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Year 4 - Mental Health > Psych - Dementia > Flashcards

Psych - Dementia Flashcards

1
Q

What is the most comprehensive test of cognitive function?

A

Addenbrooke’s Cognitive Examination

(ACE-iii or ACE-R for revised)

  • Tests 5 basic executive functions
  • Score out of 100
  • < 82 = considered abnormal (NOT a diagnostic test)
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2
Q

What 5 aspects of cognition does an ACE-iii examine?

A
  1. Memory
  2. Attention
  3. Fluency
  4. Visuospatial skills
  5. Language

N.B. informally it also tests your higher executive function i.e. task planning / management - which requires the above basic executive functions.

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3
Q

Name 2 short/simple cognitive assessments?

A
  • MOCA (Montreal Cognitive Assessment)
    • Score out of 30
    • < 26 = suggests MCI (mild cognitive impairment)
    • < 17 = suggests dementia)
  • MMSE (mini mental state examination) - less used due to copyright issues
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4
Q

What assessment tool can be used to discriminate between dementias with impact on frontal executive function and Alzheimer’s dementia?

A

Frontal Assessment Battery (FAB)

  • Can be used in mildly demented pts or better (MMSE > 24)
  • Total score is out of 18 (higher score = better performance)
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5
Q

Dementia syndromes can be divided into cortical and subcortical.

To what do these regions refer to?

How are cortical and subcortical dementia characterised?

A

Cortical = outer layer i.e. cerebral cortex

Subcortical = areas beneath cortex e.g. basal ganglia, limbic system (amygdala, hippocampus), diencephalon (thalamus, hypothalamus)

  • Cortical dementia = early symptoms include higher function difficulty e.g. memory, language, dyspraxia (visuospatial), lack extra-pyramidal features
  • Subcortical dementia = early symptoms don’t tend to involve higher function, but do include; behaviour, mood/affect, motor slowing, extra-pyramidal features
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6
Q

Dementia syndromes can be divided into cortical and subcortical.

Give examples of each cortical and subcortical dementia.

A

Cortical:

  • Alzheimer’s dementia
  • Lewy-body dementia (memory before motor)
  • Fronto-temporal dementia (Pick’s disease)

Subcortical:

  • Vascular dementia
  • Parkinson’s dementia (motor before memory)
  • Wilson’s dementia
  • Huntington’s
  • HIV/AIDS dementia
  • MND / MS dementia
  • Alcohol related dementias
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7
Q

Which parts of the brain does Alzheimer’s disease characteristically affect?

A
  • Medial temporal lobe i.e. hippocampus - impacts episodic memory (anterograde amnesia)
  • Lateral temporal lobe i.e. Wernicke’s area - can cause receptive dysphasia (difficulty understnading written or spoken language but have fluent speech without meaning i.e. word salad)
  • Anterior + inferior temporal lobe - impacts semantic memory (general knowledge e.g. facts, ideas, concepts)
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8
Q

What are the four most common types of dementia?

A
  1. Alzheimer’s disease (2/3rds of dementia)
  2. Vascular dementia
  3. Lewy Body dementia (~15% of dementia)
  4. Fronto temporal dementia
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9
Q

What investigations are reccomended for someone with suspected dementia?

A
  • Bloods:
    • Done to exclude reversible causes
    • FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels
  • MRI / CT:
    • Done to exclude reversible causes e.g. subdural haematoma, normal pressure hydrocephalus
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10
Q

What are the recommended pharmacological management steps for Alzheimer’s disease?

A
  1. One of the 3 acetylcholinesterase (AChE) inhibitors - mild-moderate AD
    • Donepezil
      • ​once daily, long-half life, start 5mg and ↑ to 10mg after 1 month
    • Galantamine​
      • Oral solution, tab and modified release cap
    • Rivastigmine (also a butyrylcholinesterase inhibitor)
      • short half life (1hr), BD, daily patch more common
  2. Memantine (NMDA receptor antagonist) recommended:
    • Monotherapy in severe AD OR
    • Moderate AD + intolerant / contraindication to AChE inhibitors OR
    • In addition to AChE inhibtors for moderate-severe AD
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11
Q

What are the recommended pharmacological management steps for NON- Alzheimer’s disease?

