OPS2: Dementia

Question 1

what simple tasks can elderly people struggle with

Answer 1

· Mobility →Stairs, Getting to the shops

· Dexterity → making a cup of tea , Brushing teeth

· Communication → sight and hearing → isolation

Question 2

what age does WHO define as old

Answer 2

65 years old

Question 3

what do older people value

Answer 3

Company and relationships

Time

A desire to contribute to society

Someone listening

Question 4

what is dementia

Answer 4

Dementia is a syndrome – usually of a chronic or progressive nature

Deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing

Dementia is an acquired progressive loss of cognitive functions, intellectual and social abilities

Question 5

what does dementia affect

Answer 5

○ Memory
○ Thinking
○ Orientation
○ Comprehension
○ Calculation 
○ Learning capacity
○ Language
○ Judgement

Question 6

what is dementia characterised by

Answer 6

○ Amnesia (especially for recent events)
§ Memory loss
§ More recent events tend to be more common

○ Inability to concentrate,

○ Disorientation in time, place or person
§ Ie not recognising someone they should

○ Intellectual impairment

Question 7

what is alzheimer’s

Answer 7

· Most common (60%) type of dementia

· Reduction size of the Cortex, severe in hippocampus
○ Cortex is linked to your personality or motor function, the ability to process sensory information, language processing
○ If there is damage of the hippocampus (first area of the brain to be damaged in this condition) it will cause short term memory loss and disorientation

· We believe that Alzheimer’s is caused by abnormal amounts of protein, protein aggregates, then called amyloids which results in plaque
○ Plaquesare deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells.
§ These plaques then disrupts the normal brain function of nerves and this results in a loss of brain function

• We don’t know why these proteins start to cause problems but there is a theory about TAU proteins (protein abnormalities) which initiate the disease cascades and the theory is that these proteins pair up together to cause a tangle with the nerve cell bodies
§ Tanglesare twisted fibers of tau protein build up inside cells.

Question 8

what are distinctive features of alzheimer’s

Answer 8

○ STML = short term memory loss
○ Aphasia = difficult comprehending or forming language
○ Communication Difficulties
○ Muddled over everyday activities
○ mood swings
○ Withdrawn
○ loss of confidence

Question 9

what are associated factors with alzheimer’s

Answer 9

○ Age

○ Gender – Women >Men

○ Head Injury

○ Lifestyle:
§ Increased risk = Smoking, hypertension, low folate and high blood cholesterol
§ Reducing risk = physical, mental and social activities

○ Genetic– Abnormalities on chromosome 1, 14 or 21

Question 10

what is vascular dementia

Answer 10

Vascular dementia is caused by reduced blood flow to the brain, which damages and eventually kills the brain cells.

Question 11

what can vascular dementia develop as a result of

Answer 11

This candevelop as a result of:
· narrowing and blockage ofthe small blood vessels deep inside the brain(known as small vessel disease)
○ Ie lots of small blood vessels in the brain become either narrowed or blocked

· a single largestroke
○ (where the blood supply to part of the brain is suddenly cut off)

· lots of mini-strokes that cause tiny, but widespread, damage to the brain
○ Ie be quite small but cause widespread damage

· In many cases, these problems are linked to underlying health conditions– such ashigh blood pressureanddiabetes– as well as lifestyle factors, such as smoking and being overweight.

Question 12

what are distinctive features of vascular dementia

Answer 12

○ Memory problem of sudden onset

○ visuospatial difficulties
§ Difficulty getting up stairs with depth and distance perceptions

○ Anxiety

○ Delusions

○ Seizures

○ Can be stroke symptoms

Question 13

what is dementia with lewy bodies

Answer 13

· Deposits of anabnormal protein called Lewy bodies inside brain cells
○ These abnormal proteins are deposited on the brain cells and areas that are responsible for memory and muscle movements

· These deposits, which are also found in people withParkinson’s disease, build up in areas of the brain responsible for things such as memory and muscle movement
○ Link between Parkinson’s disease and dementia with Lewy Bodies

