Types and Treatment of Dementia Flashcards
What are the 5 types of dementia?
1) Alzheimer’s
2) Vascular dementia
3) Mixed Alzheimer’s/vascular
4) Dementia with Lewy bodies (DLB)
5) Fronto-temporal dementia (FTD)
Describe the neuropathologies of the types of dementia
- DLB and FTD have v different neuropathologies
- Alzheimer’s, vascular and mixed have got overlapping neuropathologies
What is the order of how common the types of dementia are?
1) Alzheimer’s
2) DLB
3) Vascular, mixed, FTD
What are the clinical features of Alzheimer’s?
- Gradual onset
- Memory involved early/first (hippocampus involved, medial temporal lobe atrophy)
- Progressive cognitive decline (can predict stages) - memory then language difficulties then functional changes
What causes vascular dementia?
- Infarcts or small vessel disease superimposed with infarcts
- Often co-exists with Alzheimer’s so often have Alzheimer’s pathology as well
What are the clinical features of vascular dementia?
- Stepwise deterioration in cognitive function as you have each stroke
- Medial temporal lobe atrophy and evidence of strokes
- Subtle/mild neurological symptoms
- Sometimes will not have an obvious hemianopia, hemiplegia or neurological sign to go with the strokes (won’t necessarily have be strokes could be in frontal love where they don’t really cause any neurological symptoms)
- Cognitive deficits depend on where was stroke
What are the risk factors for vascular dementia?
Normal vascular risk factors e.g. smoking, high BP, diabetes
What are the clinical features of dementia with Lewy bodies (v different from clinical picture of Alzheimer’s or vascular)?
- Day to day fluctuation in cognition
- Visual hallucinations
- Disturbances of consciousness
- Parkinsonism - tremors, slow movements
- Falls/syncope (autonomic symptoms)
Why is there overlap with DLB and delirium?
Bc they have fluctuation and delirium like episodes
What drugs are patients with DLB sensitive to?
Antipsychotics
What is the neuropathology of DLB?
Synucleinopathy (Lewy bodies)
What is the difference between DLB and PD?
- DLB presents with a cognitive presentation at the beginning whereas in PD you start with motor problems
- Probably everyone with PD if they live long enough will get a dementia but call it PD with dementia rather than DLB
What are the clinical features of frontotemporal dementia?
- Early decline in social/personal conduct (first presenting feature)
- Memory preserved in early stages so easily missed bc don’t present with memory problems
- Some variants affect behaviour and language bc of which parts of the brain are affected so language and behaviour changes may be the first presenting signs
Describe the decline in social/personal conduct that occurs in frontotemporal dementia
- e.g. personality changes, eating preferences, sexual behaviour, psychopathic traits (emotional coldness etc)
- Bc anterior temporal or frontal lobe is linked to personality
- These features occur in the 5 years before it becomes obvious they have dementia and so it is often missed and thought to be something else
Where is typical dementia diagnosed?
Memory clinics (old age psychiatry/geriatrics)
When might dementia be diagnosed in neurology?
- Younger onset
- Strange presentations may go to neurology first
- e.g. FTD bc no memory problem
When is long term follow up done by old age psychiatry?
If JUST dementia (if co-morbidities then geriatric clinic who also look after dementia)
What are the general principles of dementia treatment?
1) Treat associated disorders - anything making cognition worse or adding to delirium e.g. chest infections, UTIs, physical co-morbidities
2) Address functional problems
3) Carer support and advice
4) Manage risk factors (e.g. smoking, BP) esp. for vascular dementia and also for AD
How do you address functional problems in dementia treatment?
- OT involvement
- Assistive technology
- e.g. alarm that asks if need to go out when open door, tracking on fit bit, medication reminder
What safeguarding issues may someone with dementia have problems with?
1) Preparing food and drink
2) Wandering
3) Self care
4) Ability to deal with finances - susceptible to being tricked, financial manipulation, understanding financial implication of things or how to move money and save and how much they have
5) Exploitation from others
What do you need to make an assessment of if see someone with dementia or early cognitive problems?
- Need to make an assessment if there is a safety issue/how safe is this person
- Process of alerting someone else if there are concerns and then a social service lead process can investigate
What are the aims of disease modifier drug treatment in dementia?
- Currently no disease reversing medication for neurodegeneration in dementia
- But can slow down some of the NT effects and maybe some of the follow on consequences of neuronal damage
What is the only medication use to treat dementia?
Acetylcholinesterase (AChE) inhibitors
What are the effects of AChE inhibitors?
- Boost ACh and can buy you a couple of years of living independently and slowing down cognitive changes
- Also useful for treating some of the behavioural symptoms
- Good for treating hallucinations and maybe some of the delirium episodes as well
What are the 3 AChE inhibitors?
1) Donepezil
2) Galantamine
3) Rivastigmine
What are treatments used to treat symptoms in dementia (lot that can be done but just not a cure for underlying neurodegenerative process)?
1) Non-pharmacological approaches to reduce stress and help people maximise their memory e.g. reminiscence therapy, aromatherapy, stress reliving things in care homes for people with dementia
2) Medication for specific symptoms e.g. depression, hallucinations, agitation, pacing, sleep disturbance
What are options for care settings for dementia patients?
1) Carer/spouse
2) At home with social services support (not so expensive)
3) Care home (v expensive)
When does a care home become necessary?
- When having visual hallucinations and arguments with carers/spouse
- Or physical co-morbidities
Describe finances related to a care home
- ~ £1000/week
- Payment by social care or patient depending on financial resources
- If have savings < £30,000 local authority will pay but if have any more than that need to pay yourself and for most people who have a property that asset will be used to pay for your care
- Doesn’t mean have to sell house there and then but whenever property is sold, local authority will take back the money
- So if best interests decision is made for patient with dementia who lacks capacity to go to a care home even if they don’t want to, patient is forced to pay (deprivation of liberty act, MCA)
What are two exceptions where you don’t have to pay for your care (can keep all properties and money)?
1) If have ever been sectioned under section 3 of MHA linked to dementia (not if e.g. in teens)
2) NHS continuing care - if dementia is bad enough that would need hospital bed for life then moved into community care home and funded by NHS
