Memory problems

Question 1

1) What is thought to be the crux of old age psychiatry?
2) Why do MHOA teams usually assess people at home?
3) What professions take part in assessment and management of older people with mental health needs?
4) What is the emphasis for management of mental health conditions in older people concentrated on?
5) What percentage of older people in the community are depressed at any time?

Answer 1

1) Not the symptoms, but how these symptoms affect a person’s everyday life and ability to function.
2) Because this gives a realistic view of how they are managing in their own environment.
3) Social workers, specialist nurses, psychologists, occupational therapists and psychiatrists in conjunction with carers.
4) Maintaining quality of life.
5) 15%

Question 2

1) What percentage of older people in hospitals are depressed?
2) Give 5 factors that play aetiological roles in depression in older people.
3) What 3 presentations of depression might be more obvious in older people?
4) What 3 risks are extremely important in older people who are depressed.
5) Why is it important to follow-up people who suffer pseudo-dementia?

Answer 2

1) 30%
2) Multiple bereavements, social isolation, poverty, physical illness and chronic pain are more common in older adults.
3) May be more obvious physical symptoms (constipation), agitation/ retardation or memory problems (pseudo dementia).
4) Completed suicide, self-neglect and poor food/ fluid intake are extremely important.
5) Because they are at a higher risk of developing actual dementia.

Question 3

Name 4 stages in the management of depression in older people.

Answer 3

1) Problem solving, increasing socialisation and daytime activities.
2) Psychological therapies
3) Antidepressants
4) ECT is sometimes used for psychotic or life-threatening depression.

Question 4

1) Name the 5 psychological therapies which can be helpful in treating depression in older people.
2) What medication is first line in treating depression in older people?
3) Why do you need to check sodium levels when treating older people with SSRIs?
4) What happens to the prevalence and incidence of anxiety disorders with increasing age?
5) In older people, who is more commonly affected by anxiety disorders?

Answer 4

1) CBT, psychodynamic psychotherapy, group, family and couple therapy.
2) SSRIs such as citalopram.
3) Because SSRIs can cause hyponatraemia in the elderly.
4) Prevalence and incidence of anxiety disorders fall with age, possibly because of under-reporting.
5) Women are more commonly affected, especially those who are isolated or who have suffered adverse life events.

Question 5

1) What does management of anxiety in older people usually consist of?
2) Which organic conditions in older people can present with psychotic symptoms?
3) Psychotic symptoms in older people can occur secondary to what?
4) Who is late-onset schizophrenia more common in?
5) Name an organic risk factor for late-onset schizophrenia.

Answer 5

1) Usually psychological, although SSRIs can be useful.
2) Delirium and dementia.
3) They can occur secondary to sensory impairment.
4) Women - especially those who are single, isolated, widowed or childless.
5) Sensory deficits are a risk factor.

Question 6

1) What types of symptoms are more prominent in late-onset schizophrenia/ psychosis in older people.
2) What are the 3 steps of management of psychosis/ late-onset schizophrenia?
3) What is Charles Bonnet syndrome?

Answer 6

1) Positive symptoms are more prominent than negative symptoms.
2) Reduction of sensory impairment, exclusion of an organic cause/ Lewy-Body dementia and then low-dose antipsychotics.
3) Complex visual hallucinations secondary to visual impairment alone.

Question 7

1) Define dementia.
2) Why is the effect of dementia on ADLs an important part of a dementia assessment?
3) For a confident diagnosis of dementia, what does the patient need to have experienced?
4) The risk of dementia increases with what?
5) What is the prevalence of dementia in people >65?

Answer 7

1) It is an acquired, chronic and progressive cognitive impairment, sufficient to impair activities of daily living.
2) Because a low MMSE alone cannot diagnose dementia.
3) Problems need to have been present in clear consciousness for at least 6 months.
4) Age.
5) 5%

Question 8

Name 5 possible causes of a low MMSE.

