Week 3 - Dementia

Question 1

Name some treatable causes of dementia symptoms?

Answer 1

Structural

• Subdural haematoma
• Normal pressure hydrocephalus
• Brain tumour

Endocrine

• Hypothyroidism
• Addison’s disease

Infectious - tertiary syphilis, HIV

Chronic drug use - alcohol, barbituates

Depression

Medications

Question 2

What are the 2 pathophysiology pathways of Alzheimer’s disease?

Answer 2

1. Plaque build up of Beta-amyloid protein
   
   1. gets in between neurons
   2. impairs signalling
   3. gets around blood vessels ↑ risk of haemorrhage
2. Tangles of TAU inside neurons
   
   1. ↓ signalling
   2. ↑ apoptosis → brain atrophy

Question 3

How does alzheimer’s progress?

Answer 3

1. Short term memory loss
2. loss of some motor and language skills
3. long term memory loss
4. disorientation
5. bed-ridden

Question 4

Spot diagnosis dementia:

speech deficits, inability to remember the meaning of words

Answer 4

Alzheimer’s

Question 5

Spot diagnosis

Telegraphic speech - missing out link words like “the”

Answer 5

Vascular - switching off lights - hyperintensities on MRI

Question 6

Spot diagnosis

Socially disinhibited, impulsive, eating sugary foods

Answer 6

frontal-temporal dementia

Question 7

Spot diagnosis

Visual hallucinations

Answer 7

Dementia with Lewy Bodies

Question 8

How does vascular dementia typically progress?

Answer 8

Stepwise - e.g. with each fall gets a bit wors.

Dominant subcortical effects

Question 9

What are the differentials to consider with dementia like symptoms?

Answer 9

1. Delirium
2. Drugs / alcohol effects
3. Deficiency - B12 or thiamine
4. Depression
5. Medications (polypharmacy in elderly, maybe benzos)
6. Hypothyroidism
7. Malignancy
8. Normal pressure hydrocephalus
9. Sensory deficits

Question 10

How is dementia defined?

Answer 10

→ Dementia = 6 month decline in mental function significant enough to interfere with ADLs.

Affects at least 2

1. cognitive domains (memory , thinking, language, orientation and judgement) and
2. social behaviour (emotional control and motivation).

Cannot be explained by another disorder or medication effects.

Question 11

How would you approach a dementia patient with an episode of challenging behaviour?

Answer 11

1. Treat the underlying cause (bodily functions, infection etc)
2. Advise moving the person to a safe, low-stimulation environment (such as a quiet room) away from others.
3. Advise use of verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, pictures, and symbols).

Question 12

How are Donepezil and galantamine metabolised?

Answer 12

Liver

enzyme inducers (e.g. carbamazepine) may reduce levels

Question 13

How is Rivastigmine metabolised?

Answer 13

At the site of action (very useful for polypharmacy!)

Question 14

How is Memantine excreted?

Answer 14

Renally

Question 15

How might cholinesterase inhibitors interact with other drugs?

Answer 15

All ACh-esterase-inhibitors (donepezil, galantamine and rivastigmine) will interact with anti-cholinergic drugs such as antipsychotics (clozapine, haloperidol), benzos and codeine.

Warfin interacts too but then it interacts with everything.

The interaction is to increase each others’ effects.

Beta blockers also interact this way.

Question 16

What do the words mean:

aphasia

expressive aphasia

receptive aphasia

Answer 16

Aphasia = is when a person has difficulty with their language or speech.

Expressive aphasia = difficulty communicating their thoughts, ideas and messages to others.

Receptive aphasia = difficulty understanding things they hear or read. They may also have difficulty interpreting gestures, drawings, numbers and pictures.

Question 17

What does agnosia mean?

Answer 17

Agnosia = the inability to process sensory information.

Often there is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss.

It is usually associated with brain injury or neurological illness, particularly after damage to the occipitotemporal border, which is part of the ventral stream.

Agnosia only affects a single modality, such as vision or hearing.

Question 18

What is the main principle of capacity?

What are 3 of the sub-principles of Capacity?

Answer 18

Capacity = Time and decision specific

1. Presume that they have capacity unless you prove otherwise
2. Patient has to have a disability or disorder of the mind - anything that affects your mental state there and then e.g. pain, meds, sleep deprived, learning disability
3. Pick the best time for the patient if they have any fluctuating capacity - legally must delay til capacity returns in 24 hours (if it is safe to leave)

Question 19

What are 4 principles in the DOLS section of the mental capacity act?

Answer 19

1. Least restrictive option must always be chosen
2. When patient lacks capacity to agree to arrangements
3. Patient must have a representative
4. Representative has the right to challenge through court of protection

Question 20

What are those patients suffering from either dementia with Lewy bodies or Parkinson’s disease dementia at increased risk of in terms of certain medications?

Answer 20

neuroleptic (antipsychotic) sensitivity

Question 21

What is REM sleep behaviour disorder?

Answer 21

Disorder in which person exhibits dream enacted behaviours

• Not usually confused when woken
• It is seen more often in people suffering from neurological disorders.
• Clonazepam is effectively used to treat REM sleep behaviour disorder