Deterioration of Intellect

Question 1

Cortical causes of intellect deterioration

Answer 1

Alzhiemer’s dementia.
Fronto-temporal dementia
Creutzfeldt-Jakob (Mad cow disease/Prion disease)
Chronic subdural haematoma

Question 2

Subcortical causes of intellect deterioration

Answer 2

Parkinson’s disease
Huntingtons disease
HIV

Question 3

Mixed subsocrtical and cortical causes of intellect deterioration

Answer 3

Vascular dementia.
Lewy body dementia
Normal pressure hydrocephalus.

Question 4

Delirium definition

Answer 4

Acute confusional state.

A syndrome of acute, fluctuating disturbed consciousness, attention, cognition and perception.

Question 5

Common causes of delirium

Answer 5

METABOLIC = hypoxia, hyponatraemia, hypoglycaemia, anaemia, B12 deficiency, folate deficiency, dehydration.
INTRACRANIAL = meningitis, hepatic encephalopathy, space occupying lesion, head trauma, epilepsy (post-ictal), subarachnoid haemorrhage, subdural haematoma, encephalitis.
DRUGS = L-dopa, benzodiazepines, opiates, steroids, tricyclic antiDx, opiates.
Alcohol withdrawal/delirium tremens.
Sleep deprivation
Heart failure
Post-operative.
Relocation in an elderly person

Question 6

Hypoactive delirium

Answer 6

lethargy, reduced concentration, poor appetite. Apathetic and withdrawn

Question 7

Hyperactive delirium

Answer 7

Inappropriate behaviour, hallucinations. Restless and agitated patient.

Question 8

Symptoms and signs of delirium

Answer 8

COGNITIVE = poor memory, poor concentration, aphasia, disorientation.
Acute onset of confusion.
Inattention and distractible.
Disorganised thinking, rambling, unclear flow of ideas.
Unable to hold conversation.
Altered perceptions e.g. delusions and hallucinations
Altered level of consciousness.
Loss of appetite
Mood change e.g. agitation, apathy, anxiety.

Question 9

Diagnosing delirium

Answer 9

Via DSM-IV criteria or CAM criteria. Ask about risk factors, co-lateral history from relative/carer. Cognitive test (GP-COG). Investigate for cause (FBC, urinalysis, u+e etc)

Question 10

Management of delirium

Answer 10

Most admitted for assessment, monitoring and treatment in secondary care.
Primary care management if known cause and treatment in primary care possible. Optimise treatment of co-morbidities, treat delirium cause, advise family/carers of reorientation strategies, safe mobility, sleep-wake cycle, plan if delirium develops again, written info on delirium, arrange follow up.

Question 11

Difference between delirium and dementia

Answer 11

Delirium = acute onset, fluctuating course, altered level on consciousness, disrupted sleep-wake cycle, incoherent speech.
Dementia = gradual onset, normal sleep-wake cycle, normal consciousness, difficulty finding words, progressive deterioration.

Question 12

Management of dementia and aims

Answer 12

Aims = promote independence, maintain function and manage symptoms (not curative)
Non-pharma = group stimulation programmes, cognitive rehabilitation. Advance care planing. Good sleep hygiene. Carer support!!
Alzheimer’s = Donepezil, galantamine or rivastigmine, memantine.
Lewy Body = Donepezil or rivastigmine.
Fronto-temportal = NOT ANTICHOLINESTERASE INHIBITORS!!!

Question 13

How does rivastigmine act

Answer 13

Reversible non-competitive acetylcholinesterase inhibitor.

Question 14

How does Donepezil act

Answer 14

Reversible acetylcholinesterase inhibitor.

Question 15

How does Memantine act

Answer 15

Glutamate receptor antagonist.

Question 16

Name 4 tools to test cognition

Answer 16

6 item cognitive impairment test
GP Assessment of Cognition (GPCOG)
Mini mental state examination
Abbreviated mental test
Test your memory test.

Question 17

Further investigations for dementia (examine which subtype)

Answer 17

Imaging = CT, SPECT or PET.
LP = assess CSF for tau protein or beta-amyloid for Alezheimer's.