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MRCP Part 1 > Geriatrics 1 > Flashcards

Geriatrics 1 Flashcards

Dementia Delirium

1
Q

A 78yo female has been diagnosed with mild to moderate dementia. What is an effect of a cholinesterase inhibitor?

A

Improvement in activities of daily living

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2
Q

Patients with Alzheimer’s disease have reduced production of choline acetyl transferase. What impact does this have on them biochemically?

A

Decreased choline acetyl transferase production leads to a decrease in acetylcholine synthesis and impaired cortical cholinergic functioning.

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3
Q

What is the role of cholinesterase inhibitors in Alzheimer’s disease?

A
  • Provide some improvement in cognitive function and improve ADLs.
  • There is no role for cholinesterase inhibitors in advanced Alzheimer’s disease.
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4
Q

Describe the genetics of Alzheimer’s Disease.

A
  • Most cases are sporadic
  • 5% of cases are inherited as an autosomal dominant trait.
  • Mutations on Chromosomes 21, 14, and 1 are thought to cause an inherited form.
  • Apoprotein E allele E4 - encodes a cholesterol transport protein
  • RF = Down’s Syndrome
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5
Q

What are the macroscopic pathological changes seen in an Alzheimer’s brain?

A

Widespread cortical atrophy, particularly involving the cortex and hippocampus

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6
Q

What are the microscopic pathological changes seen in an Alzheimer’s brain?

A
  • Cortical plaques due to deposition of type A-Beta-Amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of tau protein
  • Hyperphosphorylation of the tau protein.
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7
Q

What are the biochemical pathological changes seen in an Alzheimer’s brain?

A

A deficit of acetylcholine from damage to an ascending forebrain projection.

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8
Q

What are ‘neurofibrillary tangles’?

A
  • Paired helical filaments are partly made from tau.
  • Tau interacts with tubulin to stabilise microtubules
  • In AD, tau proteins are excessively phosphorylated, impairing the function.
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9
Q

What is the characteristic pathological feature of Lewy Body dementia?

A

Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.

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10
Q

What are the features of Lewy Body dementia?

A

1) Progressive cognitive impairment:
- > early impairments in attention and executive function, rather than just memory loss.
- > cognition may be fluctuating

2) Parkinsonism
3) Visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)

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11
Q

How is Lewy Body dementia diagnosed?

A
  • Usually clinical diagnosis

- SPECT (Single-photon emission CT) is increasingly used. Commercially known as a ‘DaTscan’.

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12
Q

What is the Sensitivity and Specificity of a SPECT scan in diagnosing Lewy Body dementia?

A

Sensitivity = 90%

Specificity = 100%

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13
Q

What is the management of Lewy Body Dementia?

A
  • Acetylcholinesterase inhibitors (Donepezil, Rivastigmine)

- Memantine

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14
Q

Why should neuroleptics be avoided in patients with Lewy Body dementia?

A
  • Patients are extremely sensitive and may develop irreversible parkinsonism.

Note: questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent.

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15
Q

What is the most common cause of Dementia in the UK?

A

Alzheimer’s Disease

followed by Vascular and Lewy Body dementia

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16
Q

Diagnosis of Dementia can be difficult and is often delayed. List 2 assessment tools recommended by NICE for the non-specialist setting in assessing for dementia.

A

1) 10-point cognitive screener (10-CS)

2) 6-item cognitive impairment test (6CIT)

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17
Q

What score on the Mini Mental State Examination implies dementia?

A

A MMSE score of 24 or less out of 30 suggests dementia.

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18
Q

Describe a patient’s pathway when they are en-route to getting a dementia diagnosis.

A

Primary Care: blood screen is usually sent to exclude reversible causes.
Refer to Memory Clinic / Old Age Psychiatry.

Secondary Care: Neuroimaging is performed to exclude reversible conditions (eg. subdural haematoma, normal pressure hydrocephalus), and to help provide information on aetiology to guide prognosis and management

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19
Q

Which bloods might a Primary Care Physician request in order to identify the reversible causes of Dementia?