Answer 8

1) Dementia
2) Delirium
3) Most psychiatric illnesses (depression, anxiety, psychosis)
4) Learning disability
5) Sensory impairment
6) Language barrier
7) Feeling unwell/ tired/ irritable

Question 9

1) What is the prevalence of dementia in people > 80?
2) What is the most common cause of dementia?
3) What are the 2nd and 3rd most common causes of dementia?
4) What are initial problems of dementia normal attributed to?
5) Describe 2 main initial problems of dementia.

Answer 9

1) 20%
2) Alzheimer’s disease
3) Vascular dementia and Lewi-Body dementia.
4) Normal ageing or absent-mindedness.
5) Forgetfulness, principally for recent events and mild mistakes in day-to-day activities

Question 10

1) What 2 co-morbidities might occur early in dementia, especially when insight is intact?
2) In what order does disorientation occur in dementia?
3) What is the main risk factor for Alzheimer’s disease.
4) Who is Alzheimer’s disease more common in?
5) Name 5 risk factors for Alzheimer’s disease.

Answer 10

1) Anxiety and depression
2) For time, then place and then person.
3) Age.
4) Marginally more common in women.
5) Age, Genetics, vascular risk factors such as HTN, low IQ/ poor educational level and head injury.

Question 11

Name 7 categories of problems which might occur in a patient with dementia.

Answer 11

1) Wandering
2) Sleep disturbance/ day-night reversal
3) Delusions
4) Hallucinations
5) Calling out, shouting, screaming, swearing
6) Inappropriate behaviour, including sexual disinhibition
7) Aggression

Question 12

1) What is familial early-onset Alzheimer’s disease usually due to?
2) Name 3 mutations which can occur in early-onset Alzheimer’s disease.
3) Late onset Alzheimer’s disease is associated with what allele?
4) What does E4 increase?
5) Over what age is Alzheimer’s disease classed as late-onset?

Answer 12

1) Rare autosomal dominant gene mutations causing increased Beta-amyloid.
2) Presenilin 1 gene (chromosome 14), presenilin 2 gene (chromosome 1), beta-amyloid precursor protein (APP) gene (chromosome 21).
3) Apolipoprotein E4 allele (chromosome 19)
4) E4 is thought to increase early arteriosclerosis.
5) Over 65.

Question 13

1) What is the most worrying type of Alzheimer’s disease for children of people with dementia?
2) Which people are at high risk of Alzheimer’s disease by middle age and why?
3) What are the 4 key elements in the pathology of Alzheimer’s disease?

Answer 13

1) Early onset is most worrying in terms of inherited risk.
2) People with Down syndrome are at high risk of AD by middle age, probably because of the extra copy of the APP gene in trisomy 21.
3) Atrophy, plaque formation, neurofibrillary tangles and cholinergic loss.

Question 14

1) What does atrophy of the brain in Alzheimer’s disease occur due to?
2) What area of the brain is affected early in atrophy and what is this part of the brain essential for?
3) Which 2 lobes of the brain are affected by atrophy later?
4) What may be enlarged on a CT scan in Alzheimer’s disease?
5) Why is this enlargement abnormality not diagnostic?

Answer 14

1) Due to neuronal loss.
2) The hippocampus is affected in early atrophy and it is responsible for new learning and visuospatial skills.
3) The temporal and the parietal lobe.
4) The natural spaces of the brain (sulci and ventricles).
5) Because this process occurs in normal ageing.

Question 15

1) What can APP be abnormally cleaved into?
2) How does plaque formation occur?
3) What surrounds the core of the plaques once they are formed?

Answer 15

1) Beta-amyloid.
2) Beta-amyloid aggregates into insoluble lumps which form the core of the plaques.
3) The beta-amyloid aggregates are surrounded by dystrophic neurites.

Question 16

1) What are dystrophic neurites that surround the plaque cores filled with?
2) What are neurofibrillary tangles made up of?
3) What does tau protein normally do?
4) What happens to tau when it is phosphorylated?
5) What do neurofibrillary tangles do to the neuron?

Answer 16

1) Dystrophic neurites are filled with hyperphosphorylated tau protein.
2) Abnormal (hyperphosphorylated) tau protein.
3) Usually holds microtubules together within a neutron.
4) It cannot attach to microtubules and so accumulates in the cell as insoluble paired helical filaments.
5) They fill up the neuron and kill it.

