Old age (MRCP) Flashcards
After a specifi c number of subcultivations in the laboratory, normal human cells undergo irreversible cessation of mitosis and enter a non-dividing state. This phenomenon is known as A. Programmed cell death B. Hayfl ick phenomenon C. Pruning D. G0 phase arrest E. Cellular atrophy
B. The process of ageing can be classifi ed as primary ageing, which accounts for the relatively
constant lifespan observed in a species, and secondary ageing, which explains much of the
unpredictability among individual members of the species. The primary ageing process is most
probably constitutional and is probably wired in the cellular machinery. This was demonstrated
by Hayfl ick and colleagues, who showed that the maximum number of cell divisions that can
occur in normal human cells in culture is approximately 40–60. Many functional capacities of the
cells reduce as the cells approach the Hayfl ick limit. This ‘Hayfl ick phenomenon’ is under genetic
control; it is not limited to laboratory culture methods. Pruning is a developmental phenomenon
by which unnecessary synapses formed during brain development are removed. Apoptosis refers
to programmed cell death.
The Hachinski Ischaemic Score is used to aid clinical differentiation of
Alzheimer’s dementia from vascular dementia. Which of the following
clinical features support a diagnosis of Alzheimer’s dementia rather than
vascular dementia?
A. Stepwise progression
B. Fluctuating course
C. Abrupt onset
D. Early change in personality
E. Nocturnal confusion
D. The Hachinski Ischaemic Score is an easy-to-use clinical tool that aids in the bedside
differentiation of Alzheimer’s dementia from vascular dementia. It has been validated in patients
with pathologically confi rmed dementia. A cut-off score ≤4 supports a diagnosis of Alzheimer’s
dementia while a score ≥7 favours vascular dementia. These cut-off values have a sensitivity of
89% and a specifi city of 89%. Abrupt onset, fl uctuating course, history of stroke, presence of
focal neurological symptoms and signs strongly favour a diagnosis of vascular dementia. Other
supporting features for a diagnosis of vascular dementia include stepwise deterioration, presence
of nocturnal confusion, absence of changes in personality, presence of emotional incontinence,
depression and a history of hypertension
Which of the following statement regarding the assessment of activities of
daily living (ADL) in elderly people is correct?
A. ADL scales are used as outcome measures
B. The Barthel index is a self-rating scale
C. In dementia basic ADL are affected earlier than complex instrumental ADL
D. None of the validated ADL scales depend on the patient’s self-report
E. The choice of ADL scale in a patient depends on the patient’s gender
A. In dementia complex ADL that require use of tools and equipment (instrumental ADLs)
are affected earlier than basic ADL. Although self-report ADL measures are rare, they do exist.
For example, the ADL-Prevention Instrument (ADL-PI) has a self-rated version and an informant
version. Self-ratings are found to be closer to research observer’s ratings, while family members
tend to under-rate the ADL. Data from self-report of functioning predicts mortality better than
informant data. The Barthel Index consists of 10 items that measure a person’s ADL and mobility.
It can be used to determine a baseline level of functioning and also to monitor changes in ADL
over time. It is rated by carers or professionals. Currently, functional capacity measures are
being used increasingly in pharmacological trials of patients with dementias as primary outcome
measures. ADL scales are not gender biased and are commonly used in both sexes.
Schizophrenia-like psychosis is a prominent feature of which of the following dementing illnesses? A. Pick’s disease B. Creutzfeldt–Jakob disease (CJD) C. Vascular dementia D. Huntington’s dementia E. Lewy body dementia
D. Huntington’s disease is inherited in an autosomal dominant fashion. It is a
neurodegenerative disorder related to expansion of a trinucleotide repeat sequence in the short
arm of chromosome 4. Clinical features include a triad of choreic movements, cognitive decline,
and psychiatric syndromes starting in the fourth to fi fth decade. Psychiatric presentation is usually
variable and can precede motor and cognitive changes. Most common psychiatric problems
include change in personality (impulsive, disinhibited, and dissocial) and depression. Paranoid
schizophrenia-like symptoms occur in 6–25% of cases. Such schizophrenia-like presentation is
very rare in other conditions listed.
A 78-year-old man is treated with diazepam by his general practitioner for
disabling anxiety related to a recent bereavement. The half-life of diazepam
is most likely to be increased in this man due to
A. Increase in intestinal absorption
B. Increase in oral bioavailability
C. Increase in plasma protein binding
D. Increase in volume of distribution
E. Decrease in renal elimination
D. Body composition changes with advancing age resulting in alterations in the way drugs
are metabolized and circulated. Muscle mass and body water decline by as much as 25% by age
70 while the body lipid content increases. Body fat constitutes >40% of body weight in elderly
women and >30% in elderly men. As a result, elderly people have a larger volume of distribution
and longer half-life of lipophilic drugs. Lipid-soluble drugs such as diazepam have greater volume
of distribution and half-life with slower clearance in elderly individuals
Which of the following scales can be used to record the behavioural and
psychological features associated with dementia in elderly people?
