S2W10Demen Flashcards
Dementia
A cognitive disorder and not a mental health disorder.
DSM-V
At least one of:
• Aphasia
• Apraxia
• Agnosia
Memory problems:
Early – difficulty learning and STM problems
Severe – forget previously learned material e.g. names
Difficulty with spatial tasks
Poor judgement and insight:
Little awareness of memory loss
Unrealistic expectations of own abilities
May lead to conflict
Aphasia
Difficulty producing and understanding speech
Apraxia
difficulty carrying out purposeful movements
Agnosia
deficit in visual perception and inability to recognise objects
Statistics
850k in UK
225k per year (1 every 3 minutes)
1 in 6 people over 80
40k under 65
25k ethnic minorities
Types of dementia
Alzheimer’s – 2/3 of people
Vascular – 2nd common
Lewy bodies – 3rd common 15% of dementia sufferers
Frontotemporal dementia (Pick’s disease) – rare and happens in younger people
Alzheimer’s plaques
Clumps of protein develop around brain cells
Neuritic plaques – extracellular at axon terminals
Interfere with connections between neurons and impair functioning
Protein is called amyloid – present in healthy brains
Alzheimer’s Neurofibrillary tangles
Develop in plaques causes nerve cells to die
Develop within areas of the cerebral cortex, particularly within temporal lobe
Found within nerve cells (intracellular) and consist of protein called tau
Normally, tau transports nutrients to other parts of the cell
Here tau functions abnormally causing microtubules to collapse
Hippocampus alzheimer’s
Remember things early on better than things that happened yesterday.
Older memories don’t rely as much on hippocampus, which is damaged early on.
Amygdala one of last to be affected.
Symptoms
Memory loss
Language impairment
Disorientation
Loss of understanding of written material/writing
Loss of ability to perform calculation and arithmetic
Difficulty managing finances
Recognition of objects and faces lost
Visual and motor abilities decline, as well as planning
Problems with simple routines e.g. hygiene
Delusion or abnormal belief
May accuse relative of stealing valuables
20% display aggression
Vascular dementia
Vascular diseases block blood flow to areas of the brain (stroke) resulting in the death of tissue.
In contrast to gradual Alzheimer’s it comes suddenly and proceeds in step-wise deterioration.
Co-existence of Vascular and Alzheimer’s common over age of 70.
Types of vascular dementia
Multi-infarct dementia
Small vessel disease
Cerebral vasculitis
Multi infarct dementia
Secondary to 2+ strokes.
Small vessel disease
Narrowing of blood vessels
Gradual syndrome where patient slows down mentally and develops physical problems.
Most common.
Cerebral vasculitis
Inflammation of blood vessels to brain
Rapidly progressive.
Causes of vascular dementia
High blood pressure and coronary artery disease increase risk.
Controlling blood pressure, lowering cholesterol, and stop smoking associated with improved cognitive functioning.
Which functions deteriorate initially depend on which part of the brain is affected
Patients with advanced vascular dementia present similar to Alzheimer’s.
Display highs and drops in cognitive abilities.
Drops after stroke but then some improvement when brain is less swollen.
Dementia with Lewy bodies (DLB)
Small intracellular bodies develop inside the brain.
Prevent communication between cells.
Found in brainstem and cerebral cortex.
Two groups:
Parkinson’s disease but earlier cognitive problems = DLB.
Parkinson’s for over a year before = Parkinson’s with dementia.
Features of dementia with Lewy bodies
Difficulty in planning task – which might manifest as apathy
Slowness in thought and responses, and in motor movement
Visual hallucinations of figures or animals (either the patient recognises or faceless)
Frontotemporal dementia (FTD)
Frontal and temporal lobes begin to shrink.
Usually develops in people under 65.
Rarer than other types.
Most common changes are apathy and disinhibition
Apathy
lose interest in family and hobbies.
Disinhibition
might start talking to strangers, picking up other people’s things.
FTD other changes to behaviour
Over spending
Lack of hygiene
Criminal behaviour
Sexual behaviour
Change of food preferences
Repetitive behaviour
Objective measures of dementia
Mental Test Score (MTS) and Abbreviated Mental Test Score (AMTS)
Mini Mental State Examination (MMSE)
Addenbrokes Cognitive Examination (ACE) and (ACE-R)
Test of awareness of Dementia (untrained people – non cognitive)
The patient may:
Ask same questions
Repeats the same story
Forgets routine activities
Get lost in familiar places
Forgets personal hygiene
Becomes dependent when making decisions
Mental Test Score (MTS)
Name and age Time of day Address Sate Place Recognition of two people School attended Former occupation Name of wife Date of World Wars Monarch/Prime Minister Months of year backwards Counting
Abbreviated Mental Test Score (AMTS
Age Time Address (repeated at end) Year Location Identify two people Date of birth First World War Name of Monarch Count 20 to 1
Mini Mental State Examination (MMSE)
Most commonly used
Not suitable for diagnosis
10 minute duration
Won’t detect subtle memory losses.
People from different cultures/low education may score poorly
Well-educated may score well despite impairment
Not appropriate if patient has learning, communication or sensory disabilities
Measures of orientation, immediate memory, STM and language function
Well validated.
25-30: normal
21-24: mild
10-20: moderate
<10: severe
Addenbrooke’s Cognitive Examination (ACE)
Some aspects of MMSE but more detailed assessment:
More rigorous memory test
Test of frontal lobe function
Easy to perform in daily clinical practice.
Revised version created to deal with weaknesses.
Classical memory errors
Confabulations
Intrusional errors
Delusion:
Confabulations
Filling in gaps in memory
Intrusional errors
Mixing up two different events
Delusion
Related to misplacing objects
Episodic memory (STM)
Personally experienced events.
Up to 30 seconds.
Limited capacity 7 +/- 2
Memory span is reduced for individuals with dementia, especially with delay or interference
Problems with encoding
Episodic memory (LTM)
LTM:
Longer than 30 seconds
Problems recalling:
o List of words
o Stories
o Faces or pictures
Failure of semantic processing, reducing strength of LTMs
Retrieval might also be impaired
Remote memory
Tend to remember events from the past more clearly than recent events.
Semantic memory
Knowledge about the world, rules, facts, categories.
Detereoriation less striking than episodic memory.
Not linked to personal experiences.
Experimental studies show patients are good with category names but confuse objects in a category.
Problem due to degradation of memory (not retrieval).
Reminiscence Therapy
Provides context in which patients can use LTM to recall past life events.
Since LTM remains more intact reminiscence therapy reduces the experience of failure.
Ebersole (1978) benefits:
Socialisation when applied groups
Self-actualisation
Applied to early dementia with fairly good communication abilities.
Dementia and Language
Main characteristics:
Impoverish speech
Difficulty in finding the right words or in naming objects
In advanced dementia, speech might be entirely lost
Naming Task
More difficult in dementia.
Naming low frequency objects the hardest.
Patients have:
Misperception of the object
Semantic errors - produce the word of an object that is semantically related
Word Fluency
Related to semantic memory.
Task to assess word fluency (name obects):
Starting with the letter “F”,
That are flowers
Found in the supermarket
Patients with dementia do very poorly.
Severity affects performance
Spontaneous Oral Speech
Patients with early stage dementia have same vocabulary than controls but word fluency is slower.
In conversation:
Produce less sentences
Initiate irrelevant topics of conversation due to poor memory and losing track
Include more requests
Advanced dementia: speech entirely lost.
