Older Person's Health - Dementia Flashcards
Cognitive things that get better/ mainatin with age?
Crystallised intelligence - skills, ability, and knowledge over learned, well practised and familiar, accumulate over time
- Vocabulary
- General knowledge
Visuospatial (simple)
Memory (Non-declarative):
* Procedural – memory how to do things e.g. ride bike
* Recognition – ability to retrieve information when given a cue
* Temporal order – memory for correct time or sequence of past events
Cognitive things that get WORSE with age?
Fluid cognition - innate ability to learn new information, problem solve (reduces from 3 rd decade, 0.02SD per year)
* Processing speed
* Psychomotor ability
* Complex attention: Selective and divided
* Verbal fluency
* Executive function
* Visual-construction
Declarative memory
* Episodic – “specific events to self”
* Semantic – “general knowledge/facts”
Risk factors for MCI?
- Apolipoprotein E allele
- Age
- Male
- Low SES
- Vascular risk factors
- Family history cognitive impairment
- Sedentary
- Comorbidities
Conversions from MCI
Amnestic MCI 5-16% per year conversion to Alzheimer dementia
Conversion rate to “normal cognition” 30 – 50%
Factors associated with conversion:
* Single cognitive domain
* Normal hippocampal volume
* Depression
* Anticholinergic burden
* Higher cognitive scores
* Absence of apolipoprotein E
Correctable factors -> MCI
Medical Conditions:
* thyroid,
* BP
* BSLs
* OSA
* NPH
* AF
Meds
* anticholinergics,
*sleeping tablets,
Psych
Vitamin def
Sensory loss
Infection
Who should do genetic tests for dementia in?
Young ppl with dementia.
Familial AD
* Autosomal dominant inheritance
* Early onset < 65 years old
* APP (Ch21), PSEN1, PSEN2 mutation account for 70% early onset AD
MCI due to AD citeria with biomarkers
What should you always do before prescribing cholinesterase inhibitor
ECG - Contraindicated in bradycardia/conduction issues, long QTc.
Main cholinesterase inhibitors
- Donepezil (tablet)
- Galantamine (tablet)
- Rivastigmine (tablet or patch)
main AE Cholinesterase inhibitors
- Contraindicated in bradycardia/conduction issues, long QTc.
- Risk with syncope, falls, fractures
- GI side effects most common
AE of memantine
May worsen delusions and hallucinations
What is Aducanumab?
(Aduhelm)
- Amyloid beta-directed monoclonal antibody
- Controversially FDA approved June 2021
- 30-40% Amyloid-related imaging abnormalities (ARIA), some serious
% of dementia post single/ recurrent strokes
~ 10% after single
> 30% with recurrent
Increased risk with:
* age
* previous stroke
* large volume stroke
* aphasia
* Left hemisphere lesion
* haemorrhagic stroke
Radiologic changes in cerebral small vessel disease
- Subcortical infarcts
- White matter hyperintensities (MRI) or hypodensities (CT)
- Microbleed MRI
- Atrophy
Main cognitive issues in cerebral small vessel disease
Subcortical pathology interrupts frontostriatal circuits. Deficits in:
* Attention
* Information processing
* Executive function –poor problem solving/initiation (apathy)
Apathy - often misinterpreted as depression
Pseudobulbar affect
Gait disorder
(Memory often relatively intact – problem with retrieval rather than encoding i.e recall improves with prompt)
Treatment for vascular CI
Hypertension:
* Tight control to prevent vascular disease BUT
* Hypotension accelerates cognitive decline in established small vessel disease
- Exercise improves cognition post stroke
- No evidence for antiplatelets or statins in cognitive improvement
- Some role of cholinesterase inhibitor in improving cognitive function and ADLS
Cerebral amyloid angiopathy
- Aβ protein in cortical and leptomeningeal blood vessel walls
- Hereditary (AD) and sporadic forms
Lobar, cortical, cortical-subcortical haemorrhage in > 55 years old
* No other causes of haemorrhage
* Microbleeds and cortical superficial siderosis
- Advanced CAA exhibit cognitive impairment
- Antiplatelets and anticoagulation increases bleeding risk
Clin features CADASIL
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
- Migraine with aura
- Lacunar syndrome stroke
- Subcortical features: pseudobulbar affect, gait dyspraxia, urinary incontinence, dementia
- Mood disorder (depression and apathy)
- Acute encephalopathy
- Seizures
Core clinical features DLB
- Fluctuating cognitive impairment
- Visual hallucinations
- REM sleep behavior disorder
- Parkinsonism: at least 1 of rigidity, bradykinesia or tremor
DLB/PDD treatment
Avoid antipsychotics: 2-3x mortality
* If absolutely necessary, low dose Quetiapine
Cholinesterase inhibitor - improve fluctuations, apathy, anxiety, hallucinations, sleep (single RCT)
~1/3 modest response of motor symptoms to L-dopa – worth a trial if parkinsonism is significant ( rigidity and bradykinesia)
Most common dementia < 60 yo?
Actually alcohol, but after that
FTD
- Mean age 62 years with normal distribution: less common >70yrs
Associations with FTD
Motor neuron disease ~15%
FHx: ~ 40% genetic with autosomal dominant pattern family history (most causing Tau mutations)
Causes of rapidly progressing dementia?
Creutzfeldt Jacob Disease - basically only cause
Diagnosis CJD
- Cerebellar, extrapyramidal, extraocular, myoclonus, akinetic mutism
AND
- EEG
OR
- 14-3-3 CSF (positive predictive value 95% if dementia <2 years)- contact infection control prior to LP
OR
- Ribbon sign MRI
Most important factor for preventing dementia?
hearing loss
DSM criteria delirium
A. Disturbance in attention and awareness
B. Disturbance developed over short period of time, acute change from baseline, and fluctuate throughout the day
C. Additional disturbance in cognition
D. Disturbance in A. and C. not explained by new or evolving NCD and do not occur in context of coma
E. Disturbance direct physiological consequence of medical condition, substance intoxication/withdrawal, exposure to toxin, due to multiple aetiologies.