Question 17

1) What is the severity of dementia caused by Alzheimer’s disease most closely associated with?
2) How do neurofibrillary tangles form?
3) Which pathways are most affected in Alzheimer’s disease?

Answer 17

1) The number of neurofibrillary tangles.
2) Phosphorylated tau protein attaches to microtubules and these accumulate in the cell as insoluble paired helical filaments. These become tangles which fill up the neuron and kill it.
3) Cholinergic pathways are the most affected in Alzheimer’s disease.

Question 18

Describe the clinical presentation of Alzheimer’s disease (the 4 A’s).

Answer 18

1) Amnesia: recent memories are lost first and disorientation occurs early.
2) Aphasia: word-finding problems occur, speech can become muddled and disjointed.
3) Agnosia: recognition problems (for example, difficulties with facial recognition –> prosopagnosia).
4) Apraxia: inability to carry out skilled tasks despite normal motor function (e.g. dressing)

Question 19

1) What does Vascular dementia occur due to?
2) Risk factors for Vascular dementia are the same as for what?
3) List 7 risk factors for Vascular dementia.
4) What type of co-morbidity is a patient with Vascular dementia likely to have?
5) Name the 3 key points in the pathology of vascular dementia.
6) What may happen in Alzheimer’s disease as the features of dementia progress?

Answer 19

1) Thrombo-emboli or arteriosclerosis.
2) Stroke disease.
3) Older age, male sex, smoking, HTN, diabetes, hypercholesterolaemia and AF.
4) Other signs of arteriosclerosis such as heart attacks or transient ischaemic attacks.
5) Arteriosclerosis, cortical ischaemia and infarction are the key points.
6) The personality of the patient may erode.

Question 20

1) Classically, what type of progression is seen in vascular dementia?
2) What is strategic infarct dementia?
3) What do the symptoms of vascular dementia reflect?
4) Describe the presentation of vascular dementia in one word.
5) Which 2 areas tend to be ‘spared’ in the presentation of vascular dementia?

Answer 20

1) A stepwise progression, with each ‘step’ representing a sudden deterioration as an infarct occurs.
2) When one strategically located stroke has the ability to cause dementia.
3) The sites of the lesions.
4) ‘Patchy’.
5) Personality and some areas of cognition tend to be spared.

Question 21

1) What does each ‘step’ in the progression of vascular dementia represent?
2) Give 3 signs/ symptoms of vascular dementia.
3) What are Lewy bodies?
4) What are Lewy bodies composed of?
5) Where are Lewy bodies found in Parkinson’s disease?

Answer 21

1) A sudden deterioration as an infarct occurs.
2) Neurological signs such as hemiparesis or aphasia and episodes of confusion.
3) Eosinophilic intracytoplasmic neuronal structures.
4) Alpha-synuclein with ubiquitin.
5) In the brainstem.

Question 22

1) Where are Lewy bodies found in Lewy body dementia?
2) How many of the main symptoms of Lewy body dementia should be present for you to consider the diagnosis?
3) Name 3 other symptoms of Lewy body dementia which are not the main 3.
4) Which area of memory is less affected in Lewy body dementia?
5) Why can Lewy body dementia resemble delirium?

Answer 22

1) They are seen in the brainstem, cingulate gyrus and neocortex.
2) Two of the main 3 symptoms should be present to alert you to the possibility of LBD.
3) Repeated falls, syncope and transient losses of consciousness.
4) Short-term memory is less affected in LBD.
5) Due to fluctuating cognition and visual hallucinations that can occur.

Question 23

Name the 3 main symptoms of Lewy body dementia.

Answer 23

1) Fluctuating confusion with marked variation in levels of alertness.
2) Vivid visual hallucinations (often of people or animals).
3) Spontaneous (new onset) Parkinsonian signs.

