Types and Treatment of Dementia

Question 1

What are the 5 types of dementia?

Answer 1

1) Alzheimer’s
2) Vascular dementia
3) Mixed Alzheimer’s/vascular
4) Dementia with Lewy bodies (DLB)
5) Fronto-temporal dementia (FTD)

Question 2

Describe the neuropathologies of the types of dementia

Answer 2

• DLB and FTD have v different neuropathologies

- Alzheimer’s, vascular and mixed have got overlapping neuropathologies

Question 3

What is the order of how common the types of dementia are?

Answer 3

1) Alzheimer’s
2) DLB
3) Vascular, mixed, FTD

Question 4

What are the clinical features of Alzheimer’s?

Answer 4

• 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

Question 5

What causes vascular dementia?

Answer 5

• Infarcts or small vessel disease superimposed with infarcts
• Often co-exists with Alzheimer’s so often have Alzheimer’s pathology as well

Question 6

What are the clinical features of vascular dementia?

Answer 6

• 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

Question 7

What are the risk factors for vascular dementia?

Answer 7

Normal vascular risk factors e.g. smoking, high BP, diabetes

Question 8

What are the clinical features of dementia with Lewy bodies (v different from clinical picture of Alzheimer’s or vascular)?

Answer 8

• Day to day fluctuation in cognition
• Visual hallucinations
• Disturbances of consciousness
• Parkinsonism - tremors, slow movements
• Falls/syncope (autonomic symptoms)

Question 9

Why is there overlap with DLB and delirium?

Answer 9

Bc they have fluctuation and delirium like episodes

Question 10

What drugs are patients with DLB sensitive to?

Answer 10

Antipsychotics

Question 11

What is the neuropathology of DLB?

Answer 11

Synucleinopathy (Lewy bodies)

Question 12

What is the difference between DLB and PD?

Answer 12

• 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

Question 13

What are the clinical features of frontotemporal dementia?

Answer 13

• 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

Question 14

Describe the decline in social/personal conduct that occurs in frontotemporal dementia

Answer 14

• 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

Question 15

Where is typical dementia diagnosed?

Answer 15

Memory clinics (old age psychiatry/geriatrics)

Question 16

When might dementia be diagnosed in neurology?

Answer 16

• Younger onset
• Strange presentations may go to neurology first
• e.g. FTD bc no memory problem

Question 17

When is long term follow up done by old age psychiatry?

Answer 17

If JUST dementia (if co-morbidities then geriatric clinic who also look after dementia)

Question 18

What are the general principles of dementia treatment?

Answer 18

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

Question 19

How do you address functional problems in dementia treatment?

Answer 19

• OT involvement
• Assistive technology
• e.g. alarm that asks if need to go out when open door, tracking on fit bit, medication reminder

Question 20

What safeguarding issues may someone with dementia have problems with?

Answer 20

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

Question 21

What do you need to make an assessment of if see someone with dementia or early cognitive problems?

Answer 21

• 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

Question 22

What are the aims of disease modifier drug treatment in dementia?

Answer 22

• 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

Question 23

What is the only medication use to treat dementia?

Answer 23

Acetylcholinesterase (AChE) inhibitors

Question 24

What are the effects of AChE inhibitors?

Answer 24

• 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

Question 25

What are the 3 AChE inhibitors?

Answer 25

1) Donepezil
2) Galantamine
3) Rivastigmine

Question 26

What are treatments used to treat symptoms in dementia (lot that can be done but just not a cure for underlying neurodegenerative process)?

Answer 26

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

Question 27

What are options for care settings for dementia patients?

Answer 27

1) Carer/spouse
2) At home with social services support (not so expensive)
3) Care home (v expensive)

Question 28

When does a care home become necessary?

Answer 28

• When having visual hallucinations and arguments with carers/spouse
• Or physical co-morbidities

Question 29

Describe finances related to a care home

Answer 29

• ~ £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)

Question 30

What are two exceptions where you don’t have to pay for your care (can keep all properties and money)?

Answer 30

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