Memory Problems: Clinical Aspects and Management

Question 1

what types of advance planning should be encouraged while patients have capacity to decide about future needs?

Answer 1

practical and legal advice (eg powers of attorney, driving)

Question 2

in general, what is the diagnostic criteria for dementia?

Answer 2

history consistent with global cognitive decline over months-years
cognitive testing consistent with history
decline in level of function
no evidence of reversible cause

Question 3

what are four examples of cognitive tests?

Answer 3

ACE-III (standard in most POA depts)
MoCA (shorter, in many languages)
Frontal Assessment Battery
Detailed neuropsychological testing (standardised according to premorbid ability)

Question 4

what type of test can be used to get a collateral history?

Answer 4

short informant questionnaire on cognitive decline in the elderly (short IQCODE)

Question 5

what type of occupational therapy assessment is undertook for those with dementia?

Answer 5

cognitive performance test

• observation of activities - washing, dressing, usually a phone, shopping, making toast, travelling
• estimates cognitive level and level of supervision required for daily living

Question 6

what are common reversible causes of cognitive impairment?

Answer 6

delirium 
alcohol 
medication 
thyroid and other endocrine / metabolic disorder
depression 
brain lesions 
neuro infections / inflammation

Question 7

what classifies mild cognitive impairment?

Answer 7

noticeable cognitive impairment with little deterioration of function

ACE-III usually 75-90, MoCA usually 24-26

Question 8

what should you do when someone has mild cognitive impairment?

Answer 8

repeat cognitive testing yearly

may benefit from home based memory rehabilitation

Question 9

what is subjective cognitive impairment?

Answer 9

patient feels that they are cognitively impaired but cognitive testing and day to day function are normal
often associated with anxiety, depression or stress and is often difficult to convince pt they dont have dementia

*cycles of increasing anxiety about memory causing more lapses common

Question 10

what are the features of alzheimers disease?

Answer 10

memory loss particularly short term
dysphasia
dyspraxia
agnosia

Question 11

what does alzheimers disease look like on imaging?

Answer 11

CT/MRI normal
may show medial temporal lobe atrophy or temporoparietal atrophy

*look on lecture

Question 12

what are the two variants of alzheimers disease?

Answer 12

frontal

posterior cortical atrophy

Question 13

what are the features of vascular dementia?

Answer 13

dysphasia, dyscalculia, frontal lobe symptoms and affective symptoms more common

may have focal neurological signs, vascular risk factors or step wise decline

Question 14

what does vascular dementia look like on imaging?

Answer 14

CT/MRI - moderate / severe small vessel disease or multiple lacunar infarcts

SPECT - patchy reduction in tracer uptake throughout brain

*look on lecture

Question 15

what are the three syndromes of frontotemporal dementia?

Answer 15

behavioural variant - behavioural changes, executive dysfunction, disinhibition, impulsivity, loss of social skills, apathy, obsessions and change in diet

primary progressive aphasia - effortful non-fluent speech, speech sound/articulatory errors, lack or grammar or words

semantic dementia - impaired understanding of meaning of words, fluent but empty speech, difficulty retrieving names

Question 16

what does frontotemporal dementia look like on imaging?

Answer 16

CT/MRI - frontotemporal atrophy

SPECT - frontotemporal reduction in tracer uptake

*look on lecture

Question 17

what is the criteria which fits dementia with lewy bodies?

Answer 17

dementia - common early involvement of reduced attention, executive function and visuospatial skills

two of

• visual hallucinations
• fluctuating cognition (delirium-like)
• REM sleep behaviour disorder
• parkinsonism (not more than 1 year prior to onset of dementia
• positive DAT scan

Question 18

when does 80% of parkinsons dementia occur and what is its clinical presentation?

Answer 18

15-20 years after parkinsons disease
*must have parkinsonism for at least 1 year prior onset

presentation similar to DLB & positive DAT scan

Question 19

when should you present that something less common is going on in terms of memory impairment?

Answer 19

fast progression 
young patient 
neurological signs 
family history of rare or young dementia
clues in PMH eg HIV 
something just doesn't fit

Question 20

what four types of imaging can be used for memory impairment?

Answer 20

CT
single photon emission CT (SPECT)
DaT (dopamine active transporter) scan
MRI

Question 21

when would a CT scan be used?

Answer 21

currently standard
dont scan if patient is over 80 with typical history of alzheimers
otherwise, helpful in excluding tumour / bleed /large stroke, quantifying vascular changes or identifying structural features

Question 22

when would a MRI scan be used?

Answer 22

young, fast progression or other atypical features

Question 23

when would a SPECT scan be used?

Answer 23

most useful for frontotemporal

may also be used if trying to clarify alzheimers diagnosis

Question 24

when would a DAT scan be used?

Answer 24

for suspected DLB / DPD when a patient doesnt have enough supporting features to be sure of a diagnosis

Question 25

what cholinesterase inhibitors are used in alzheimers?

Answer 25

donepezil
rivastigmine
galantamine

Question 26

what cholinesterase inhibitor is the only one licensed for DLB and DPD?

Answer 26

rivastigmine

Question 27

in which disease does cholinesterase inhibitors have more effect - DLB/DPD or alzheimers?

Answer 27

DLB/DPD

Question 28

what are the common side effects of cholinesterase inhibitors?

Answer 28

GI (nausea and diarrhoea most common)
headache
muscle cramps
bradycardias
worsen COPD / asthma

Question 29

bearing in mind the side effect of bradycardia, what should be checked before prescribing or increasing dose of cholinesterase inhibitors?

Answer 29

pulse

Question 30

in which conditions should you not prescribe cholinesterase inhibitors?

Answer 30

active peptic ulcer

severe asthma / COPD

Question 31

what is memantine licensed for?

Answer 31

alzheimers disease

slow cognitive decline, prevents BPSD

Question 32

what are the possible side effects of memantine?

Answer 32

well tolerated but may cause:

• hypertension (check BP before starting)
• sedation
• dizziness
• headache
• constipation

Question 33

what is the rules surrounding driving with dementia?

Answer 33

always discuss at diagnosis 
must be reported to DVLA
patient fills in CG1 form 
DVLA request report from doctor
doctor decides if patient can drive while investigations ongoing 
rockwood driving battery 
on road test

Question 34

what are the behavioural and psychological symptoms (BPSD) which patients often get in later stages?

Answer 34

hallucinations 
delusions
insomnia
anxiety
depression
aggression 
agitation 
disinhibition

Question 35

what can be used for the pharmacological management of agitation in alzheimers?

Answer 35

antipsychotics, citalopram, memantine, analgesia, dextromethorphan

Question 36

what can be used for pharmacological management of agitation in FTD?

Answer 36

trazodone

Question 37

what other pharmacological treatments are used in practice for BPSD?

Answer 37

anxiety - antidepressants, benzodiazepines, pregabalin

visual hallucinations - cholinesterase inhibitors, antipsychotics

other psychotic symptoms - antipsychotics

insomnia - melatonin, Z drugs, benzodiazepines, sedating and antidepressants

agitation and aggression - benzos, antipsychotics, sedating antidepressants, cholinesterase inhibitors, memantine, pregabalin