Question 24

1) Why must you not prescribe antipsychotics for a person with Lewy body dementia?
2) What is the ‘mirror’ sign which is sometimes seen in Dementia?
3) Describe the phenomenon of ‘sun-downing’.
4) What may sun-downing be due to?
5) Give 3 differential diagnoses of dementia.

Answer 24

1) Because extreme antipsychotic sensitivity in the form of neuroleptic malignant syndrome can result in death.
2) This is where sufferers no longer recognise their own reflection (autoprosopagnosia).
3) Where confusion in dementia often worsens as evening draws in.
4) The exact cause is not known, but may relate to the increased risk of illusions in poor light when tired.
5) Delirium, reversible dementia and pseudodementia.

Question 25

1) How does Delirium present?
2) When might symptoms of delirium resolve?
3) How do ‘reversible’ dementias present?
4) Name 3 neurological causes of ‘reversible’ dementia.
5) Name 4 endocrine causes of ‘reversible’ dementia.

Answer 25

1) It presents suddenly with altered or ‘clouded’ consciousness - losing touch of surroundings (poor attention is a good marker of this).
2) Once the underlying cause is treated.
3) With cognition impairment that may resolve if treated.
4) Subdural haematoma, space-occupying lesions and normal pressure hydrocephalus.
5) Hypothyroidism, hyperparathyroidism, Addison’s disease and Cushing’s syndrome.

Question 26

1) Name 4 vitamin deficiencies which can cause ‘reversible’ dementia.
2) State how to differentiate between dementia and pseudodementia.
3) What must you do if someone presents for the first time in later life with any psychiatric illness?

Answer 26

1) B12, folate, thiamine and niacin.
2) Memory problems in severe depression can resemble dementia. In depression, low mood normally precedes cognitive problems and there may be a past history of depression. Depressed people lack motivation to answer questions, where as people with dementia are often keen but make mistakes.
3) You must rule out any underlying organic cause.

Question 27

State 6 investigations that you might do for a patient with suspected dementia.

Answer 27

1) Basic observations and physical examination.
2) Blood tests: FBC, U&Es, TFTs, glucose, LFTs, B12, Folate, Calcium levels and VDRL.
3) MMSE
4) Collateral Hx
5) Sepsis screen (MSU, CXR, blood cultures, wound swabs, sputum/ stool samples - choose as appropriate as suggested by symptoms)
6) CT/ MRI head of indicated.

Question 28

1) Why might you check FBC for a patient with suspected dementia?
2) Why might you check U&Es in a patient with suspected dementia?
3) Why might you check TFTs in a patient with suspected dementia?
4) Why might you check B12 and folate in a patient with suspected dementia?
5) Why should you do a septic screen in a patient with suspected dementia?

Answer 28

1) To check for infection/ anaemia (can cause delirium)
2) To rule out dehydration/ renal failure/ hyponatraemia as these can cause delirium.
3) To check for hypothyroidism as this can mimic dementia.
4) As deficiencies in these can cause reversible dementias.
5) To rule out any causes of sepsis as sepsis can cause delirium which is a differential diagnoses for dementia.

Question 29

Give 3 indications for a CT/MRI in a patient with suspected dementia.

Answer 29

1) Unusual presentation/ neurological signs.
2) First onset of psychotic symptoms later in life (especially if olfactory or visual hallucinations are present).
3) If you are planning to start anti-dementia medication.

Question 30

1) What 3 factors does management of dementia focus on?
2) Name 3 things that social support can offer to help patients with dementia.
3) What 4 things do support carers do?
4) What is the golden rule of prescribing in older adults?

Answer 30

1) Quality of life, preservation of independence and preservation of dignity.
2) Personal care, meal preparation or medication prompting/ day centres for activities and social contact/ day hospitals to enable daily psychiatric care for more complex patients.
3) Emotional support, education about dementia, training to manage common problems and provision of respite care.
4) Start low and go slow.

Question 31

Name the 6 areas of management for patients with dementia.

Answer 31

1) Adaptations for patients
2) Social support
3) Support carers
4) Optimise physical health
5) Psychological therapies
6) Psychotropic medications

Question 32

Name 6 adaptations that might be made in order to help a patient with dementia.

