Psychiatry through the Lifecourse

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

Describe the pathophysiology of Alzheimers?

Answer 2

Amyloid plaques
Neurofibrillary tangles (NFTs)

Up to 50% loss of neurons and synapses in the cortex and hippocampus

Question 3

What are amyloid plaques?

Answer 3

insoluble β-amyloid peptide deposits as senile plaques or β-pleated sheets in the hippocampus, amygdala, and cerebral cortex. Increased density with advanced disease

Question 4

What are Neurofibrillary tangles?

Answer 4

consist of phosphorylated tau protein and are found in the cortex, hippocampus, and substantia nigra.

(NFTs also found in normal ageing

Question 5

What are the genetics involved in dementia?

Answer 5

Chromosome 21,19,14 and 1

Question 6

What is chromosome 21 responsible for?

Answer 6

the gene for amyloid precursor protein (APP) is found on the long arm. Also implicated in Down’s syndrome.

Question 7

What is chromosome 19 responsible for?

Answer 7

codes for apolipoprotein E4. Presence of E4 alleles increases risk of AD; some 15% of Europeans carry the allele.

Question 8

What is chromosome 14 responsible for?

Answer 8

codes for presenilin 1 (implicated in B-amyloid peptide).

Question 9

What is chromosome 1 responsible for?

Answer 9

codes for presenilin 11 (implicated in B-amyloid peptide).

Question 10

What is the cholinergic hypothesis?

Answer 10

the pathological changes lead to degeneration of cholinergic nuclei in the basal forebrain (nucleus basalis of Meynert). This results in reduced cortical acetylcholine (ACh).

Question 11

Give an example of an acetylcholinesterase inhibitor

Answer 11

Donepezil

Question 12

Give an example of a NMDA receptor antagonist

Answer 12

Memantine

Question 13

What are the early symptoms of Alzheimers?

Answer 13

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

Question 14

What are the features of progressive disease?

Answer 14

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.

Question 15

What is seen in advances Alzheimers Disease?

Answer 15

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

Question 16

What are the psychiatric symptoms of Alzheimers?

Answer 16

Delusions (15%)—usually of a paranoid nature.
Auditory and/or visual hallucinations (10–15%)—which may be simple misidentification, and indicate rapid cognitive decline.
Depression is common, requiring treatment in up to 20% of patients

Question 17

What are the behavioural disturbances with Alzheimers?

Answer 17

aggression, wandering, explosive temper, sexual disinhibition, incontinence, excessive eating, and searching behaviour.

Question 18

What are the features of personality change in Alzheimers?

Answer 18

often reflects an exaggeration of premorbid traits with coarsening of affect and egocentricity.

Question 19

What are routine test conducted in Alzheimers?

Answer 19

FBC, ESR, CRP - anaemia, vasculitis
T4 and TSH - hypothyroidism
biochemical screen - hypercalcaemia or hypocalcaemia
urea and creatinine - renal failure, dialysis dementia
glucose
B12 and folate - vitamin deficiency dementia
clotting and albumin - liver function

Question 20

What imaging is used in Alzheimers?

Answer 20

Use structural imaging to exclude other cerebral pathologies and help establish the subtype of dementia:
imaging may help to identify treatable causes such as subdural haematoma, normal pressure hydrocephalus, cerebral tumours
prefer MRI to assist with early diagnosis and detect subcortical vascular changes. However, CT scanning could be used