Question 14

what are distinctive features of dementia with lewy bodies

Answer 14

○ STML

○ Cognitive ability fluctuates
§ Ie days which are really good then days which are much more severe

○ visuospatial difficulties

○ attentional difficulties

○ overlapping motor disorders

○ speech and swallowing problems

○ sleep disorders

○ Delusions

Question 15

what is frontotemporal dementia

Answer 15

• Lot less common but still important to know about it
• Frontal lobes at the front of the brain and temporal lobes just a little further on around the brain
• The frontal lobes of the brain, found behind the forehead, deal with behaviour, problem-solving, planning and the control of emotions

· Younger age of onset

· Ubiqitin associated clumps of protein

•TDP-43

Question 16

what are distinctive features of frontotemporal dementia

Answer 16

○ STML not always present

○ uncontrollable repetition of words

○ Mutism

○ repetition of words of other people

○ personality change

○ decline in personal and social conduct
§ Act out of character

Question 17

what are rarer forms of dementia

Answer 17

· HIV – related genitive impairment

· Parkinson’s disease

· Corticobasal degeneration

· Multiple Sclerosis

· Niemann-Pick disease

· Creutzfeldt-Jakob disease

Question 18

what are dementia risk factors

Answer 18

• Age
○ Older age

• Gender
• Genetic background
• Medical history

• Lifestyle
○ Diet high in carbohydrates, high calories, low proteins

Question 19

what needs to be considered when planning for the future for patients with dementia

Answer 19

• living arrangements
• legal eg power of attorney
• banking, driving

Question 20

what needs to be considered about the patient benefit for patients with dementia

Answer 20

• functional benefit
  > independence?
  > perform daily tasks>
• quality of life
• delay progression
• opportunity to complete life goals or desires

Question 21

what needs to be considered about the cost of patients with dementia

Answer 21

• delay placement in care home
• fewer medications
• caregiver has more time in work place
• less home health aid

Question 22

what are early stage symptoms of dementia usually misattributed to

Answer 22

Early stage symptoms are often misattributed to stress, bereavement or normal ageing.

Question 23

what do the early stage symptoms include

Answer 23

○ Loss of short-term memory

○ Confusion, poor judgement, unwilling to make decisions

○ Anxiety, agitation or distress over perceived changes

○ Inability to manage everyday tasks.

○ Communication problems – a decline in ability or interest in talking, reading and writing

Question 24

what are middle stage symptoms

Answer 24

· More support required, including reminders to eat, wash, dress and use the lavatory;

· Increasingly forgetful and may fail to recognise people;

· Distress, aggression, anger, mood changes – frustration;

· Risk of wandering and getting lost, leaving taps running, gas unlit, cooking unattended or forgetting to light the gas;

· May behave inappropriately e.g. Going out in nightclothes;

· May experience hallucinations, throw-back memories.

Question 25

what are late stage symptoms

Answer 25

· Inability to recognise familiar objects, surroundings or people – but there may be some flashes of recognition.
○ Increasing physical frailty, may start to shuffle or walk unsteadily, eventually becoming bed/wheelchair confined.

· Difficulty eating and sometimes swallowing, weight loss.
○ Incontinence and gradual loss of speech
○ Can be changes to their diet
§ These patients are often encouraged to have soft, high calorie diets just to gain some sort of nutrition

· Symptoms are progressive and irreversible

Question 26

what is a MMSE

Answer 26

Mini mental state exam = MMSE

Question 27

how is dementia diagnosed

Answer 27

· Dementia screen to eliminate treatable causes - FBC, U&E’s, kidney, liver and thyroid function tests
○ Ie the doctor will do blood tests to make sure there is no other condition causing these symptoms

· Glucose, serum B12, Folate and Calcium, C-Reactive Protein and Urinalysis

· If indicated - Syphilis serology, autoantibody screen, serum cholesterol and CT

· Neurological examination and detailed cognitive testing (MMSE)

