Psychiatric Disorders Across the Lifecourse Tutorial

Question 1

What is dementia?

Answer 1

Degenerative disease of the brain with:

Cognitive and behavioural impairment

Sufficiently severe to interfere significantly with social and occupational function

Question 2

What is the epidemiology of Alzheimer’s Dementia?

Answer 2

Leading cause of death in women, second in men
Most common cause of dementia is Alzheimer’s disease (70%)
Vascular dementia 2nd most common

Question 3

What is the pathophysiology of dementia?

Answer 3

Amyloid plaques - insoluble beta-amyloid peptide desposits as senile plaques or beta-pleated sheets in the hippocampus, amygdala, and cerebral cortex

Neurofibrillary tangles (NFTs) - phosphorylated tau proteins in the cortex, hippocampus and dubstantia nigra

Neuro-synapses are deteriorating and the plaques begin to take up the degenerating space

Question 4

What do PET scans of healthy VS Alzheimer’s patients show?

Answer 4

Greater amyloid plaques on brain imaging compared to healthy individual

Greater phosphorylated tau proteins on brain imaging compared to healthy individual

Question 5

What are the 4 common chromosomes that may be involved in dementia?

What do these 4 chromosomes code for?

Answer 5

Chromosome 21 - the gene for amyloid precursor protein (APP) is found on the long arm, also implicated in Down’s syndrome

Chromosome 14 - code for E4 allele, increases risk of Alzheimer’s Disease

Chromosome 9 - codes for presenilin 1 (implicated in beta amyloid peptide)

Chromosome 1 - codes for presenilin 11 (implicated in beta amyloid peptide)

Question 6

What is the cholinergic hypothesis of dementia?

What medication can help slow down Alzheimer’s / manage the symptoms?

Answer 6

Pathological changes lead to degeneration of cholinergic nuclei in the basal forebrain - results in reduced cortical ACh

Acetylecholinesterase inhibitors - e.g. Donepezil

NMDA (glutamate) receptor antagonists - e.g. Memantine

Question 7

What are some early, progressive and advanced signs of Alzheimer’s disease?

Answer 7

Early symptoms:

Absent-mindedness
Difficulty recalling names and words
Difficulty learning new information
Disorientation in unfamiliar surroundings
Reduced social engagement 

Progressive Disease:

Marked memory impairment
Reduced vocabulary
Loss of less complex speech patterns
Mood swings and/or apathy
Decline in ADL’s & social skills
Emergence of psychotic phenomena

Advanced AD:

Monosyllabic speech
Psychotic symptoms
Behavioural disturbance
Loss of bladder and bowel control
Reduced mobility

Question 8

What is the relevant psychiatric history and mental state in this case study?

Answer 8

Absent mindedness
Difficulty recalling names and words
Difficulty learning new information

Psychiatric symptoms
Delusions
Auditory and/or visual hallucinations
Depression is common

Behavioural disturbances - aggression, explosive temper, sexual disinhibition, inconctinence, excessive eating and searching behaviour

Personality change

Question 9

What are some clinical features of dementia?

Answer 9

Psychiatric symptoms:
Delusions (15%) - usually paranoid
Auditory and/or visual hallucinations (10–15%) - indicate rapid cognitive decline
Depression is common

Behavioural disturbances:
Aggression, wandering, explosive temper, sexual disinhibition, incontinence, excessive eating, and searching behaviour

Personality changes

Question 10

What is a clinical diagnosis of probable Alzheimer’s?

Answer 10

Presence of dementia

Insidious onset

Deterioration from individual’s baseline

Unlikely to be accounted for by another cause

Question 11

What does the MMSE consist of?

Answer 11

Mini Mental State Examination - each q weighted differently

1. Year? Season? Date? Day? Month? [5]
2. Where are we now? [5]
3. 3 words to remember [3]
4. Could backwards from 100, in 7s / spell WORLD backwards [5]
5. Recall 3 words [3]
6. Name simple objects [2]
7. Repeat phrase [1]
8. Fold paper [3]
9. Read instructions and follow them [1]
10. Write a sentence [1]
11. Copy a picture [1]

Question 12

What score did Mrs Caddock achieve on MMSE?

Answer 12

18 - moderate

Question 13

What does Mrs Caddock’s son say in the collateral history?

Answer 13

Getting more forgetful

Repetition

Question 14

According to her son, Mrs Caddock is presenting with?

Answer 14

Progressive disease - marked memory impairment and decline in social skills

Question 15

What is the difference between delirium VS dementia VS depression?

Answer 15

Conditions: Delirium | Dementia | Depression
Onset: Acute | Insidious | Acute or insidious
Course: Fluctuating | Progression | May be chronic
Duration: Hours to weeks | months to years | months to years
Consciousness: Altered | Usually clear | Clear
Attention: Impaired | Normal except severe dementia | May be decreased
Psychomotor changes:

Question 16

What are the routine dementia investigations? Why are they carried out?

Answer 16

Blood tests: 
FBC, ESR, ERP - anaemia, vasculitis
T4 and TSH - hypothyroidism 
Biochemical screen - hypercalcaemia,
Urea and creatinine - renal failure, midstream urine test 
Glucose
B12 and folate - vitamin deficiency dementia
Clotting and albumin - liver function

Primarily to exclude reversible causes of cognitive deterioration

Question 17

What types of imaging can be carried out for dementia investigations? What are they carried out?

Answer 17

Prefer MRI to CT, as they assist with early diagnosis and can better detect subcortical vascular changes

Structural imaging is used to exclude other cerebral pathologies (haematoma, tumours etc.) and help establish the subtype of dementia