A 
FBC
U&Es
LFTs
Calcium
Glucose
TFTs
Vitamin B12
Folate
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20
Q

When and why might acetylcholinesterase inhibitors be contraindicated in a patient with Alzheimer’s?

A

SE of acetylcholinesterase inhibitors (Donepezil, Rivastigmine, Galantamine) = BRADYCARDIA (or SA block or AV block).

Hence, meds might be CI / started with caution in patients with conduction abnormalities or those taking beta blockers, rate-limiting CCBs, or Digoxin.

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21
Q

List some possible side effects of Acetylcholinesterase inhibitors.

A
  • Neuroleptic Malignant Syndrome very rare!!
  • GI: N&V, anorexia, diarrhoea
  • Agitation
  • Hallucinations
  • Syncope
  • EPSEs
22
Q

Who prescribes Acetylcholinesterase inhibitors?

A
  • Should be initiated by specialists with expertise in the area of prescribing these meds
    eg. Psychiatrists, Elderly Care Specialists, Neurologists.

Note: GPs may be asked to take over the prescribing and monitoring under Shared Care Agreements.

23
Q

List 5 factors favouring delirium over dementia.

A
  1. Impairment of consciousness
  2. Fluctuation of symptoms: worse at night, some periods of normality
  3. Abnormal perception (eg. illusions and hallucinations)
  4. Agitation, fear
  5. Delusions
24
Q

Which factors might cause an ‘Acute Confusional State’?

A
  • Physical: dehydration, constipation, UTI
  • Medication changes / being in an unfamiliar environment
  • Delirium is more common among elderly patients, especially those with poor hearing/eyesight or pre-existing memory problems.
25
Q

What is the main factor favouring delirium over dementia?

A

Delirium => impairment of consciousness eg. reduced GCS

26
Q

Describe the non-pharmacological management of Alzheimer’s Disease.

A

Offer:
- ‘a range of activities to promote wellbeing that are tailored to the person’s preference’
- ‘group cognitive stimulation therapy for patients with mild and moderate dementia’
Consider:
- group reminiscence therapy and cognitive rehabilitation

27
Q

Describe the pharmacological management of Alzheimer’s Disease.

A
  • Acetylcholinesterase inhibitors (eg. Donepezil, Galantamine, Rivastigmine) for mild to moderate Alzheimer’s Disease
  • Memantine (NMDA receptor antagonist). Reserved for patients with:
    > moderate AD who are intolerant of, or CI to, AChE inhibitors
    > as an add on drug to AChE inhibitors
    > Monotherapy in severe AD.
28
Q

Describe the management of non-cognitive symptoms of Alzheimer’s Disease.

A
  • NICE does NOT recommend antidepressants for mild to moderate depression
  • Antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress.
29
Q

What are the considerations when prescribing Donepezil in patients with AD?

A
  • Donepezil is relatively contraindicated in patients with bradycardia.
  • Adverse effects include insomnia.
30
Q

How might Frontotemporal dementia present?

A
  • Social disinhibition
  • Develops later in life
  • Often family history is present
31
Q

What are the 3 recognised types of Frontotemporal lobar degeneration (FTLD)?

A
  • Frontotemporal dementia (Pick’s Disease)
  • Progressive non-fluent aphasia (chronic progressive aphasia, CPA)
  • Semantic dementia
32
Q

What are the 4 common features of frontotemporal lobar dementias?

A
  • Onset before 65yrs
  • Insidious onset
  • Relatively preserved memory and visuospatial skills
  • Personality change and social conduct problems
33
Q

How might Pick’s disease present?

A
  • Personality Change
  • Impaired social conduct
    Other common features:
  • hyperorality
  • disinhibition
  • increased appetite
  • perseveration behaviours
34
Q

What macroscopic changes are seen on neuroimaging in Pick’s disease?