A. Neuropsychiatric inventory
B. Schedule for clinical assessment in neuropsychiatry
C. Bristol scale
D. Cornell scale
E. Abbreviated mental test
A. The Neuropsychiatric inventory (NPI) can be used to measure behavioural and
psychological features of dementia in elderly people. It was created by Cummings et al. It
evaluates 10–12 neuropsychiatric disturbances common to dementia using frequency, severity
and the carer’s distress as indices. The Bristol scale is used to measure activities of daily living;
the Cornell depression scale is used to assess depression in demented patients. The abbreviated
mental test is a quick and easily administered test that is used as a screening tool for dementia.
Which of the following diagnostic tests has been most widely used to
monitor treatment response in anticholinesterase trials for dementia?
A. Behaviour Pathology in Alzheimer’s Disease rating scale
B. Clock drawing test
C. Alzheimer’s disease assessment scale – cognitive section (ADAS-Cog)
D. Mini Mental State Examination (MMSE)
E. Magnetic resonance imaging (MRI) brain scan
C. The ADAS-Cog is used as the de facto standard primary outcome neuropsychological
measure for dementia trials. It measures several cognitive domains, including memory, language,
and praxis with total scores ranging from 0 to 70. A four-point change on the ADAS-Cog at 6
months after starting antidementia drugs has been used as an arbitrary cut-off point indicating a
clinically important difference. This pharmaceutical cut-off on ADAS-Cog must be interpreted in
the context of overall response when it is translated to clinical practice. MMSE is not as sensitive
to change as ADAS-Cog; hence, it is rarely used as a primary outcome measure in dementia trials.
An MRI brain scan currently has no role in monitoring treatment response
The average annual decline on the MMSE scores for patients with a natural course of Alzheimer’s dementia is A. 1–2 points/year B. 3–4 points/year C. 5–6 points/year D. 7–9 points/year E. 9–11 points/year
B. Alzheimer’s dementia is associated with an annual decline on the MMSE of 3–4 points.
Similarly using the ADAS-Cog scale, the natural disease progression averages a 7-point decline
per year. But the average change on ADAS-Cog when using antidementia drugs is about
2.7 points. Thus cholinesterase inhibitors are considered to delay this progression by 6 months
on average. MMSE is a reasonable tool for monitoring disease progression in a clinical setting, but
the occurrence of functional impairment is more likely to be relevant to the patient and their
carers than MMSE scores. Performance in instrumental activities of daily living such as telephone
use, taking own medication, handling fi nances, and transport correlates well with cognitive
impairment.
Hyponatraemia is a troublesome side-effect of treating depression in elderly
people. All of the following are true with regard to the above except
A. More common in males
B. More frequent when diuretics are co-prescribed
C. Often related to inappropriate ADH secretion
D. Risk increases with increase in age
E. Symptoms overlap with primary depressive features
A. Generally, a high level of suspicion is needed to detect hyponatraemia in a depressed
patient who does not undergo regular blood tests for electrolytes. The symptoms of
hyponatraemia overlap with those of depression, making it hard to diagnose. Hyponatraemia due
to selective serotonin reuptake inhibitors (SSRIs) or other antidepressant use is often linked to
the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Increased age, female
gender and co-prescription of diuretics are notable risk factors. Symptoms usually occur when
the blood serum level falls below 130 mmol/L. These include lethargy, fatigue, muscle cramps, and
headaches.
Presenilin mutations that are associated with early-onset Alzheimer’s
dementia are proposed to affect which of the following enzymes?
A. κ Secretase
B. Tau phosphorylation enzymes
C. α Secretase
D. β Secretase
E. γ Secretase
E. Plaques seen in the brain of patients with Alzheimer’s dementia are insoluble
extracellular deposits composed mainly of Aβ peptides. These Aβ peptides are derived from a
transmembrane protein called B-amyloid precursor protein (APP) through proteolytic processing.
APP is generally cleaved by β-secretase or α-secretase enzymes followed by γ -secretase.
Aβ peptides are generated when APP is cleaved by β-secretase followed by γ -secretase. This
pathway is amyloidogenic and forms the major metabolic pathway of APP in brain tissue; the
non-amyloidogenic α-secretase pathway is the major pathway in other tissues. Presenilins are
necessary for proteolytic activity of γ –secretase. PS/ γ -secretase complex is widely considered
as a potential target for developing therapies against Alzheimer’s disease
Which of the following is an observational tool designed to evaluate the quality of care and well-being of people with dementia in formal care settings? A. Bristol Scale B. Burden Interview C. Caregiver Burden Scale D. Clinical Dementia Rating (CDR) E. Dementia Care Mapping (DCM)
E. DCM is an observational tool designed to evaluate the quality of care and well-being
of people with dementia in formal care settings. It was designed by Kitwood in 1992. DCM is
based on the social–psychological theory of dementia care, which states that much of the decline
in patients with dementia is a direct consequence of the social and environmental situation
experienced. Better social care may result in less suffering than would otherwise be expected
from their neurological state. The Washington University CDR is a global scale developed to
clinically denote the presence of Alzheimer’s dementia and stage its clinical severity using
semi-structured interviews with the patient and informants. The Burden Interview and Caregiver
Burden Scale are used to measure the degree of caregiver strain.
A 67-year-old retired educational psychologist presents with forgetfulness.