A

Lewy-Body:

  1. Offer donepezil or rivastigmine
  2. Consider galantamine (only if donepezil or rivastigmine not tolerated)
  3. Consider memantine (if AChE inhibitors not tolerated/contraindicated)
  4. Some parkinson’s medication (e.g. levodopa) can help with movement impairment

Vascular:

  1. Only consider AChE inhibitors or memantine for vascular IF they have suspected comorbid AD, PD dementia or Lewy-body

Fronto-temporal dementia or MS cognitive impairment:

  1. DO NOT offer AChE inhibitor OR memantine
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12
Q

What investigations need to be done prior to starting a AChE inhibitor or NMDA receptor antagonist (memantine)?

A
  • ECG - to assess HR, arrhythmias and QTc interval
    • AChE inhibitors are contraindicated for pts with; bradykinesia, Left Bundle Branch Block or a ↑ QTc interval
    • AChE inhibitors also contraindicated if Hx of; gastric ulcers or seizures
  • U+Es:
    • Memantine can cause acute renal failure
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13
Q

What are some common side effects of AChE inhibitors?

A
  1. Nausea / vomiting
  2. Diarrhoea
  3. Urinary incontinence
  4. Headache / dizziness
  5. Insomnia
  6. Muscle cramps
  7. ↓ Appetite –> weight loss
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14
Q

In addition to cognitive symptoms of dementia, what other categories of symptoms are there?

A

Non-cognitive i.e.

Behavioural and Psychological symptoms of dementia (BPSDs) e.g.

  1. Hallucinations
  2. Delusions
  3. Anxiety
  4. Behaviour: marked agitation, aggression, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity such as shouting
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15
Q

What psychological treatments are available for the management of cognitive + BPSDs in dementia?

A
  1. Cognitive stimulation therapy (CST)
  2. CBT
  3. Reminiscence therapy
  4. Aromatherapy
  5. Sensory stimulation
  6. Music therapy
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16
Q

What pathological changes occur to a brain with Alzheimer’s?

A

Macroscopic:

  1. Widespread cerebral cortical atrophy
  2. Medial temporal lobe atrophy (particularly hippocampus)
  3. Enlarged ventricles (due to cerebral atrophy)

Microscopic:

  1. Beta-amyloid plaques (cortex)
  2. Neurofibrillary tangles (intraneuronal aggregation of tau protein)

Biochemical:

  1. Acetylcholine deficit (due to factors above) - loss of cholinergic neurons and ↓ ACh
17
Q

Describe dementia in layman’s terms.

A

A chronic, often progressive, mental disorder caused by brain disease or injury and marked by:

1) memory changes
2) personality changes
3) impaired reasoning / ↓ executive function
4) Impact on ADLs

18
Q

What are some risk factors for dementia?

A
  • Age
  • Gender:
    • Female (AD)
    • Male (VD and DLB)
  • Ethnicity:
    • South asians and Afro-Caribbean (VD)
    • African (AD)
  • Depression - if in mid-life or later life
  • Head injuries (Parkinson’s dementia)
  • Lifestyle factors: smoking, alcohol, exercise, education
19
Q

How does Alzheimer’s present clinically?

A
  • Four A’s:
    • Amnesia (most common)
    • Aphasia (language impairment - production or comprehension of speech)
    • Agnosia (inability to process sensory info e.g. can’t recognise objects, sounds, smells, get lost etc.)
    • Apraxia (motor planning impairment due to brain damage)
  • Others:
    • Apathy - ↓ motivation + anhedonia
    • Misplace / lose items (memory or visuospatial decline)
    • ↓ ADLs
    • Slow progressive
    • Late / early onset
20
Q

What pattern of inheritance does early onset Alzheimer’s follow?

What genes are involved?

A

Follows autosomal dominant pattern (50% chance inheritance)

Genes:

  • Chromosome 14 PSEN-1 (presenilin 1) gene
    • 80% of familial AD
    • Symptoms as young as 30yrs
  • Chromosome 1 PSEN-2 (presenilin 2) gene
    • Symptoms later than PSEN-1
  • Chromosome 21 APP (amyloid precursor protein) gene
21
Q

What genetic disorder conveys a high risk of also developing Alzheimer’s?