A
  • Focal gyral atrophy with a knife-blade appearance

- Atrophy of the frontal and temporal lobes

35
Q

What microscopic changes are seen on neuroimaging in Pick’s disease?

A
  • Pick bodies: spherical aggregations of tau protein (silver staining)
  • Gliosis
  • Neurofibrillary tangles
  • Senile plaques
36
Q

Describe the management of Pick’s disease (FTD).

A

NICE do NOT recommend that AChE inhibitors or Memantine are used in people with FTD.

37
Q

What is the chief factor of Chronic Progressive Aphasia?

A
  • Non-fluent speech
  • Short utterances that are agrammatic
  • Comprehension is relatively preserved.
38
Q

What are the features of Semantic Dementia?

A
  • Patient has fluent progressive aphasia.
  • Speech is fluent, but empty and conveys little meaning.
  • Unlike in Alzheimer’s memory is better for recent rather than remote events.
39
Q

Why are acetylcholinesterase inhibitors used in Alzheimer’s dementia?

A
  • People with AD have reduced amounts of cholinergic neurones.
  • AChE inhibitors increase the amount of AChE in the synaptic cleft leading to increased effects at the postsynaptic receptor.
40
Q

What does the enzyme Tyrosine Hydroxylase do?

A

Breaks down Catecholamines (Dopamine, Epinephrine, Norepinephrine).

41
Q

What do COMT (Catechol-I-methyltransferase) inhibitors do?

A

COMT inhibitors (eg. Entacapone, Tolcapone) stop the peripheral breakdown of Levodopa, increasing the levels that cross the blood-brain barrier.

42
Q

What are MAOI’s used for?

A

Treatment of many conditions including depression and panic disorder.

43
Q

What are the side effects of Memantine (an NMDA receptor antagonist).

A

Sleepiness

44
Q

How is ‘Acute Confusional State’ / Delirium assessed?

A

Confusion Assessment Method:

  • An acute onset of a change in mental state from the patient’s baseline with inattention, in addition to either disorganised thinking or altered consciousness.
  • Sleep-wake cycle is often reversed.
45
Q

List some causes of Acute Delirium.

A
  • Pain
  • Infection
  • Constipation
  • Urinary Retention
  • Metabolic: hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
  • Medications eg. opioids
  • Hypoxia
46
Q

List 5 factors predisposing a patient to delirium.

A
  • Age over 65yrs
  • Background of dementia
  • Significant injury eg. hip fracture
  • Frailty or multimorbidity
  • Polypharmacy
47
Q

List some factors which might precipitate an acute delirium.

A
  • Infection eg. UTI
  • Metabolic eg. hypercalcaemia, hypo/hyperglycaemia, dehydration
  • Change of environment
  • Any significant cardiovascular, respiratory, neurological or endocrine condition
  • Severe pain
  • Alcohol withdrawal
  • Constipation
48
Q

How might acute confusional state (delirium) present?

A
  • Memory disturbances (loss of short term)
  • agitated / withdrawn
  • disorientation
  • mood change
  • visual hallucinations
  • disturbed sleep cycle
  • poor attention
49
Q

Describe the management of delirium.

A
  • Treatment of the underlying cause
  • Modification of the environment
  • Haloperidol 0.5mg as first line sedative
  • Olanzapine
50
Q

Is Donepezil safe to give in renal failure?

A

Yes.

It is not renally excreted.

51
Q

Is there an interaction between Donepezil and Warfarin?

A

No.

52
Q

Why should antipsychotics be avoided in Dementia patients?

What about Lewy Body dementia patients?

A

Due to the increase in mortality, particularly from cardiovascular causes.

Lewy Body dementia:

  • Patients are particularly sensitive to neuroleptic medication.
  • Neuroleptic medication will worsen motor symptoms, and increases the risk of Neuroleptic Malignant syndrome.

MRCP Part 1 (16 decks)

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