GP 2 Flashcards
Dementia: signs and symptoms
- Memory loss: recent information
- Difficulty with familiar tasks i.e. cooking
- Language: struggling to find the right word
- Disorientation
- Poor judgement
- Changes in mood and behaviour: irritability, anxiety or depression
- Withdrawing from social activity
- Personality change
- Difficulty in abstract thinking
Dementia: diagnosis
- Assess cognitive decline with MMSE, MOCA, mini-cog, ACE-III
- Blood test: FBC, U&E, LFTs, CRP/ESR, Ca2+, TFTs, B12, folate, syphilis, HIV
- MRI or CT head
- If dementia is suspected refer to specialist dementia diagnostic service (memory clinic)
Assessing risk in patients with dementia ‘HOW SAFE’
- HOme safety (gas)
- Wandering
- Self neglect
- Abuse
- Falls
- Eating
General management of dementia
- Lifestyle – patients encourage to stay physically and mentally active. Written information for all patients.
- Social – adult social services, occupational therapy assessment. May need support at home
- Planning ahead: lasting power of attorney, end of life care, advanced decisions
- Psychological – group stimulation therapy.
- Pharmacological – e.g. donepezil (mild-moderate AD), memantine (severe AD), acetylcholinesterase inhibitors for LBD, optimising CV profile in VD.
- BPSD in dementia – where delirium has been ruled out. 6-12/52 low-dose risperidone
- Antipsychotics are last line and contraindicated in LBD and PD
Vascular dementia definition
caused by ischaemic or haemorrhage cerebrovascular disease, with progressive stepwise cognitive deterioration over months or years. Typical presentations are stroke-related vascular disease, subcortical vasculardementia (small vessel disease), and mixeddementia (combination of Alzheimers and vascular). Second most common type of dementia.
Vascular dementia presentation
less impairment in episodic memory and more in visual skills, semantic memory and executive functioning
Criteria for vascular dementia
- the onset of dementia within three months following a recognised stroke
- an abrupt deterioration in cognitive functions
- fluctuating, stepwise progression of cognitive deficits
Diagnosis of vascular dementia
- A comprehensive history and physical examination
- Formal screen forcognitive impairement
- Medical review to exclude medication cause of cognitive decline
- MRI scan - may show infarcts and extensive white matter changes
- Imaging: in MRI head there is extensive white matter change and infarcts evident
Management of vascular dementia
- Reduction of cardiovascular risk factors like hypertension, diabetes and smoking
- Cognitive stimulation programmes; music and art therapy
- Symptomatic treatment, including cognitive enhancers such as cholinesterase inhibitors or memantine - if there is evidence of co-existent AD, Parkinson’sdementia, ordementia with Lewy bodies.
Lewy body dementia pathophysiology
alpha synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas). Accounts for 20% of dementia (third most common)
Lewy body dementia features
- progressivecognitive impairement: in contrast to Alzheimer’s, early impairments in attention and executive function rather than just memory loss
- cognition may be fluctuating, develops 1 year before parkinsonism
- parkinsonism
- visualhallucinations: classically of small creature, children (other features such as delusions and non-visual hallucinations may also be seen)
Lewy body dementia: investigations and management
- Investigations: clinical diagnosis but can use DAT scan
- Management: use acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine
Alzheimers pathophysiology
Chronic, neurodegenerative disorder caused by the accumulation of (alpha-beta) amyloid plaques and tau tangles in the brain. As it develops it can lead to neuronal loss and brain atrophy. Causes defecit in the neurotransmitter acetylcholine and neuroinflammation. Most common cause of dementia
Alzheimers: clinical features
- Memory impairment: early on, recalling recent events
- Language impairment, difficulties in activities of daily living, executive dysfunction, behavioural changes (agitation), disorientation, psychological (hallucination)
- MRI: brain atrophy and amyloid plaques. May be predominantly in the medial temporal lobe
Alzheimers medical management
- The cholinesterase inhibitors rivastigamine, galantamine, and donpezil in mild-moderatedementia
- NMDA inhibitor memantine in severedementia(as classified using the MMSE score: severe: <10; moderate: 10-20; mild: 21-26/30.
- If evidence of behavioral and psychological symptoms ofdementia(BPSD), low-dose risperidone may be started
Fronto temporal dementia
- Definition: Neurodegenerative disorder due to atrophy of the frontal and/or temporal lobes of the brain
- One of the most common forms of early onset dementia but rare overall
- Lots of different causes: some are familial
- Can be caused by Pick’s disease: due to ‘Pick’s bodies’ accumulation of TAU protein within neurons (familial)
- Prognosis is 7-13 years
- Starting age 40-60
Fronto temporal dementia presentation
- Personality changes: often exhibit disinhibited behaviour and apathy early on
- Language impairment
- Cognitive decline: memory is relatively preserved early on, executive function is relatively impaired
- Motor abnormalities: may get muscle weakness and dysarthria
Fronto temporal dementia investigations
- MRI or CT: shows atrophy of the frontal and/or temporal lobes. Specifically MRI can show focal gyral atrophy and knife blade appearance
- Genetic testing: if you suspect an inherited form of FTD
Fronto temporal dementia management
- Counselling, Behaviour modification strategies, caregiver support. Discuss driving- have to inform DVLA of diagnosis
- Referral to specialist psychiatry or neurology services
- SSRI’s and antipsychotics: help control behavioural symptoms. Benzos if acute
- Don’t use Memantine and cholinesterase inhibitors
- Supportive: SALT and occupational therapy