A

Down Syndrome (Trisomy 21)

  • 3 copies of APP (amyloid precursor protein)
  • 50% of Down’s syndrome people who live to 60 get AD
22
Q

What are the features of dementia with Lewy-bodies?

A
  1. Progressive cognitive impairment:
    • Visuo-spatial decline, language, dyspraxia
  2. Parkinsonism triad:
    • Bradykinesia, rigidity, tremor
  3. Visual hallucinations e.g. children/little people or animals
  4. Autonomic dysregulation: urinary incontinence, constipation
  5. Sleep disturbances: nightmares, aggressive movements, disturbed sleep
  6. Antipsychotic sensitivity - can develop irreversible parkinsonism
23
Q

Which of the following are mandatory parts of a standard dementia screening of an individual with memory loss which are essential for dementia diagnosis? (Select TWO)

  • Neuropsychological assessment
  • Cognitive testing
  • History-taking
  • SPECT scan
  • Brain imaging - MRI/CT
A

Although all 5 are useful - these 2 are REQUIRED for dementia diagnosis:

  1. History taking (most important)
  2. Cognitive testing
  • SPECT scan - type of functional neuroimaging that can help to differentiate between Alzheimer’s and Frontotemporal dementia
  • MRI/CT - never diagnostic but could help to settle the diagnosis and show cerebrovascular issues
24
Q

How would you summarise the treatment available for Alzheimer’s?

(think conservative and pharmacological/medical)

A

Conservative:

  • CBT, Cognitive stimulation therapy
  • Aromatherapy, music therapy, reminiscence therapy

Medical:

  • AChE Inhibitors (Donepezil, Galantamine, Rivastigmine)
  • NDMA receptor antagonist (Memantine)
25
Q

Vascular Dementia:

  1. What are the risk factors?
  2. What is the pathophysiology?
  3. How would you summarise the treatment?
A

Risk Factors:

  • AF, HTN, hyperlipidemia, smoking, diabetes (all risk factors for stroke/TIA)

Pathophysiology:

  • Microvascular disease (e.g. atherosclerosis) –> thrombi / emboli –> infarcts –> neuronal death
  • STEP-WISE decline

Treatment:

  • Stop smoking
  • Manage the same as stroke/TIA:
    • Acute: aspirin (2 weeks)
    • Prevention: Statin, anticoagulation, antihypertensives
26
Q

What investigations would you do as part of a confusion screen?

(think: bedise, bloods, imaging)

A

Beside:

  • Clinical history (+ collateral)
  • Observations - can identify sepsis
  • Physical examination e.g. abdo (suprapubic tenderness - UTI?), head trauma, alcohol withdrawel (tremor, fever, sweating)
  • MSE
  • Cognitive assessment

Bloods:

  • FBC - ↑ WCC (infection)
  • CRP - ↑ in context of infection
  • U+Es - uraemia, hyponatraemia, hyper/hypocalcemia
  • B12 & Folate - deficiency can cause confusion
  • TFTs - confusion mor eommon in hypothyroidism
  • Glucose - hypoglycaemia
  • LFTs - liver failure (hepatic encephalopathy)
  • Coagulation / INR - important in context of cranial bleed

Imaging:

  • CT head –> MRI head
27
Q

Anticholinergic drugs DECREASE the effect of AChE inhibitors.

Name some anti-cholingeric drugs.

A

Image shows anticholinergic burden table - mild, moderate, severe impact on ACh levels and thus their impact on ↓ AChE inhibitor efficacy.

  • All antipsychotics have anticholinergic properties
  • Beta-blockers + AChE-Is –> ↑ each others effects –> worsening bradycardia + syncope
  • Memantine + glutamate-R antagonists (e.g. ketamine, amantadine) –> ↑ each others effects –> pharmacotoxic psychosis
28
Q

Seperate the following statements by whether they are true of Alzheimers or DLB.