Question 28

what are the different methods of cognitive testing

Answer 28

· Mini-mental State Examination ( Folstein)
○ More common test
○ Includes things like repeating name prompts to get someone’s attention or recall their language ability and their ability to follow simple commands and orientation

· Blessed Dementia Scale
○ This scale registers changes in managing daily activities
○ Eg if they are misplacing or forgetting things, loss of bodily functions etc

· The Montreal Cognitive Assessment (MoCA)
○ Assesses the short term memory

· Single Neuropsychological Tests:
○ Clock draw
	§ Drawing tends to be more disrupted the more severe the disease is
○ Delayed word recall
○ Category Fluency

· Combined single tests
○ 7 minute screen
○ IQCODE
	§ Informative questionnaire for the cognitive decline of the elderly
○ AD8 Dementia Screening

Question 29

what are the pros of mini-mental state examination

Answer 29

> well known
easy to administer
samples range of cognitive functions
test re-test and inter-rater availability

Question 30

what are the cons of the MMSE

Answer 30

• only 3 words to be remembered on recall - not sensitive to mild impairment
• old ~ new knowledge
• non-standardised time between registration and recall
• not sensitive in testing frontal lobe

Question 31

what is single test category flucency

Answer 31

• You have 1 minute:
Name as many animals as you can……….
Name as many football teams as you can…
Name as many countries as you can…..

Question 32

what is delayed word recall

Answer 32

given 10 words and tested to see if they have been remembered

Question 33

what is the treatment for dementia

Answer 33

• There is no pharmacological, surgical or behavioural cure
○ There can be symptom relief and slowing of the progression

• Counselling may delay residential care by up to 1 year
○ Great for the independence and quality of life for the patient

• Aspirin and reducing cardiac risks (control of BP, weight, exercise etc..) may halt deterioration of vascular type dementias.
• Non Steroidal Anti Inflammatory Drugs (NSAIDs) may slow progression.
• Vitamin E and Ginko Biloba may slow progression.

Question 34

how is dementia treated with drugs

Answer 34

• Anticholinesterases for mild/moderate Alzheimer’s
○ Donepezil (Aricept®)
○ Galantamine
○ rivastigmine (Exelon®)

• May delay admission to residential care, assist in behavioural difficulty, defer deterioration in cognition

• Specialist instigation and review
○ 1 in 3 on these drugs?

Treatment should continue until the patient, carer, and/or specialist decide it is the right time to stop, if it is not working, or if the person’s MMSE score falls below 10.

Question 35

what is the drug treatment for vascular dementia

Answer 35

• In a review of six RCTs involving 597 people, Cerebrolysin significantly improved cognitive function compared to standard care alone or placebos.
○ It had a small positive effect on patients’ overall clinical state.

• Some evidence that long-term treatment may give greater benefits, although only two trials looked at long-term effects
Possibility for use in the future

Question 36

how can care homes be made dementia friendly

Answer 36

• Walls, floor coverings, skirting boards and doors are all different colours
○ provides good visual contrast to aid wayfinding

• Fix labels and images to drawers to help let people find what they need without assistance
○ Encourages the patient to be more independent as they are able to find what they want without needing help

• A bedroom WC should be visible from the bed on sitting and when lying down
○ As a reminder

• Position personal pictures and items with personal relevance
• Radiators should be low temperature heating

• Furniture traditional and domestic
○ Nothing fancy or too modern

○ Different colours
○ Everything well laid out
○ No obstacles or dangers anywhere

Question 37

what is included in a dementia friendly healthcare environment

Answer 37

• Reception desk visible from the entrance door
• Ceilings, floors and floor coverings should be acoustically absorbent to support audible communication
• Colour and tone of walls should be distinctive from the flooring
• Colour and tone of furniture should be distinctive from the flooring
• Avoid non-essential signs
• Any signage should be at eye level with simple clear use of text and colour. Use pictorial elements
• Ensure good levels of natural light to minimise artificial light
• Any staff only or locked rooms should be coloured the same as the walls to avoid attention