Answer 32

1) Always carry ID, address and contact number in case of getting lost.
2) Dossett boxes/ blister packs to aid medication compliance.
3) Change gas to electricity (to decrease risks of the gas being accidentally left on).
4) Reality orientation (visible clocks and calendars)
5) Environmental modifications (patterned can predispose to visual hallucinations)
6) Assistive technology (door mat buzzers alert relatives to wandering)

Question 33

Give the 4 areas of optimising physical health in a patient with dementia.

Answer 33

1) Treat sensory impairment (hearing aids/ glasses)
2) Exclude superimposed delirium
3) Treat underlying risk factors (for example, antihypertensives or statins)
4) Review all medication (prescribed and non-prescribed)

Question 34

Name 5 psychological therapies that can be used for patients with dementia

Answer 34

1) Behavioural approaches: identify and modify underlying triggers for difficult or risky behaviours.
2) Reminiscence therapy: talking about ‘the old days’ enhances a sense of belonging, reinforces identity and builds confidence.
3) Validation therapy: Reassure and validate the emotion behind what is said (for example, if your patient is looking for their mother, recognise the possible underlying need for reassurance)
4) Multisensory therapy: As dementia advances and speech is lost, it may be easier to respond to touch, music, etc.
5) Cognitive stimulation therapy: memory training and re-learning.

Question 35

1) Why do you often need to start with low doses in older people?
2) What class of drug is often used to treat patients with dementia?
3) Which types of dementia do drugs such as Donepezil and Rivastigmine work for slowing down the disease progression?
4) What can some non-psychotropic medications do to people with dementia?

Answer 35

1) Because older people are often very sensitive to drug side effects.
2) Acetylcholinesterase inhibitors.
3) Alzheimer’s disease and dementia with levy bodies.
4) They cam impair cognition in dementia patients because of the anticholinergic effects.

Question 36

Describe how acetylcholinesterase inhibitors work.

Answer 36

They prevent acetylcholinesterase from breaking down acetylcholine. This increases neurotransmitter levels in the synapse and compensating for the overall cholinergic loss.

Question 37

1) When might you consider using drugs such as Trazodone, sodium valproate, low dose antipsychotics or BDZs?
2) What class of drug is Trazodone?
3) Which 2 drugs should you avoid using to treat behavioural symptoms in dementia?
4) Why should you avoid using these drugs?
5) What proportion of people with dementia live in their own home or with a carer?

Answer 37

1) They are a last resort for the management of behavioural disturbance.
2) Sedative antidepressant.
3) Avoid Olanzapine and Risperidone.
4) Olanzapine and Risperidone increase the risk of stroke in the elderly.
5) Two-thirds.

Question 38

1) When would a carer be more likely to abuse a person with dementia?
2) Name 2 risk factors for abuse of patients with dementia in institutions.
3) Who is elder abuse such as neglect, psychological, financial, physical or sexual abuse more likely to occur in?

Answer 38

1) If they are socially isolated, unsupported, mentally ill (depressed/ substance misuse) or have a personal history of childhood abuse.
2) Poor supervision and training of staff working in isolation.
3) Patients who are female, patients who are living alone with the abuser and depend upon them for their physical and mental health needs.

Question 39

1) What are organic psychiatric disorders?
2) What are functional illnesses?
3) Which lobe is Broca’s area in?
4) Which lobe is Wernicke’s area in?
5) What is the primary motor cortex responsible for?

Answer 39

1) Organic psychiatric disorders are those caused directly by a demonstrable physical problem.
2) Those traditional viewed as having no organic basis.
3) Frontal lobe.
4) Temporal lobe.
5) Contralateral movement.

Question 40

1) What is the supplementary motor cortex responsible for?
2) Define delirium.
3) Give 5 risk factors for delirium.
4) Describe the onset for delirium.
5) When do the symptoms of delirium tend to worsen?

