at home
  8. Mobility
    - Encourage mobility with an emphasis on safety as well
90
Q

What is the principle of managing BPSD?

A

As BPSD affects each individual differently, a person-centred approach is needed.

Remember that behaviour is usually an expression of an underlying need

91
Q

What are the most appropriate medications used for the following BPSD cases?

  1. Depression
  2. Sleep disturbance
  3. Aggression due to psychosis
  4. Agitation due to constipation
  5. Shouting due to pain
A
  1. Citalopram
  2. Zopiclone
  3. Risperidone
  4. Senna
  5. Paracetamol
92
Q

What are the indications for anti-psychotics in BPSD?

A

Help with physical aggression, agitation and psychosis

93
Q

What are the problems with anti-psychotics in the elderly?

A
  1. 3-fold increase in the risk of stroke with antipsychotics
    - Risk of stroke may be even higher above the age of 80
  2. Side effects include parkinsonism, falls and lethargy
    - Typical antipsychotics have more side effects than atypical ones
    - Should only be prescribed by specialists
94
Q

In which dementias should anti-psychotics be avoided in (2)?

A

LBD and PDD

95
Q

If social services are involved in the care of a patient with dementia, what would their assessment include (5)?

A
  1. the person’s present living arrangements, and arrangements for care
  2. the person’s health and disabilities, and what they can and cannot do
  3. the person’s worries, and how they want to be supported
  4. the types of service sought and how they want these to be arranged
  5. the concerns of the carers
96
Q

After a social services assessment, a care plan is recommended. What can a care plan include (6)?

A
  1. home help to assist with activities of daily living
  2. specific equipment and adaptations
  3. meals on wheels
  4. respite service
  5. day care facilities
  6. care home placement
97
Q

How often are care plans reviewed?

A

Reviewed after 3 months, then annually or as the need changes

98
Q

How many people are currently living with dementia in the UK?

A

850,000

99
Q

What are the general symptoms that dementia encompasses (4)?

A
  1. Memory loss
    - forget names, people and places
    - repetitive
    - misplacing items in old places
    - confusion about time of day
    - getting lost
    - inability to remember new information
  2. Difficulties with thinking
  3. Problem-solving
  4. Language

All types of dementia are progressive. This means
that the structure and chemistry of the brain
become increasingly damaged over time. The
person’s ability to remember, understand,
communicate and reason gradually declines

HCOLL (17 decks)

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