Psychiatry - Vascular Dementia Flashcards
Vascular Dementia
Many patients have preserved positive personality traits and personal attributes but the following features may become evident as the disease progresses:
- memory loss, language impairment, disorientation, changes in personality, difficulty in carrying out daily activities, self-neglect
- psychiatric symptoms - apathy, depression or psychosis
- unusual behaviour - aggression, sleep disturbance or disinhibited sexual behaviour
Vascular Dementia
How can it be divided?
- young-onset dementia – formerly known as “pre-senile dementia”, refers to patients who develop dementia before the age of 65 years
- late-onset dementia – previously known as “senile dementia”, refers to patients who develop dementia after the age of 65 years
Vascular Dementia
Risk Factors?
Non modifiable risk factors:
- age – advancing age is the most important risk factor in developing dementia
- learning disabilities – in people with Down’s syndrome, dementia develops 30–40 years earlier than in a normal person
- gender – rate of dementia is higher in women than in men (specially for Alzheimers disease)
- genetic factors
Modifiable risk factors:
- alcohol consumption
- smoking – particulary for Alzheimers
- obesity
- hypertension
- hypercholesterolaemia
- head injury
- education and mental stimulation
Vascular Dementia
Aetiology (1)?
Causes of dementia:
Alzheimer’s disease (AD) -
- the cause of most cases of dementia, accounting for about 60% of all cases (1)
- is a degenerative cerebral disease, with insidious onset, which is characterised by a slow progressive decline in cognition and ability to function
vascular dementia (VaD) and dementia with Lewy bodies (DLB) are responsible for most other cases of dementia (15 to 20% of cases in each)
- vascular dementia usually arises from multiple infarcts or generalised small vessel disease - has a more sudden onset than Alzheimer’s disease.
- DLB is slowly progressive - DLB shares many of the features of Alzheimer’s disease and Parkinson’s disease
Vascular Dementia
Aetiology (2)?
Mixed cases (e.g. Alzheimer’s disease and vascular dementia or Alzheimer’s disease and dementia with Lewy bodies) are recognized increasingly, especially in older people:
- In young onset dementia, frontotemporal dementia (FTD) is an important cause (after Alzheimer’s disease) (1).
- Other causes of dementia include (accounts for less than 5%):
- other degenerative diseases - Huntington’s disease
- prion diseases - Creutzfeldt-Jakob Disease
- reversible causes
- psychiatric disorders - ‘pseudodementia’ of depression
- space-occupying lesions
- toxic and metabolic disorders - alcohol-related dementia, vitamin B12 or folate deficiency
- endocrine abnormalities – hypothyroidism
Vascular Dementia
Clinical Features?
Suspect dementia when:
- family members report to the physician about memory impairment but the patient denies it
- the patient is questioned, he/she looks at the carer for an answer - the ‘head-turning sign’
loss of a variety of abilities in the spheres of:
- decline in memory – mostly impairment of learning new material or retaining new information, repetitive questioning, difficulty recalling time or date
- failure of other areas of higher cognitive functioning which will affect normal daytime activities and executive functions
- difficulty in performing complex tasks
- difficulties in judgement and planning, analytic thought
- problems in finding one’s way around familiar places (spatial awareness) -
- impairment in language – problems with expressing themselves or getting “lost” in conversations
Challenging behaviour;
- depression
- apathy
- agitation
- disinhibition
- psychosis (delusions or hallucinations)
- wandering
- aggression
- incontinence
Vascular Dementia
History & Examination (1)
gathered from a person who has known the patient for a period of six months at least and if possible directly from the patient:
- age
- medical and PHx of the family e.g. - dementia or other mental health problems
- origin and progression of condition
- associations:
- myoclonus
- seizures
- depression, anxiety (1)
- past and present medical and PHx - e.g. diabetes, hypertension, cerebrovascular accident
- exposure to toxins:
- alcohol
- lead
- drugs e.g. barbiturates
Vascular Dementia
History & Examination (2)
Examination of the demented patient should:
- exclude dysphasia
- social functioning which would not be normal in dementia
- physical examination – to recognize physical disorders which may be responsible for cognitive impairment
- evidence of CVA
- neurological examination
- endocrine system – signs of hypothyroidism
- mental state examination – to identify other psychiatric disorders (e.g. – depression) or non-cognitive symptoms that may be associated with dementia (e.g. – delusions, hallucinations)
- cognitive examination – to estimate the extent of how different cognitive domains are affected and should include examination of attention and concentration, orientation, short and long-term memory, praxis, language and executive function. Standardised screening tests used for this purpose include
- 30-item Mini Mental State Examination (MMSE) – commonly used
- 6-item Cognitive Impairment Test (6-CIT)
- the General Practitioner Assessment of Cognition (GPCOG)
- 7-Minute Screen
- the clock drawing test – to assess praxis and executive function
Vascular Dementia
Management?
Consent should be obtained from the patient. If the patient lacks the capacity to make any decisions on their own, the provisions of the Mental Capacity Act 2005 should be followed:
Patients should be offered written information and advice about:
- signs and symptoms of dementia
- course and prognosis of the disease
- treatments
- local care and support services
- support groups
- sources of financial and legal advice and advocacy
- medico-legal issues, including driving
- local information sources, including libraries and voluntary organizations
Interventions in dementia can be aimed at:
- cognitive symptoms
- noncognitive symptoms and challenging behavior
- reduction of comorbid emotional disorders
Vascular Dementia
Mild Cognitive Impairment?
Mild cognitive impairment is a subtle pattern of cognitive impairment .
- It can be described as an intermediate zone which is seen between a cognitively normal elderly person and person with clear dementia. It does not fall under any type of dementia.
- Mild cognitive impairment (MCI) is defined as syndrome of cognitive impairment (a reduction in the ability to think, concentrate, formulate ideas, reason and remember) which is greater than the expected for an individual’s age and education level and without experiencing considerable changes in usual activities of everyday life.
- Cognitive performance between ‘normal’ ageing and mild cognitive impairment overlap considerably .
- The possibility of developing dementia (mostly Alzheimer disease) in an individual with MCI is 5 to 10 times greater when compared to cognitively healthy individuals.
- There are several different types of MCI:
- amnestic type - memory is affected
- non-amnestic - memory is not affected