All of the following are features seen in mild cognitive impairment (MCI)
except
A. Presence of subjective memory complaint
B. Objective memory impairment for age
C. Preserved general cognitive function
D. Normal functional activities
E. Presence of family history of dementia
E. An array of various terms has been used to describe age-associated cognitive impairment
not amounting to dementia. The most popular term is MCI, of which several types have been
described of late. The amnestic MCI refers to the original description of MCI. Diagnosis of MCI
requires the presence of memory complaint (preferably corroborated by an informant), objective
memory impairment for age, preserved general cognitive function, normal functional activities,
and no dementia. The presence or absence of family history of dementia is not a criterion used
to describe MCI.
Lund–Manchester criteria are used in the diagnosis of which of the following conditions? A. Alzheimer’s dementia B. Vascular dementia C. Lewy body dementia D. Frontotemporal dementia E. Huntington’s dementia
D. The Lund–Manchester criteria are used in the diagnosis of frontotemporal dementia.
The criteria were initially developed in 1994 and were later updated in 1998. The following core
components are required for a diagnosis:
1. insidious onset and gradual progression
2. early decline in social interpersonal conduct
3. early impairment in regulation of personal conduct
4. early emotional blunting
5. early loss of insight
Other supportive diagnostic features include:
A. Behavioural disorder (decline in personal hygiene, mental rigidity and infl exibility, distractibility
and impersistence, hyperorality and dietary change, utilization behaviour)
B. Speech and language disturbances (altered speech output, stereotypy of speech, echolalia,
perseveration, mutism)
C Physical signs (primitive refl exes, incontinence, akinesia, rigidity, tremor)
D. Abnormal investigations (neuropsychological evidence of impaired frontal lobe function,
normal conventional EEG despite clinically evident dementia and predominant frontal and/or
anterior temporal abnormality in neuroimaging)
Males >females
Age 45-65
Positive FHx in 50%
Association between FTD and MND
All of the following are features of visual hallucinations reported in
dementia of Lewy bodies except
A. The images are vivid
B. The images are mostly grey or black and white
C. Animate objects are often seen
D. The images are usually three dimensional
E. They predict better response to cholinesterase inhibitors
B. Visual hallucinations dominate the clinical picture of dementia with Lewy bodies (DLB)
in many patients. Visual hallucinations have a tendency to persist despite treatment in many
patients. In phenomenological quality, the hallucinations of DLB are similar to those reported
in Parkinson’s disease dementia: they are vivid, colourful, three-dimensional, and generally mute
images of animate objects. Visual hallucinations are associated with greater defi cits in cortical
acetylcholine and predict better response to cholinesterase inhibitors
Two patients are admitted to an inpatient unit for elderly people with
movement disturbances. Patient A has a diagnosis of Parkinson’s disease
while patient B is diagnosed with dementia with Lewy bodies. Which of the
following is correct with regard to the extrapyramidal symptoms in these
conditions?
A. Patient A is more likely to have greater postural instability than patient B
B. Patient A is more likely to have greater facial impassivity than patient B
C. Patient A is more likely to have tremors than patient B
D. Both patients will have similar profi les of extrapyramidal features
E. Patient B is more likely to have prominent cerebellar signs
B. Visual hallucinations dominate the clinical picture of dementia with Lewy bodies (DLB)
in many patients. Visual hallucinations have a tendency to persist despite treatment in many
patients. In phenomenological quality, the hallucinations of DLB are similar to those reported
in Parkinson’s disease dementia: they are vivid, colourful, three-dimensional, and generally mute
images of animate objects. Visual hallucinations are associated with greater defi cits in cortical
acetylcholine and predict better response to cholinesterase inhibitors
Which of the following is associated with poor antidepressant response in
geriatric depression?
A. Earlier age of onset
B. Structural white matter abnormalities
C. Enlarged cerebral ventricles
D. Cingulate hyper-metabolism during depression
E. Presence of somatic symptoms
B. Multiple factors have been examined in an attempt to predict the treatment response in
elderly depressed patients. A prospective study examining neurological and neuropsychological
factors showed that a combination of extrapyramidal signs, pyramidal tract signs, and impairment
of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant
monotherapy, with 89% sensitivity and 95% specifi city. Microstructural white matter abnormalities
may also perpetuate depressive symptoms in older adults by disrupting connectivity with
cortico-striato-limbic networks, which form the basis of mood regulation. Lower fractional
anisotropy in this network predicted poorer treatment response in geriatric depression.
Although enlarged cerebral ventricles have been reported in some studies, this is not examined
as a predictor of treatment response. Earlier age of onset and somatic symptoms suggest better
response to initial antidepressant treatment.
Which of the following present at the time of onset of depression predict greater risk of depressive relapse after treatment discontinuation in elderly patients with depression? A. Depressive cognitions B. Presence of guilt C. Executive dysfunction D. Episodic memory loss E. Psychomotor retardation
C. Executive dysfunction predicts a poor or delayed response to antidepressant therapy
and also a greater risk of relapse after discontinuing treatment. None of the other core
symptoms of depression has been shown to be strong predictors of later relapse.