  • More common in men
  • Gradual decline in cognitive impairment
  • Fluctuating cognitive impairment
  • More common in women
  • Physical deterioration usually at a late stage
  • Decrease in facial expression develops later in disease
  • Visual hallucinations occur early
  • Hallucinations may occur, but in late stages
  • Early problems with balance
  • Face shows very little emotion from early in the disease
A

Alzheimers:

  1. More common in women
  2. Gradual decline in cognitive impairment
  3. Hallucinations may occur, but in late stages
  4. Physical deterioration usually at a late stage
  5. Decrease in facial expression develops later in disease

DLB:

  1. More common in men
  2. Fluctuating cognitive impairment
  3. Visual hallucinations occur early
  4. Early problems with balance
  5. Face shows very little emotion from early in the disease
29
Q

What do the BMJ list as core clinical features of dementia with Lewy-bodies?

(supportative clinical features or biomarkers are less important but can add to picture)

A

Core clinical features: (first 3 often occur early)

  1. Fluctuating cognition + pronounced variability in attention/ alertness
  2. Visual hallucinations (typically well formed and detailed)
  3. REM sleep behaviour disorder (RBD - acting out dreams)
  4. 1 or more parkinsonism features: bradykinesia, rest tremor, rigidity

For PROBABLE DLB diagnosis, 2 or more core clinical features are needed or 1 + indicative biomarkers (see BMJ criteria - don’t need to know)

Supportive clinical features:

  1. Severe sensitivity to antipsychotics
  2. Autonomic dysfunction: constipation, orthostatic hypotension, urinary incontinence)
  3. Postural instability (poor balance)
  4. Repeated falls
  5. Delusions
  6. Depression
30
Q

What is the pathology underpinning DLB?

A

alpha-synuclein deposits within neurons in brain

location of lewy-bodies influences symptom profile

31
Q

What medication can be given to manage REM sleep behaviour disorder (RBD - can be a feature of dementia with lewy-bodies)?

A

Clonazepam

Benzodiazepine tranquilizer - enhances activity of GABA by binding to benzodiazepine receptor on GABAA

32
Q

In patients with DLB and who have psychotic symptoms which are making the patient challenging (e.g. shouting, hitting etc) - if you choose to give an anti-psychotic, what are the best choices?

A

Pts with DLB or Parkinson’s dementia are at risk of antipsychotic sensitivity!!

  1. Quetiapine (low dose)
  2. Clozapine (involves a lot of monitoring - thus quetiapine is preferred)
33
Q

How can you differentiate between DLB and Parkinson’s disease with dementia?

A

DLB:

  • Dementia starts BEFORE and WITHIN 1 YEAR of the onset of PD symptoms

Parkinson’s dementia:

  • Dementia starts > 1 YEAR after onset of PD symptoms

Lewy Body Disease:

  • If time frame of dementia / PD symptoms is unknown then the name Lewy-Body disease might be used
34
Q

What are common features of Fronto-temporal dementia

also called Pick’s disease?

A
  1. Insidious onset < 65 yrs
  2. Relatively preserved memory + visuospatial
  3. Language issues:
    • non-fluent aphasia - slow, hesitant speech, grammer errors, can’t understand complex scentences
    • semantic dementia - anomia, describe items, can’t recognise familiar people
  4. Personality changes:
    • loss of sympathy / empathy
    • change in eating habits (e.g. crave sweet or fatty food, no table manners, don’t stop eating / drinking)
  5. Social / behaviour problems:
    • socially disinhibited + impulsive
    • apathy
    • repetitive, compulsive ritualised behaviours (hoarding, repeating phrases/gestures)
35
Q

What are the features (symptoms and radiological) of normal pressure hydrocephalus?

A

Symptoms:

  1. Fluctuating dementia and bradyphrenia (slowness of thought)
  2. Urinary incontinence
  3. Gait abnormality (often similar to Parkinson’s disease i.e. shuffling)

Radiological:

  1. Ventriculomegaly - widening of temporal horns of lateral ventricles, enlarged 4th ventricle
  2. Callosal angle < 90 degrees (angle between superior parts of lateral ventricles)
  3. Absence of substantial sulcal atrophy
  4. Tight high convexity - CSF spaces over convexity (superior brain) are narrowed

Year 4 - Mental Health (6 decks)

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