Lecture: Dementia Part 1 Flashcards
What is dementia?
- Organ brain syndrome
- Global impairment of cognition, social and occupational functioning
- Affects ADLs
- Clinical syndrome
- Progressive, leading to dependency and death
How does mild cognitive impairment (MCI) differ from dementia?
MCI:
- Evidence of cognitive impairment
- Amnestic or non-amnestic
- DOES NOT affect activities of daily living
- Some will improve
What are the most common dementia subtypes?
60% Alzheimer’s
20% Vascular
10% Mixed
4% DLB
2% FTD
2% PDD
2% other
If a patient has a rapidly progressive dementia (occurs over months) what should you do?
Refer to a neurological service for LP/EEG to examine for rarer conditions like CJD
People <65 have a greater incidence of what type of dementia?
FTD
Less vascular dementia
What are the overall requirements for a diagnosis of dementia?
- Clinical evaluation (history, examination, functional assessment)
- Cognitive assessment
- Basic laboratory evaluation
- Structural imaging
- Other Ix if indicated
What are the aims of dementia assessment?
- Establish if they have dementia
- Exclude other conditions
- Establish sub-type
- Evaluate the impact
- Evaluate family and social support
- Evaluate comorbidity
What are some common symptoms that may be clues someone has dementia?
- Memory loss; losing things, missing appointments
- Confusion
- Repetitiveness
- Becoming lost in a familiar area
- Personality change (irritable, inappropriate, hoarding, indifference, rituals
- Apathy and withdrawal
- Apraxia (forgetting how to use things)
- Agnosing (not recognising objects)
- Impaired language skills
- Loss of ability with iADLs
What are some common symptoms that may be clues someone has dementia?
- Memory loss; losing things, missing appointments
- Confusion
- Repetitiveness
- Becoming lost in a familiar area
- Personality change (irritable, inappropriate, hoarding, indifference, rituals
- Apathy and withdrawal
- Apraxia (forgetting how to use things)
- Agnosing (not recognising objects)
- Impaired language skills
- Loss of ability with iADLs
What are some potentially reversible causes of cognitive impairment?
Delirium
Depression/anxiety
Alcohol/substance use
Medication: BZD, narcotics, anti-epileptics
Neurological disease
Normal Pressure Hydrocephalus (NPH)
B12/folate deficiency
Hypothyroid
Hypercalcaemia
Neurosyphilis
Cerebral vasculitis
What are some aspects of the history from a patient with suspected dementia?
- Symptoms (cognitive, mood, BPSD)
- Collateral
- Time course: onset + progression
- PMHx, Meds, FamHx
- Vascular RFs
- Functional decline: ADLs, iADLS
- RFs: alcohol, head injury, mood disorders
- Driving
- Safety
- Living arrangements
- Legal (will, EPA/EPG, advanced care planning)
What are ADLs?
Activities of Daily Living
Bathing
Toilet
Grooming
Dressing
Transferring
Feeding
What are IADLs?
Instrumental Activities of Daily Living
Home cleaning
Managing Finances
Shopping
Cooking
Managing medications
Using communication tools
Managing transportation
What is benign forgetfulness?
- Slower learning, mental processing, minor forgetfulness with age
- Not of severity to interfere with daily life
- Subjective memory complaints
What is delirium?
- Recent onset
- Fluctuating course
- Sleep-wake cycle altered
- Perceptual disturbance
What is depression?
- Can accompany or mimic dementia
- Often a past history of mood disturbance
- Decreased interest and attention
- Persistent sadness or loss of pleasure in life
- Poor sleep, poor appetite, lack of energy, difficulty concentrating
Are cognitive screening tests ‘true’ screening tests?
No
Screening tests detect disease among healthy community members
They’re case finding: detection of cognitive impairment where there is a high probability of disease in a particular population or setting
What are some limitations of cognitive screening tests?
- Scores must be interpreted considering age, literacy and education achievement
- Disability will affect the reading and writing parts
- Don’t make a diagnosis of dementia
- Detect cognitive impairment from any cause
- A ‘normal’ score doesn’t exclude early cognitive decline
What is the difference between the MMSE and the MOCA?
MMSE:
- Orientation, recall, language, attention and calculation
- Insensitive to early stages of dementia
- Well known for reliability and validity
- Culturally biased
MOCA:
- Assesses many of the same areas as the MMSE but is more in depth and includes the CDT and trail test
- More sensitive: can detect deficits the MMSE misses
- Better for detected of MCI
- Score >26 is normal
When would you do neuropsychological testing?
- Not required in all cases
- When diagnosis is uncertain or there are atypical features
- Especially when younger onset
- If possibility of depression
What is included in a typical dementia workup in terms of laboratory tests?
Basically just searching for reversible causes:
FBC
UEC
LFT
Glucose
Calcium
ESR
TFT
B12
Folate
What neuroimaging is included in a dementia work-up?
- Non-contrast CT or MRI is almost universally included as part of the work-up but the yield is low
- Do when there are atypical features (fast progression, young) and to identify treatable conditions (NPH, subdural etc)
- Identify characteristic changes that suggest AD or vascular disease or other causes of dementia
What do you see on head CT of someone with AD?
Shrinkage in specific areas: hippocampus
Where is the brain shrinkage in FTD?
Frontal and/or temporal lobes
