Memory Problems: Clinical Aspects and Management Flashcards
what types of advance planning should be encouraged while patients have capacity to decide about future needs?
practical and legal advice (eg powers of attorney, driving)
in general, what is the diagnostic criteria for dementia?
history consistent with global cognitive decline over months-years
cognitive testing consistent with history
decline in level of function
no evidence of reversible cause
what are four examples of cognitive tests?
ACE-III (standard in most POA depts)
MoCA (shorter, in many languages)
Frontal Assessment Battery
Detailed neuropsychological testing (standardised according to premorbid ability)
what type of test can be used to get a collateral history?
short informant questionnaire on cognitive decline in the elderly (short IQCODE)
what type of occupational therapy assessment is undertook for those with dementia?
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
what are common reversible causes of cognitive impairment?
delirium alcohol medication thyroid and other endocrine / metabolic disorder depression brain lesions neuro infections / inflammation
what classifies mild cognitive impairment?
noticeable cognitive impairment with little deterioration of function
ACE-III usually 75-90, MoCA usually 24-26
what should you do when someone has mild cognitive impairment?
repeat cognitive testing yearly
may benefit from home based memory rehabilitation
what is subjective cognitive impairment?
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
what are the features of alzheimers disease?
memory loss particularly short term
dysphasia
dyspraxia
agnosia
what does alzheimers disease look like on imaging?
CT/MRI normal
may show medial temporal lobe atrophy or temporoparietal atrophy
*look on lecture
what are the two variants of alzheimers disease?
frontal
posterior cortical atrophy
what are the features of vascular dementia?
dysphasia, dyscalculia, frontal lobe symptoms and affective symptoms more common
may have focal neurological signs, vascular risk factors or step wise decline
what does vascular dementia look like on imaging?
CT/MRI - moderate / severe small vessel disease or multiple lacunar infarcts
SPECT - patchy reduction in tracer uptake throughout brain
*look on lecture
what are the three syndromes of frontotemporal dementia?
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
what does frontotemporal dementia look like on imaging?
CT/MRI - frontotemporal atrophy
SPECT - frontotemporal reduction in tracer uptake
*look on lecture
what is the criteria which fits dementia with lewy bodies?
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
when does 80% of parkinsons dementia occur and what is its clinical presentation?
15-20 years after parkinsons disease
*must have parkinsonism for at least 1 year prior onset
presentation similar to DLB & positive DAT scan
when should you present that something less common is going on in terms of memory impairment?
fast progression young patient neurological signs family history of rare or young dementia clues in PMH eg HIV something just doesn't fit
what four types of imaging can be used for memory impairment?
CT
single photon emission CT (SPECT)
DaT (dopamine active transporter) scan
MRI
when would a CT scan be used?
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
when would a MRI scan be used?
young, fast progression or other atypical features
when would a SPECT scan be used?
most useful for frontotemporal
may also be used if trying to clarify alzheimers diagnosis
when would a DAT scan be used?
for suspected DLB / DPD when a patient doesnt have enough supporting features to be sure of a diagnosis
what cholinesterase inhibitors are used in alzheimers?
donepezil
rivastigmine
galantamine
what cholinesterase inhibitor is the only one licensed for DLB and DPD?
rivastigmine
in which disease does cholinesterase inhibitors have more effect - DLB/DPD or alzheimers?
DLB/DPD
what are the common side effects of cholinesterase inhibitors?
GI (nausea and diarrhoea most common) headache muscle cramps bradycardias worsen COPD / asthma
bearing in mind the side effect of bradycardia, what should be checked before prescribing or increasing dose of cholinesterase inhibitors?
pulse
in which conditions should you not prescribe cholinesterase inhibitors?
active peptic ulcer
severe asthma / COPD
what is memantine licensed for?
alzheimers disease
slow cognitive decline, prevents BPSD
what are the possible side effects of memantine?
well tolerated but may cause:
- hypertension (check BP before starting)
- sedation
- dizziness
- headache
- constipation
what is the rules surrounding driving with dementia?
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
what are the behavioural and psychological symptoms (BPSD) which patients often get in later stages?
hallucinations delusions insomnia anxiety depression aggression agitation disinhibition
what can be used for the pharmacological management of agitation in alzheimers?
antipsychotics, citalopram, memantine, analgesia, dextromethorphan
what can be used for pharmacological management of agitation in FTD?
trazodone
what other pharmacological treatments are used in practice for BPSD?
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