Answer 40

1) Organisation of complex movement.
2) An acute and transient state of global brain dysfunction with clouding of consciousness; the patient is not fully aware of or in touch with their environment.
3) old age, pre-existing physical or mental illness (especially dementia), substance misuse, poly pharmacy and malnutrition.
4) Sudden onset (hours to days) with symptoms fluctuating throughout the day.
5) In the evening and at night.

Question 41

Give 6 functions of the frontal lobe.

Answer 41

1) Executive function
2) Personality/ social behaviour.
3) Initiative/ motivation.
4) Speech production (Broca’s area: dominant lobe)
5) Motor cortex
6) Suppression of primitive reflexes.

Question 42

Give 4 functions of the temporal lobe.

Answer 42

1) Auditory, olfactory and gustatory perception.
2) Understanding of speech (Wernicke’s area: dominant lobe)
3) Memory
4) Emotional regulation

Question 43

Give 4 functions of the parietal lobe.

Answer 43

1) Somatosensory perception
2) Integration of sensory perception allowing awareness and movement of the body.
3) Communication between Broca’s and Wernicke’s area.s.
4) Calculation

Question 44

Give the main function of the occipital lobe.

Answer 44

1) Visual perception and interpretation.

Question 45

What percentage of the following groups of people suffer delirium?

a) Medical inpatients
b) Post-operative patients
c) Elderly ITU patients

Answer 45

a) 20% medical inpatients.
b) ~50% post-operative patients.
c) 70% elderly ITU patients.

Question 46

List the 9 categories of causes for delirium.

Answer 46

1) Trauma: head injury/ burns.
2) Hypoxia: CV/ respiratory
3) Infective: intracranial (encephalitis) and systemic (septicaemia)
4) Metabolic: liver failure, renal failure and electrolyte imbalance.
5) Endocrine: hypoglycaemia
6) Nutritional: Wernicke’s encephalopathy
7) CNS pathology: raised ICP.
8) Drugs and alcohol: intoxication/ withdrawal.
9) Medication: anticholinergics/ opiates.

Question 47

1) Briefly describe a usual patient with delirium.
2) How is sleep usually affected in patients with delirium?
3) What are the 2 forms of behavioural change which can happen in a patient with delirium?

Answer 47

1) Patient is usually disorientated, with poor attention and short-term memory. Mood changes can be prominent (don’t mistake them for depression/ mania)
2) Sleep is commonly disturbed with insomnia or reversal of the sleep-wake cycle.
3) Hyperactivity (aggression and agitation) and hypoactivity (lethargy, stupor, drowsiness and withdrawal).

Question 48

Describe the abnormal aspects of the mental state examination which might be present in a patient with delirium.

Answer 48

Illusions, visual hallucinations, transient mumbled delusions, disorganised thinking and impoverished, pressured or rambling speech.

Question 49

Describe the hyperactivity behavioural change that can occur in delirium.

Answer 49

• Hyperactivity, agitation and aggression.
• Wandering, climbing into other patients’ beds, pulling out catheters.
• These patients tend to be easily spotted.

Question 50

State 8 investigations that you should do in a patient with suspected delirium.

Answer 50

1) Physical examination.
2) Collateral history (especially: ‘is this patient usually forgetful?’)
3) Check the drug chart for recently added drugs.
4) Bloods: FBC, U&Es, glucose, calcium, septic screen.
5) MSU
6) SaO2
7) ECG
8) CXR

Question 51

State 5 investigations that you might consider doing in a patient with suspected delirium.

Answer 51

1) LFTs
2) blood cultures
3) CT head
4) CSF
5) EEG

Question 52

Give the 5 categories of management that should be considered for a patient with delirium.

Answer 52

1) Treat the cause
2) Behavioural management
3) Medication
4) Consider referral on recovery to old age psychiatry.
5) Helping to prevent delirium.

Question 53

1) Name 3 aggravating factors for delirium.
2) What might be given in order to promote sleep and help correct the sleep-wake cycle in patients with delirium?
3) How long could it take to recover from delirium?

