Dementias

Question 1

More aggressive management of what seems to be decreasing the likelihood of developing dementia?

Answer 1

Cardiovascular risk factors

Question 2

What labs are commonly ordered in patients with dementia in order to rule out other etiologies?

Answer 2

TSH, Vitamin B12

Question 3

What are the symptoms of dementia?

Answer 3

Memory loss
Confusion
Wandering, getting lost
Problem solving difficulty
New focal neurological deficits

Question 4

What diagnostic tests are commonly used for dementia?

Answer 4

MMSE (mini-mental state exam)
MoCA (Montreal cognitive assessment)
CDR (clinical dementia rating)
Formal neuropsychiatric testing

Question 5

Describe the progression of Alzheimer’s disease

Answer 5

Slowly progressive memory loss and other cognitive decline. Steady rate of progression.

Question 6

What are the classic pathologic findings of Alzheimer’s disease on post-mortem exam?

Answer 6

Neurofibrillary tangles
Neuritic plaques
Cerebral atrophy

Question 7

What genetic mutation is associated with Alzheimer’s disease?

Answer 7

APOE E4 mutation

Question 8

What are the acquired risk factors of Alzheimer’s?

Answer 8

CV risk factors
Lower education
Sedentary lifestyle
Brain trauma
Benzodiazepine use

Question 9

What are the symptoms of Alzheimer’s?

Answer 9

Progressive memory loss despite being alert
Poor short term memory despite good long term
Inability to problem solve
Language difficulties
Sundowning
Personality change
Wandering
Symptoms not explained by delirium or other psychiatric disorder

Question 10

How is Alzheimer’s diagnosis made?

Answer 10

Clinical diagnosis
Neuropsychiatric testing
Labs to rule out reversible causes
MRI scans NOT helpful except to look for vascular cause of dementia

Question 11

How is Alzheimer’s treated pharmacologically?

Answer 11

Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) for mild AD
Memantine (NMDA receptor antagonist) for moderate to severe

Question 12

What is the mean life expectancy for patients with AD after diagnosis?

Answer 12

8-10 years
Worse prognosis in:
higher age
males
lower MMSE at dx

Question 13

What is the second most common type of dementia?

Answer 13

Vascular Dementia - caused by strokes

Question 14

Describe the progression of vascular dementia.

Answer 14

Abrupt onset followed by stepwise deterioration

Question 15

What testing should be performed if suspect vascular dementia?

Answer 15

Neuropsychiatric testing
MRI
Blood tests to rule out others and assess cholesterol
Echo of heart and carotids to look for embolic sources

Question 16

How can you treat vascular dementia?

Answer 16

Cholinesterase inhibitors and Memantine (used despite lack of strong evidence)
Treat underlying
Physical and Occupational Therapy
Caregiver education and support
Minimize change in patient's environment

Question 17

What percentage of people over the age of 65 have mild cognitive impairment?

Answer 17

10-20%

Question 18

What are the two types of MCI?

Answer 18

Amnestic

Non-amnestic

Question 19

What can be done in effort to prevent MCI progression?

Answer 19

Control BP, glucose, cholesterol
Stop smoking and EtOH
Diet high in Omega 3 fatty acids
Keep mentally active

Question 20

What are the other names for blow-induced dementia?

Answer 20

Chronic traumatic encephalopathy

Dementia pugilistica

Question 21

Who are most susceptible to CTE?

Answer 21

American football players
Soccer players who head the ball
Boxers
Domestic violence survivors

Question 22

What is the only “treatment” for blow-induced dementia?

Answer 22

Prevention
Helmets
Rest for pts with concussion
Avoid blows to head esp at young age

Question 23

What are the classic triad signs of normal pressure hydrocephalus?

Answer 23

Dementia
Gait disturbance
Urinary incontinence (not early sign of any other dementia)

Question 24

Why is it important to keep normal pressure hydrocephalus on your DDx in dementia patients?

Answer 24

~90% of cases per year go undiagnosed and it is treatable!

Question 25

HTN and large head size increase risk of what type of normal pressure hydrocephalus?

Answer 25

Primary NPH

Question 26

What causes secondary NPH?

Answer 26

Impaired CSF reabsorption across arachnoid villi due to inflammation and fibrosis caused by SAH, trauma, meningitis or cancer

Question 27

How should NPH be evaluated?

Answer 27

MRI (look for ratio of ventriculomegaly out of proportion to sulcal enlargement)
LP to test clinical response to removal of CSF
Refer to neurosurgery who may do other more invasive testing

Question 28

How is NPH treated?

Answer 28

Ventricular shunt placement

Question 29

What type of dementia causes extreme disinhibition and markedly inappropriate behavior?

Answer 29

Frontotemporal dementia

Question 30

What is the life expectancy after diagnosis for those with frontotemporal dementia?

Answer 30

6-8 years

Question 31

How can frontotemporal dementia be treated?

Answer 31

SSRIs (treat psych symptoms)
Atypical anti-psychotics
Typical anti-psychotics NOT effective
Cholinesterase inhibitors (variable results)

Question 32

What inheritance pattern does Huntington disease follow?

Answer 32

Autosomal dominant

Question 33

What is the epidemiology of Huntington’s?

Answer 33

Age 35-45
More common in white males
Fatal in 15-20 years

Question 34

What are the symptoms of Huntingtons?

Answer 34

Progressive chorea
Dementia
Bursts of anger
Antisocial behavior

Question 35

What chromosomal abnormality causes Huntington’s?

Answer 35

CAG repeat on chromosome 4

Question 36

What would prompt you to have Creutzfeldt-Jakob disease (Bovine Spongiform Encephalitis) high on your DDx?

Answer 36

Abnormality in almost every area of the neurologic system

Question 37

What is the treatment for CJD?

Answer 37

None really. Symptomatic, supportive and psychological care for patient and family