old age (dementia)

Question 1

ABCD of dementia?

Answer 1

A for Activities of Daily Living (ADLs)

B for Behavioural and Psychiatric Symptoms of Dementia (BPSD)

C for Cognitive Impairment

D for Decline

Question 2

cognitive features of dementia?

Answer 2

-Memory (dysmnesia)

Plus one or more of
-dysphasia (communication)
expressive
receptive

• dyspraxia (inability to carry out motor skills)
• dysgnosia (not recognising objects)
• dysexecutive functioning (initiation, inhibition, set-shifting, abstraction)

Question 3

what question is important to ask in patients with dementia?

Answer 3

Functional impairment

Question 4

Cars - Fitness to Drive

Answer 4

notify DVLA at diagnosis
if early dementia license may be yearly
“those with poor short term memory, disorientation or lack of insight should almost certainly not drive”

Question 5

types of dementia

Answer 5

Alzheimer’s dementia – 62%
Vascular dementia – 17%
Mixed Dementia – 10%
Lewy body dementia – 4%

Question 6

what is the aetiology of dementia?

Answer 6

Frontotemporal (Picks) (behavioural, PNFA: progressive non fluent aphasia, semantic)

Alcohol; ARBD (alcohol dementia/ Korsakoffs (thiamine deficiency))

Subcortical - Parkinson’s, Huntington’s, HIV
Prion Protein eg CJD

Question 7

what are some reversible causes of dementia?

Answer 7

Delirium
Normal pressure hydrocephalus
Subdural haemorrhage
Tumours
Vitamin B12 deficiency
Hypothyroidism
Hypercalcaemia
Alcohol misuse
Neurosyphilis
Drugs

Hypercalcaemia – abdominal pain, bone pain, kidney stones, depression and confusion

Question 8

main features of Alzheimer’s disease?

Answer 8

Early impairment of memory and executive function
Gradual progression with often unclear onset
Main features:
Amyloid plaques & tau tangles
Atrophy following neuron death
Reduction in Acetylcholine

Question 9

vascular dementia progression?

Answer 9

Step wise decline with sudden changes (every time a vessel gets affected

Small vessel disease can give gradual decline

Question 10

what will you see on examination of someone with dementia?

Answer 10

Unequal distribution of deficits
Evidence of focal impairments on neuro exam
Evidence of cerebrovascular disease - PMHx

Question 11

diagnosis if heavy calcified in left frontal region in a MRI of brain

Answer 11

meningioma

Question 12

dementia Lewy body key features (DLB)

Answer 12

Visual hallucinations
Fluctuations
Parkinsonism

Question 13

dementia Lewy body supportive changes (DLB)

Answer 13

Sensitivity to antipsychotics
Reduced dopamine uptake on SPECT or PET scan
Increased falls
REM sleep disorder

Question 14

what do you see on a DATscan in DLB

Answer 14

re-uptake in the putamen is reduced, leading to the ‘full-stop’ sign.

Question 15

Pick’s disease Axial MRI description

Answer 15

cerebral atrophy -frontal and temporal regions

gyro thickness and size of the sulci between the frontotemporal region and the parietal/occipital region

Question 16

Frontotemporal Dementia (FTD) symptoms

Answer 16

Behavioural disorder – personality change

Can be early onset

Early emotional blunting
Speech disorder - altered output, stereotypy, echolalia, perseveration, mutism

Neuropsychology - frontal dysexecutive syndrome. Memory, praxis and visuospatial function not severely impaired

Neuroimaging - abnormalities in frontotemporal lobes

Neurological signs commonly absent early; parkinsonism later; MND in a few; autonomic; incontinence; primitive reflexes

Question 17

drug treatment of dementia

Answer 17

Acetylcholinesterase Inhibitors (AChI):
donepezil
rivastigmine
galantamine

Memantine

Antidepressants

anxiolytics

anticonvulsants

Question 18

Examples of Acetylcholinesterase Inhibitors

and

side affects

Answer 18

Donepezil, Galantamine, Rivastigmine

Nausea, vomiting, diarrhoea
Fatigue, insomnia
Muscle cramps
Headaches, dizziness
Syncope
Breathing problems

Question 19

what is capacity?

Answer 19

Capacity is the ability to understand information relevant to a decision or action, and to appreciate the reasonably foreseeable consequences of not taking action or decision

Question 20

5 points of capacity

Answer 20

1) Does the patient UNDERSTAND the information?
2) Does the patient RETAIN the information long enough to make a decision?
3) Can the patient COMMUNICATE the decision?
4) Can the patient WEIGH UP the information in order to make a decision?
5) Does the patient BELIEVE the information they are given?

Question 21

8 key points of capacity

Answer 21

1) A patient is deemed to have capacity unless proven otherwise
2) A patient should be supported to make a decision
3) A person can not be deemed to incapable if their decision is eccentric or unwise
4) Anything done for the patient must be in their best interest
5) Always use the least restrictive option
6) Capacity should be assessed on the topic of question
7) Patient’s should be assessed at their ‘peak time’
8) Speak to family to get historic views? Advanced statement

Question 22

6 Cs of capacity

Answer 22

Capacity
Consent
Compliance
Coercion
Certification
Common sense

Question 23

suicide in elderly

Answer 23

Same rate as for under 25 age group
Half the rate of other age groups
Males more than females
Most are depressed

DSH is rare in the elderly

Question 24

causes of suicide in the elderly?

Answer 24

loneliness
widowed
ill health 
chronic pain
recent life events
few seeing psychiatrist