Deteriorating memory Flashcards
Which investigations should be done for a patient with memory loss?
- Urinanalysis
Checking for UTI which could cause delirium or confusion - Bloods
As part of confusion screen - CT or MRI brain scan
Could help detecting harmorrhages/clots, space-occupying lesions, and atrophy
What should you ask in a memory loss history?
HPC:
- What has the patient been forgetting?
- How are their daily activities?
- Do they remember and recognise people?
- Do they remember names?
- Do they remember significant dates?
- How have they been eating?
- Do they get lost?
- Do they put their belongings in strange places?
- Do they forget that people have passed away?
- How is their vocabulary?
- How is their concentration?
- How are they sleeping?
- Do they feel any paranoia?
- Do they intermittently seem ‘normal’?
- Have they had any falls?
- Have they had any changes in personality?
Check PMH, FHx, and SHx.
How does normal pressure hydrocephalus present?
- Memory loss
- Magnetic gait
- Incontinence
How does Huntington’s disease present?
- Memory loss
- Progressive cognitive deficits
- Choreic movements
- Family history
- Relatively young onset
How does a traumatic brain injury present?
- History of fall or trauma
- Possibly reduced or fluctuating GCS
- Acute onset of deficits
- Focal signs
- Well defined, less progressive signs
How does the ACE III test work?
The ACE III is used in testing cognitive function Comprehensive assessment of - Memory - Attention - Fluency - Visuospatial skills - Language
A score less than 82 is suggestive of possible dementia. Not diagnostic (dementia is a clinical diagnosis)
What is an alternative cognitive test to the ACE III?
The MOCA (Montral Cognitive Assessment)
What are the different types of dementia?
- Alzheimer’s dementia
- Lewy-body dementia (memory before motor)
- Fronto-temporal dementia
- Parkinson’s dementia (motor before memory
- Vascular dementia
- Wilson’s dementia
What are some differentials for dementia?
- Huntington’s disease
- Spino-cerebellar degenerations
- HIV/AIDS dementia
- MND/MS dementia
- Alcohol-related dementias
What signs are seen in temporal lobe impairment?
- Prospagnosia (difficulty recognising faces
- Difficulty understanding words
- Short term memory loss
- Semantic memory loss
- Inability to categorise objects
- Difficulty identifying and verbalising
- Visuo-spatial neglect
What signs are seen in parietal lobe impairment?
- Anomia (cannot identify objects
- Dysgraphia
- Agnosia (body parts)
- L-R disorientation
- Dyscalculia
- Apraxia
- Visuo-spatial neglect
- Loss of tactile perception
What is Gerstamnn’s syndrome?
- Dominant parietal lobe lesion
- Agnosia (finger
- Agraphia
- Acalculia
- L-R disorientation
What signs are seen in frontal lobe impairment?
- Difficulty sequencing
- Loss of spontaneity
- Loss of cognitive flexibility
- Difficulty conceptialising
- Poor concentration
- Poor impulse control
- Difficulty problem solving
- Difficulty expressing language (Broca’s aphasia)
What is the scoring for MOCA?
- Score out of 30
- Takes 10-15 minutes
- Score less than 26 gives high sensitivity but low specificity
- Less than 26 - MCI
- Less than 17 - Dementia
How would you assess function?
- Functional activities questionnaire
- Activities of daily living assessment
- Bristol functional assessment
How would you assess psychological symptoms?
Neuropsychiatric inventory (NPI)
How would you assess caregiver strain?
MBRC caregiver strain instrument
What medications are given to manage dementia?
Three main types of medication to manage Alzheimer’s and Lewy Body dementia:
- Cholinstereterase inhibitors (donepezil, galantamine)
- Butyrycholinesterase and acetylcholinesterase inhibitors (rivastigmine)
- NMDA receptor blockers (memantine)
The role of medication is to slow progress of disease
What are the non-cognitive symptoms of dementia?
- Hallucinations
- Delusions
- Anxiety
- Marked agitation
- Aggressive behaviour
These can also be pharmacologically managed
How should dementia be managed?
- Explain diagnosis and give written information
- Identify patient wishes for future care whilst they still have capacity
- Monitor physical and mental health and function
- Discuss driving
Treatments:
- Non-pharmacological interventions(structured group cognitive stimulation programmes
- Pharmacological interventions (acetylcholinesterase inhibitors)
Ask about behavioural and psychological symptoms of dementia (BPSD)
- Treat reversible causes
- Consider non-pharmalcoogical intervention (aromatherapy, exercise, animal-assisted therapy)
Antipsychotics should not be given
Home occupational therapy and physiotherapy interventions
- Assessment of home, safety, neglect risk
What investigations need to be completed before starting pharmacological treatment of a patient with dementia?
Investigations
- ECG - Assess heart rate, presence of conduction abnormalities and QTc interval
Cholinesterase inhibitors are contraindicated for patients with bradykinesia, Left Bundle Branch Block and a prolonged QTc interval - U&E – Memantine can cause acute renal failure
BNF: cholinesterase inhibitors should be used with caution in patients with a history of a gastric ulcers and seizures. Mind other medications that can increase ulcer or seizure risk
Side effects:
- Diarrhoea
- Dizziness
- Anorexia
- Weight loss
- Nausea
- Vomiting
- Insomnia.
What psychological treatments are available for BPSD?
- Cognitive stimulation therapy
- CBT
- Reminiscience therapy
- Aromatherapy
- Sensory stimulation
- Music therapy
What is dementia?
A collection of symptoms
- Chronic disorder or mental processes caused by brain disease/injury
Symptoms:
- Memory disorders
- Personality changes
- Impaired reasoning
What are the risk factors for developing dementia?
- Age
- Gender (female AD, male VD)
- Ethnicity (South Asian VD, African AD)
- Depression in mid-life or later life
- Head injuries (Parkinson’s dementia)
- Lifestyle factors (smoking, alcohol, exercise, education)
What constitutes mild dementia?
- Memory loss interferes with daily activities
- Difficulty learning and registering new information
- MMSE 20-24
- Able to manage independent life
What constitutes moderate dementia?
- Memory loss representing a serious handicap to independent living
- Only very familiar material is retained
- New information is retained occasionally/briefly
- MMSE 10-21
- Need help with ADLs
What constitutes severe dementia?
- Memory loss causes complete inability to retain information
- Only fragments of previously learnt information retain
- Unable to learn new infomation
- MMSE <10
- Completely dependent for ADLs
What are the criteria for a diagnosis of dementia?
- Memory loss
- Decline in emotional control or motivation
- Emotional lability
- Irritability
- Apathy
- Coarsening of social behaviour
Exclusion criteria:
- Absence of delirium
- Symptoms present for at least 6 months
- Should be irreversible
How does Alzheimer’s dementia present?
- Aphasia
- Agnosia
- Apraxia
- Decreased motivation and drive
- Early or late onset
- Slow progression
Investigations:
- CT/MRI brain - cerebral atrophy