Secondary depression may be caused by physical illnesses in elderly people.
Which of the following is correct with regard to depression and physical
illness?
A. Primary depression is not diagnosed in the presence of chronic medical illnesses in
elderly people
B. Secondary depression is more common than primary depression in elderly people
C. Subclinical hypothyroidism is more common among depressed than non-depressed
elderly people
D. Depression is two to three times more common in those with chronic medical illnesses
E. Many apparent physical illnesses are found on investigation to be due to somatoform
disorders
D. Late-life depression often occurs in the context of medical health issues; it is two
to three times more common in the medically ill elderly patient. The diagnosis ‘depression
due to a general medical condition’ (more commonly, secondary depression) is used when
depressed mood or anhedonia occur in patients already diagnosed with an illness that is clearly
linked to depression as a physiological consequence. For example, nearly 25% of patients with
myocardial infarction have a major depressive episode. Primary depression can exist alongside
a general medical condition with no direct physiological relationship. In fact, such co-existing
depression and a general medical condition is more common than depression secondary to
medical problems. Depression may also exacerbate the outcome of medical illnesses. Although
hypothyroidism is considered to cause depression traditionally, recent studies show that a TSH
value of 10 μU/L or greater was found in only 0.7% of elderly patients with clinical depression.
Thus the rate of subclinical hypothyroidism in an elderly depressed group may be similar to that
of the elderly population in general.
Psychosis in elderly people may be due to dementia, Parkinson’s disease, or
schizophrenia. Which of the following is correct with respect to the clinical
features of late-onset psychotic syndromes?
A. Hallucinations are more common than delusions in psychosis due to Alzheimer’s disease
B. Visual hallucination is the most common symptom in very late-onset schizophrenia
C. Partition delusions are characteristic of psychosis associated with parkinsonism
D. Negative symptoms are predominant in very late-onset schizophrenia
E. Paranoid delusions are the most common symptoms in late-onset schizophrenia
E. The term late-onset schizophrenia is applied to patients whose fi rst symptom of
schizophrenia-like psychosis begins after the age of 40. For patients whose symptoms begin after
the age of 60, the term very-late-onset schizophrenia-like psychosis (VLOSLP) is used. Paranoid
delusions are the most common symptoms in late-onset schizophrenia, followed by auditory
hallucinations. Partition delusions are often noted in late/very late-onset schizophrenia where the
patient typically believes that people, objects, or radiation can pass through what would normally
constitute a barrier to such passage. Negative symptoms are conspicuously absent in most cases.
In psychosis associated with Alzheimer’s dementia, simple paranoid delusions are more common
than hallucinations. In psychosis associated with Parkinson’s disease, visual hallucinations are more
common than delusions.
Which of the following forms of grief therapy treats unresolved grief as a form of phobic avoidance? A. Guided mourning B. Supportive grief counselling C. Focused group therapy D. Interpersonal psychotherapy E. Debriefi ng
A. Some individuals with abnormal grief reaction may be avoiding reminders of their grief,
leading to unresolved emotions. Addressing these issues by encouragement may not be suffi cient
and a behavioural approach may be needed in some cases. The approach commonly used is
known as guided mourning. This treats unresolved grief in a way similar to other forms of phobic
avoidance by exposure to the avoided situation. Thus guided mourning involves intense reliving of
avoided painful memories and feelings associated with bereavement. During treatment, patients
are exposed to avoided painful memories or situations related to the loss of their loved one –
both in imagination and in real life.
When compared with those with late-onset depression, elderly individuals
with early-onset depression have
A. Less frequent family history of mood disorders
B. Higher prevalence of dementia
C. More sensory impairment
D. Greater enlargement of the lateral ventricles of the brain
E. Less white matter hyperintensities
E. Elderly people with depression may have a relapse or recurrence of a depressive
disorder from adulthood (early onset) or they might have fresh onset late-life depression.
Late-onset major depression includes a large subgroup of patients with neurological problems.
It is possible that milder, unnoticed episodes of depression with early-onset might be a risk factor
for late-life depression by contributing to brain abnormalities. When compared with elderly
individuals with early-onset major depression, patients with late-onset major depression have a
less frequent family history of mood disorders, a higher prevalence of disorders of dementia, a
larger impairment in neuropsychological tests, a higher rate of dementia development on
follow-up, more neurosensory hearing impairment, a greater enlargement in lateral brain
ventricles, and more white matter hyperintensities
The most effective psychological intervention to reduce depression and
emotional burden in caregivers of people with dementia is
A. Psychoeducational intervention
B. Group behavioural management
C. Individual behavioural management
D. Supportive psychotherapy
E. Coping skills enhancement
C. A systematic review of studies looking at improvements in caregiver psychological
health revealed that six or more sessions of individual behavioural management therapy had the
highest quality of evidence. This intervention was effective for up to 32 months after intervention.
There was some evidence supporting individual and group caregiver coping sessions to reduce
depression among caregivers; the benefi ts may last up to 3 months. Educational interventions,
group behavioural management sessions, fewer than six individual behavioural management
sessions, and supportive therapy were not effective interventions for reducing a caregiver’s
symptoms.