Answer 53

1) Dehydration, pain and constipation need to be managed. Unnecessary medications need to be stopped.
2) Small nocturnal dose of BDZs may be able to promote sleep and help correct the sleep-wake cycle. If sedation is required, low-dose typical antipsychotics or BDZs should be used.
3) Days, weeks or rarely months to recover after Rx of the underlying cause. Some patients might never fully recover to their pre-morbid level.

Question 54

Name 9 features of management which are categorised as behavioural management

Answer 54

1) Frequent re-orientation (clocks, calendars and verbal reminders).
2) Good lighting (gloomy conditions increase hallucinations and illusions)
3) Address sensory problems (hearing aids/ spectacles)
4) Avoid over or under stimulation.
5) Minimise change (e.g. don’t keep moving the patient/ establish a routine).
6) Remove things that can be thrown or tripped on.
7) Silence unnecessary noises.
8) Allow safe or supervised wandering if possible (restraining people increases accidents).

Question 55

Give 4 ways that delirium can be prevented.

Answer 55

1) Good sleep hygiene without medication.
2) Minimal moves around the hospital.
3) Encouraging mobility.
4) Proactive management: minimise dehydration, pain, constipation, urinary retention and sensory problems.

Question 56

Give 4 factors prognostically that delirium can be associated with.

Answer 56

1) Increased mortality.
2) Longer admissions.
3) Higher re-admission rates
4) Subsequent nursing home placement.

Question 57

Describe what is meant by cortical dementias.

Answer 57

These affect cortical functions such as memory and language (e.g. Alzheimer’s disease)

Question 58

Describe what is meant by subcortical dementias.

Answer 58

These affect subcortical functions causing bradykinesia, bradyphrenia, depression, movement disorders and executive dysfunction.

Subcortical dementias affect subcortical structures such as the thalamus and basal ganglia.

Includes conditions such as Huntington’s disease.

Question 59

1) How many clinical syndromes can fronto-temporal lobar degenerations cause?
2) What does FTLD-U stand for?
2a) Describe this type of dementia.
3) When do front-temporal degeneration syndromes usually begin?
4) What is the genetic basis of Huntington’s disease?

Answer 59

1) 3.
2) Fronto-temporal lobar degeneration with tau negative ubiquitated inclusions).
2a) Tau negative inclusions are found, similar to those in motor neuron disease.
3) Between the ages of 40 and 60.
4) It is autosomal dominant, causing dementia and chorea.

Question 60

1) Describe the effects of fronto-temporal dementia.
2) Describe the effects of semantic dementia.
3) Describe the effects of progressive non-fluent aphasia.

Answer 60

1) Causes frontal lobe syndrome with prominent disinhibition and social/ personality changes.
2) Progressive loss of understanding of verbal and visual meaning.
3) Begins with naming difficulties and progresses too mutism.

Question 61

Describe the hyperactivity behavioural change that can occur in delirium.

Answer 61

• Hypoactivity, lethargy, stupor, drowsiness and withdrawal.
• Quiet delirium (silently lying in bed).
• These patients are easily missed. They appear ‘well behaved’.

Question 62

1) When does death normally occur for patients with front-temporal lobar degenerations.
2) What unites the 3 front-temporal lobar degeneration syndromes?
3) What is amnesic syndrome characterised by?
4) What occurs to other brain functions during amnesic syndrome?
5) Name 3 causes of amnesic syndrome.

Answer 62

1) Within 5-10 years.
2) Cortical atrophy.
3) Profound anterograde memory loss (an inability to lay down new memories from the time of the brain damage onwards).
4) Can be some retrograde memory loss. Limbic system can be damaged which deal with explicit memory (hippocampus, mamillary bodies, parts of the thalamus and surrounding cortex).
5) Hypoxia, encephalitis and CO poisoning.

Question 63

1) What is the most common type of amnesic syndrome?
2) Why is procedural memory intact in amnesic syndrome?
3) What might prevent Korsakoff’s syndrome from worsening?

Answer 63

1) Korsakoff’s syndrome.
2) Because the cortex, basal ganglia and cerebellum tend to be undamaged.
3) Prompt administration of parenteral thiamine. However, nothing reverses the amnesic syndrome once the damage has been done.