Older Person's Health - Dementia

Question 1

Cognitive things that get better/ mainatin with age?

Answer 1

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

Question 2

Cognitive things that get WORSE with age?

Answer 2

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”

Question 3

Risk factors for MCI?

Answer 3

• Apolipoprotein E allele
• Age
• Male
• Low SES
• Vascular risk factors
• Family history cognitive impairment
• Sedentary
• Comorbidities

Question 4

Conversions from MCI

Answer 4

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

Question 5

Correctable factors -> MCI

Answer 5

Medical Conditions:
* thyroid,
* BP
* BSLs
* OSA
* NPH
* AF

Meds
* anticholinergics,
*sleeping tablets,

Psych

Vitamin def

Sensory loss

Infection

Question 6

Who should do genetic tests for dementia in?

Answer 6

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

Question 7

MCI due to AD citeria with biomarkers

Answer 7

Question 8

What should you always do before prescribing cholinesterase inhibitor

Answer 8

ECG - Contraindicated in bradycardia/conduction issues, long QTc.

Question 9

Main cholinesterase inhibitors

Answer 9

• Donepezil (tablet)
• Galantamine (tablet)
• Rivastigmine (tablet or patch)

Question 10

main AE Cholinesterase inhibitors

Answer 10

• Contraindicated in bradycardia/conduction issues, long QTc.
• Risk with syncope, falls, fractures
• GI side effects most common

Question 11

AE of memantine

Answer 11

May worsen delusions and hallucinations

Question 12

What is Aducanumab?

Answer 12

(Aduhelm)
- Amyloid beta-directed monoclonal antibody
- Controversially FDA approved June 2021
- 30-40% Amyloid-related imaging abnormalities (ARIA), some serious

Question 13

% of dementia post single/ recurrent strokes

Answer 13

~ 10% after single

> 30% with recurrent

Increased risk with:
* age
* previous stroke
* large volume stroke
* aphasia
* Left hemisphere lesion
* haemorrhagic stroke

Question 14

Radiologic changes in cerebral small vessel disease

Answer 14

• Subcortical infarcts
• White matter hyperintensities (MRI) or hypodensities (CT)
• Microbleed MRI
• Atrophy

Question 15

Main cognitive issues in cerebral small vessel disease

Answer 15

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)

Question 16

Treatment for vascular CI

Answer 16

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

Question 17

Cerebral amyloid angiopathy

Answer 17

• 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

Question 18

Clin features CADASIL

Answer 18

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

Question 19

Core clinical features DLB

Answer 19

• Fluctuating cognitive impairment
• Visual hallucinations
• REM sleep behavior disorder
• Parkinsonism: at least 1 of rigidity, bradykinesia or tremor

Question 20

DLB/PDD treatment

Answer 20

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)

Question 21

Most common dementia < 60 yo?

Answer 21

Actually alcohol, but after that

FTD
- Mean age 62 years with normal distribution: less common >70yrs

Question 22

Associations with FTD

Answer 22

Motor neuron disease ~15%

FHx: ~ 40% genetic with autosomal dominant pattern family history (most causing Tau mutations)

Question 23

Causes of rapidly progressing dementia?

Answer 23

Creutzfeldt Jacob Disease - basically only cause

Question 24

Diagnosis CJD

Answer 24

• 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

Question 25

Most important factor for preventing dementia?

Answer 25

hearing loss

Question 26

DSM criteria delirium

Answer 26

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.