Which of the following methods of psychological management of
neuropsychiatric symptoms of dementia uses materials such as old
newspapers and household items to stimulate memories and enable people
to share and value their experiences?
A. Reminiscence therapy
B. Validation therapy
C. Reality orientation therapy
D. Cognitive stimulation therapy
E. Snoezelen therapy
A. Reminiscence therapy uses materials such as old newspapers and household items to
stimulate memories and enable people to share and value their experiences. The evidence base
for this therapy in improving behavioural problems is limited. It may have a modest impact on
mood symptoms. Validation therapy is based on Rogerian humanistic psychology; it encourages
individual uniqueness and gives the opportunity to resolve confl icts by encouraging and validating
the expression of feelings and emotions. Reality orientation therapy is based on the fact that
patients with dementia function poorly secondary to impairment in orientating information
(day, date, weather, time, and use of names) Hence reminders can improve functioning. Cognitive
stimulation therapy is similar to reality orientation therapy but aims at improving information
processing rather than factual knowledge to address problems in functioning in patients with
dementia. Snoezelen therapy is also called multisensory stimulation. It is grounded on the
supposition that neuropsychiatric symptoms may result from periods of sensory deprivation.
It combines relaxation and exploration of sensory stimuli (e.g. lights, sounds, and tactile
sensations).
A 72-year-old man presents with paranoid delusions and ideas of reference. The most common cause of new onset psychotic symptoms in this age group is A. Parkinson-related psychosis B. Very late-onset schizophrenia C. Drug-induced psychosis D. Alzheimer’s dementia E. Lewy body dementia
D. Psychosis is a prominent non-cognitive symptom seen in Alzheimer’s dementia. The
prevalence of psychosis in patients with Alzheimer’s dementia has been estimated at 30–50%.
Psychotic symptoms are seen in 0.2–4.7% of the elderly population in the community. In nursing
homes the prevalence rates are very high – 10–60%. Dementia accounts for the highest number
of psychotic symptoms diagnosed among elderly people. Prospective studies have shown that
36.7% of patients with psychotic symptoms may have dementia, most likely of Alzheimer’s type.
According to the stage theory of grief, the earliest response after a natural death of a family member is A. Numbness and disbelief B. Yearning and anxiety C. Anger E. Depressed mood F. Acceptance of the loss
A. Bowlby and Parkes proposed a stage theory of grief for adjustment to bereavement
that included four stages: shock–numbness, yearning–searching, disorganization–despair, and
reorganization. This was adapted by Kubler-Ross, who described a fi ve-stage response of
terminally ill patients to impending death: denial–dissociation–isolation, anger, bargaining,
depression, and acceptance (mnemonic: DABDA). A longitudinal cohort study (Yale Bereavement
Study) has established that in terms of absolute frequency, disbelief was not the initial grief
indicator as proposed by the original grief theory. The study found that most people endorsed
acceptance as initial reaction even in the initial month after loss in cases of natural deaths. In
contrast, family members of those who had a traumatic death and individuals with complicated
grief disorder had signifi cantly lower levels of acceptance. It was also noted that prognostic
awareness of a patient’s terminal illness for more than 6 months before death may promote
acceptance of the death.
Memory complaints that do not qualify for a diagnosis of dementia are
common in elderly people. All of the following are shown to predict
conversion from mild cognitive impairment (MCI) to dementia except
A. Hippocampal atrophy
B. Family history of Alzheimer’s dementia (AD)
C. Carers’ reports of impaired daily function
D. Signifi cantly poor cognitive abilities
E. Presence of sensory impairment
E. The presence of hippocampal atrophy in patients with amnestic MCI may predict the
onset of later dementia. The risk of conversion to dementia is four times higher in 5 years when
hippocampal atrophy is present. It is generally accepted that the closer one’s cognitive ability,
brain imaging, and genetic susceptibility are to AD, the more likely is the progression to dementia
from MCI. Other factors predicting conversion include older age, greater severity of baseline
cognitive defi cits, especially impaired episodic recall and hypoperfusion of multiple brain regions
in neuroimaging studies. It is also noted that multidomain amnestic MCI has a higher conversion
rate than pure amnestic MCI. This conversion is more pronounced if the cognitive complaints are
accompanied by carers’ reports of impaired daily function. Sensory impairment has no role in
such predictions.
The annual rate of progression from mild cognitive impairment (MCI) to dementia is estimated to be around A. 10–15% B. 20–25% C. 30–35% D. 1–2% E. 4–5%
A. It is very diffi cult to conclusively decide on epidemiological facts of mild cognitive
impairment due to the variations in diagnostic terms and inclusion criteria used in
epidemiological research. A prevalence between 3% and 19% has been reported in elderly
people. The age-specifi c prevalence of MCI is greater than that of dementia. MCI is about
four times more common than dementia when based on community assessment of noninstitutionalized
individuals. An incidence of 8–58 per 1000 per year and a risk of developing
dementia of 11–33% over 2 years have been quoted. The progression of amnestic MCI to
dementia has been examined in various clinical populations. Generally a yearly incidence of
dementia of 10–15% has been quoted for those with MCI attending memory clinics (compare
this with general rates of 1–2% in elderly people). Community-based studies show slightly lower
rates of conversion closer to 5–10% per year. A signifi cant number of those with amnestic MCI
actually improve their cognitive performance during follow up. Up to 44% of patients with mild
cognitive impairment are estimated to return to normal a year later.
Median survival from the time of diagnosis for patients with Alzheimer’s dementia (AD) is A. 1–3 years B. 3–5years C. 5–8 years D. 10–12 years E. 15–18 years
C. It is important to note that AD by itself is not a fatal disease. The median survival time
following a diagnosis of AD depends strongly on the patient’s age at diagnosis. The older the age
at diagnosis, the higher the chances of death. For example, some studies have shown a difference
in median survival time of around 5 years between those diagnosed with dementia at the age
of 65 and those diagnosed at the age of 90. The median survival from initial diagnosis is higher
for men than women in some studies but this is not consistently shown. The presence of frontal
lobe release signs, extrapyramidal signs, and gait disturbance, history of falls, congestive heart
failure, ischaemic heart disease, and diabetes at baseline may predict shorter survival. Based on
numerous longitudinal studies, a median survival of 5–8 years has been estimated. A multicentre
prospective population-based cohort study in England and Wales with 14 years’ follow-up
reported median survival after the estimated onset of dementia as 4.6 years for women and
4.1 years for men. There was a difference of nearly 7 years in survival between the younger
old and the oldest people with dementia: 10.7 years for ages 65–69 vs. 3.8 years for ages ≥90.
Signifi cant factors that predicted mortality in the presence of dementia during the follow-up
included sex, age of onset, and disability before the onset. Type of accommodation, marital status,
and self-reported health were not associated with survival.
Braak stages are used in neuropathological quantifi cation of brain changes
in Alzheimer’s disease. Which of the following is the basis of Braak’s stages?
A. Senile plaques
B. Neuritic plaques
C. Cortical atrophy
D. Neurofi brillary tangles
E. Hippocampal volume
D. Braak’s staging system has been used to grade pathologically the various degrees of
dementia severity. It is based on the appearance of neurofi brillary tangles in brain. These tangles
commence the transentorhinal and entorhinal cortex spreading to the hippocampus, and then
extend across the remaining limbic system before involving other cortical regions, followed by
the primary motor and somatosensory cortices, and fi nally the occipital cortex. This progression
is the basis of the Braak’s staging. A decline in memory test performance and mental state of the
demented patient correlate with the pathological progression through the neocortical Braak
stages.
Many subtypes of vascular dementia have been identifi ed. Which of the
following refers to Binswanger’s disease?
A. Attenuation of subcortical white matter causing cognitive impairment
B. Basal ganglia infarct causing cognitive impairment
C. Multiple cortical infarcts causing cognitive impairment
D. Periventricular white matter infarcts causing cognitive impairment
E. Single strategically placed infarct causing cognitive impairment
A. The term Binswanger’s disease refers to a type of subcortical vascular dementia caused
by widespread, microscopic atherosclerotic vascular damage to the deep white matter in the
brain. As a result patients may have frontal executive dysfunction, short-term memory loss, and
behavioural changes. The most characteristic feature is said to be the reduction of processing
speed. An MRI scan of the brain can reveal the characteristic brain lesions essential for diagnosis.
Single large infarcts or multiple cortical infarcts give rise to vascular dementia. Periventricular
white matter lesions are non-specifi c and are commonly seen in Alzheimer’s dementia, extreme
ageing with vascular risk factors, and also in patients with frank vascular dementia.
Criteria for Alzheimer’s disease
Memory impairment- impaired ability to learn new information, or to recall previously learnt information
Aphasia
Apraxia
Agnosia
Disturbance in executive functioning- planning, organising, sequencing, abstracting
Risk factors of AD
Age
FHx: 1 in 5.6 chance relatives of patient’s with AD will develop
Down syndrome
ApoE 4
Less associated: female vascular educational study head injury depression HSV FHx Down's or Parkinson's
Differences between early onset and late onset AD
Early onset AD occurs before age 60-65
Inheritance in 5%
3 genes account for 30-50% of familial AD
APP gene (B amyloid PP)-> xsome 21, Aut D pattern of inheritance
Presenillin 1 (xsome 14) and 2 (xsome 1)
Features of semantic dementia
Naming difficulties Impaired understanding of work meanings Preservation of other cognitive domains Fluent speech Pathology is mainly L) temporal lobe
Neuropathological findings in CJD
Spongiform change
Amyloid deposition
Neuronal loss and gliosis
What is the neuropathological difference between DLB and Parkinson’s
LBD has intracytoplasmic inclusions which contain alpha synuclein
PD associated with lower numbers of cortical LB
Pick’s bodies
In FTD
swollen cortical neurons containing round includions of tau or ubiquitin
Four prion diseases
Gertsmann Staussler Scheinker syndrome
Sporadic FI
CJD
Kuru
Clinical features of PSNP
Subcortical dementia with changes in mood
Supranuclear gaze-> typical vertical gaze palsy in absence of normal reflex eye movements
Gait instability, frequent falls, rigidity, dysarthria and dysphagia
Clinical features of huntington’s disease
Onset usually middle life
Anticipation
AD, 100% pattern inheritance
>35 TN repeats CAG, chromosome 4
Hypometabolism in caudate or putamen (PET)
Death occurs 10-20 years after diagnosis, usually due to aspiration pneumonia or suffocation
Motor sx
- voluntary movement- bradykinesia, rigidity, gait disturbance, dysarthria and dysphagia
- involuntary movement- chorea, athetosis, dystonia, myoclonus, motor restlessness
Cognitive impairment
- subcortical dementia
- aphasia, apraxia, agnosia
Psychiatric sx
- may precede onset of movement disorder or neurocog sx
- behavioural and personality change common, apathy, aggression, irritability, poor impulse control
- depressive illness common
- high rate of suicide
Reversible causes of dementia
Wilson's Hypothyroidism NPH Syphillis Vit B 12 deficiency OSA Depression->most common cause of reversible dementia Benign tumors
Features of wilson’s
AR, xsome 13, onset in childhood/adolescent, up to 5th decade
Clinical features
Psychiatric sx: personality change dementia psychosis behavioural disturbance
Motor sx: tremor bradykinesia dystonia dysarthria
Kayser-Fleischer rings
Ix
serum ceruloplasmin
urinary copper excretion
Treatment
copper chelating agents-penicillamine
Principles for management of dementia
Multimodal and multidisciplinary approach
1. Risk physical- neglect risk of harm to self: suicide, accidental risk of wandering risk of falls financial risk risk of exploitation
- Alliance with family and patient
determine the site of treatment- home with carer, in patient, or high level or low level nursing - Diagnostic evaluation
FBC, UEG, LFT, vit B12, TFT, syphillis, glucose, cholesterol, ECG, EEG, CXR autoimmune screen - Neuroimaging
MRI
PET-> differentiating between FTD and Alzheimer’s dementia
Biomarkers- CSF for CJD
5. Neuropsychological testing extent of dementia distunguish between dementias establish baseline cognitive function identifies strengths and weaknesses genetic testing not recommended refer to genetic counsellor Rating scales: ADAS-COG, MMSE, GDS, HoNOS 65, Cohen Mansfield Agitation Inventory
- Treatment with cholinesterase inhibitors if indicates
- Assessment of ADLs
8. Psychosocial Carers assessment ->Risk, management of BPSD Education, support family Refer to appropriate support services SW, OT Counselling Support groups Meals on wheels Day hospital Transport to attend groups Financial planners Geriatric law specialists
- Monitor for carer’s stress
carer assessment, support groups,
10. Decision making EPOA Testamentary capacity AHD Guardianship Finances
BPSD
Encompasses all symptoms of disturbed perception, mood, thought and behaviour that occur in patients with dementia (Finkel and Burns 2000)
Forgetfulness disorientation wandering incontinence aggression sexual disinhibition delusions uncontrolled emotions insomnia
management of BPSD
1. General exclude physical cause behavoiural management first maintain consistency preserve dignity encourage normal behaviour avoid punishment
- Physical environment
familiar, constant, and stress free
careful design and good staffing
buildings should: make sense, help them find their way, provide a therapeutic environment, safe environment, good facilities
3. Sensory functions evaluate hearing and vision avoid abstract/noisy avoid mirrors use soft lighting and calm colours use carpets to absorb sound music
4. Behavioural interventions identify target symptoms behavioural analysis- ABC set realistic goals intervention monitor response- Cohen mansfield agitation inventory use reinforcement to maintain desirable behaviours ensure safety avoid punishment
- Pharmacotherapy
use only after behavioural iinterventions have been trialled
3T approach
Target symptoms
Titrate from low starting dose
Time-limit prescriptions
Antipsychotics
- low dose risperidone or olanzapine
- decrease quality of life, increase risk of strokes
Use of antipsychotic medications are recommended when BPSD are psychotic in nature,
unresponsive to psychosocial interventions or there is a severe and complex risk of harm (Burns et
al., 2012). Conversely, antipsychotic medications are not recommended and are unlikely to be
effective in certain symptoms such as wandering, undressing, inappropriate voiding, verbal
aggression or screaming.
Olanzapine is the only antipsychotic approved for parenteral (intramuscular) BPSD.
Consider alternative medications – there is some evidence supporting the efficacy of
citalopram, cholinesterase inhibitors (ChEIs) and memantine in the management of
psychotic symptoms in dementia (Burns et al., 2012). - Carer support
Evidence fo pharmacotherapy in BPSD
The benefits and risks of antipsychotic medications
There have been numerous placebo controlled trials and several meta-analyses examining the
efficacy of antipsychotic medications to treat BPSD. These studies show a small effect size of 0.13
to 0.20. (Schneider, Dagerman and Insel, 2006). Notably, this effect size is smaller than some nonpharmacological approaches to treatment of BPSD.
The only antipsychotic medication that is listed by the Pharmaceutical Benefit Scheme (PBS;
Australia) and the Pharmaceutical Schedule (NZ) for patients showing ‘behavioural disturbances in dementia’ is risperidone and this medication has the strongest evidence for its effectiveness
(Brodaty et al., 2003).
In 2004, a pooled analysis by the UK Committee on Safety of Medicines of data from four
published and unpublished studies of risperidone pointed to a three-fold risk of ‘cerebrovascular
events’ (3.5% versus 1.2%) versus placebo. These events included non-specific neurological
symptoms like dizziness, headaches and ‘funny turns’ through to transient ischaemic attacks and
completed stroke. There was no difference in mortality rates. The Committee presented no data
from trials of olanzapine but concluded that it was associated with a similarly increased risk of
stroke and a two-fold increase in mortality compared with placebo (CSM, 2004).
What are the risk factors for carer burden
1. Patient factors BPSD Stigma Increased cognitive impairment Verbalaggression Increased dependency
2. Carer factors Frailty Disability in carer Ambivalent relationship Lack of support from social services Financial stress
Management of carer burden
Carer assessment- burden, specific broblems, fears and worries
Assess aditional support, coping styles, finances
Address cultural issues, and maintain cultural and ethnic sensitivity
Psychoeducation
Support and advice
Referral to psychologist
Liaison with psychogeriatric services
Other community services
Placement issues
Legal issues
Pharmacological options in dementia
Cholinesterase inhibitors
- recommended in mild to mod
- carers view of the condition at baseline and follow up should be sought
- review every 6 months with MMSE and global, behavioural and functional assessment
- continue only if improvement noted
- adverse= nausea, vomiting, insomnia and diarrhea
1. Donepezil - selective inhibitors of AChE
- once daily
- 5-10 mg/day
2. Rivastigmine - acts on both AChE and BuChE
- twice daily
- start at 1.5mg BD to max 6mg BD
3. Galantamine - selective inhibitors of AChE + nicotinic receptors
- twice daily
- 12 mg BD
NMDA R blocker
- Memantine
- indicated for mod to severe
- need MMSE <14 to meet criteria - Vit E- no conclusive
- Ginko biloba
- maidenhair tree
- cognitive enhancer
- may increase risk of bleeding - Oestrogen
- may delay onset, but not currently recommended - Other
Antiinflammator, statins, antiamyloid strategies
Pharmacological strategies for mx of LBD
ACHE inhibitors first choice for cognitive and psychotic sx
Good evidence with rivastigmine
Respond less well that PD to leva-dopa, however if motor sx, worth a trial
Clonazepam for REM sleep disorder
Important points in management of depression in Parkinson’s disease
Exclude organic cause- hypothyroidism common in PD
SSRIs reasonable choice, however caution with selegline (risk of SS)
Avoid TCAs
Consider ECT- depression and motor sx respond well but risk of delirium is high
Consider augmentation with dopamine agonists like pramiprexole or amantidine
Management of psychosis in PD
Exclude organic
If psychotic sx such as visual that are not distressing, treatment may not be necessary
Reduce or stop anticholinergics and dopamine agonists
AP can worsen movement, and DA agonist can worsen psychosis, so need a balance
Consider atypical such as quetiapine
Consider AChE I particularly if pt has co-morbid dementia
Try clozapine in small dose up to 25mg/day
Consider ECT
How to assess testamentary capacity
Testamentary capacity refers to legal status of being capable of executing a will
Task and situation specific
Criteria:
Understanding the nature of the will, knowledge and extent of one’s assets
Knowledge of those who have reasonable beneficiaries
Understanding the impact of the distribution of assets of the estate
Confirmation that the testator is free of any delusions that influence the disposition of assets
Ability to express wishes clearly and consistently in an orderly plan of disposition
Questions to ask:
Can you tell me what you understand by a will?
Can you tell me what the process in making a will is?
Why have you decided to divide your estate in this fashion?
DO you understand how individual A may feel having been excluded from the will or having been given significantly less amount that previously expected or promised>
Do you understand the economic implication of your distribution on the individual’s involved?
Can you tell me about important relationships in your family and others close to you?
Describe the nature of any family or personal disputes or tensions that may have influenced distribution?
How do you assess capacity in an individual who refuses treatment
- Multidisciplinary involvement
- Situation and time specific
- What is capacity being sought for?
- Elements of capacity
- Able to understand the information
- able to retain the information
- able to weigh the evidence of information to arrive at a decision
- free from undue influence
- able to arrive at the same decision on different occasions
- able to communicate a decision
A full psychiatric assessment especially focuses on features of the individual’s disability that might impact on decision making eg. delusions, depression, dementia (poor attention), impaired memory (retention)
Delirium
A disturbance in attention and awareness
The disturbance develops over a short period and tends to fluctuate
An additional disturbance in cognition
There is evidence from the history, PE, or lab findings that the disturbance is a direct physiological consequence of another medical condition, substance or withdrawal
Major neurocognitive impairment
Evidence of a significant cognitive decline from a previous level of performance in one or more cognitive domains
1. Complex attention
2. Executive function
3. Learning and memory
4. Language
5. Perceptual-motor
6. Social cognition
Base on:
1. Concerns of the individual, knowledgeable informant, or clinician, that there has been a significant decline in cognitive function
2. Substantial impairment in cognitive performance, preferably documented by standardised neuropsychological testing or in its absence, another qualified clinical assessment
