Year 2 - Week 1 - Dementia Flashcards
What is dementia?
Long-term, progressive condition - affecting sufferer’s cognitive skills & ability to perform everyday tasks.
Why do some GPs not diagnose dementia?
Not confident in their diagnosis
Reluctance to cause distress to P = lots of stigma attached to dementia
What can slow the progression of Alzheimer’s
Cholinesterase inhibitors
Name a test for dementia that GPs can perform
General Practitioner Assessment of Cognition (GPCOG)
Who is interviewed as part of the GPCOG test?
Patient & relative/friend
What indicates cognitive impairment on GPCOG test?
4 or > / 9 in P and
3/6 of less in relative
What is the mini-COG?
Ask P to remember 3 words - then draw clockface and add time - then recall the 3 words.
What is the longer & better test of cognitive function called?
Mini-Mental State Examination (MMSE) (or the MoCA or ACE-III).
What is the disadvantage of MMSE?
Takes much longer to complete - as tests different subsections of cognition
What can you ask a P who you suspect has memory problems?
Have friends/family commented
Is her memory causing any problems?
How are things at home - still able to do everything, shopping, finances, social life?
Mood - any depression
Sleeping pattern
Appetite
What blood tests can you do for reversible causes of dementia?
Thyroid Function Tests (check for hypothyoidism)
B12 (check for deficiency)
U&Es (check for hyponatremia)
FBC
LFTs (looking for alcohol misuse)
HIV (if high risk)
FBC + B12 + Folate (pernicious anemia)
Bilirubin (if jaundice)
Calcium (if suspected hypercalcaemia)
Plasma glucose (diabetes)
What can dementia be confused/mistaken with?
Depression
Delirium
What is delirium?
An acute confusional state
How can you differentiate between delirium and dementia?
Delirium - comes on rapidly (hours),
What things can cause delirium?
Infection
Pain
Hypoxia
Electrolyte imbalance
Drugs
Withdrawal
Liver failure
Brain injury
Urinary retention
How can you test for UTI?
Midstream urine microscopy
How can you test for pneumonia?
Chest X-Ray
How can you test for PE?
D-Dimer
CT Pulmonary Angiogram
How do you test for hyponatremia?
Serum U&Es
How do you test for liver failure?
LFTs
What are the most common types of dementia?
AD or mixed aetiology (AD + vascular)
Lewy-body dementia
Vascular dementia
Which dementia accounts for 5% of cases?
Frontotemporal dementia
Name 2 rare causes of dementia
HIV
CJD
Why is it important to try and determine which dementia a P has?
Each has different natural history & each is treated differently
How does AD present?
Initial symptom of memory loss, followed by loss of insight and gradual functioning deterioriates.
What does AD look like on CT?
Atrophy & shrinkage of hippocampus + medial temporal structures
How does Vascular dementia present?
Often Ps have some CVD
Is stepwise deterioration (not gradual)
Loss of executive function predominates - can recall facts & personality preserved
How does vascular dementia appear on CT?
Lacunar infarcts, white matter ischaemia, leukoencephalopathy & cerebral small vessel disease
How does Lewy-Body dementia present?
Marked variability in mental state & alertness day by day
May have hallucinations
Have Parkinsons like symptoms - stiffness, slowness of mvement
Does CT show any changes in LBD?
No characteristic signs on CT
Which scan can be used in LBD?
SPECT scan
How does Frontotemporal dementia present?
Behavioural / personality changes are dominant dementia - dramatic changes
Earlier onset
What can CT show in Frontotemporal dementia?
Frontal & temporal atrophy
How can you differentiate frontotemporal dementia from AD?
SPECT scan
What is another name for frontotemporal dementia?
Pick’s disease
Which dementias can be diagnosed by GP?
Cognitive tests + CT - GP can diagnose AD or VD
CANNOT diagnose without CT
Which dementia Ps should be referred to the memory clinic?
If GP is uncertain
If rarer dementia (LBD or FT is suspected)
Anyone <65
Ps who demonstrate rapid decline
What does an advance directive do?
Allows P to specify how they want to be treated if their health deteriorates to such an extent that they can no longer make / communicate decisions
What are the two power of attorneys in England?
POA about health & welfare
POA about property and financial affairs
What are the 4 things to weight up under the Mental Capacity Act when determining capacity?
- Can P understand the information to make the decision?
- Can P retain the information long enough to make the decision?
- Can P weight up the information to make the decision?
- Can P communicate their decision?
What can carers carry with them in case they are admitted to hospital in an emergency?
A Carer’s Emergency Card in their wallet
Which 3 cholinesterase inhibitors are used in AD in the UK?
Donepezil
Galantamine
Rivastigmine (patch)
What are the contraindications for cholinesterase inhibitors?
Cause bradycardia - therefore heart, asthma, COPD or peptic ulcers
Ps on Amitriptyline, Risperidone, Ipratroprium bromide
Which drugs are anticholinergic?
Amitriptyline
Ipratroprium bromide
Risperidone
What is capacity?
Ability to use and understand information to make a decision and communicate any decision made.
When should capacity be assessed?
At the time that consent is required (it can fluctuate over time)
What happens if you do not have capacity and you have not made an advance directive or formally appointed anyone to make decisions for you?
Healthcare professionals have to act in your best interests
Is irrationality the same as lacking capacity?
No - provided a P has capacity to make the decision, it doesnt matter whether it is a rational decision or not
How are best interest decisions made?
- Can you wait for P to regain capacity?
- Involve P as much as possible
- Identify issues the P would take into account themselves (e.g. religious / moral beliefs)
Who can be appointed if there is noone suitable to make medical treatment decisions?
Independent Mental Capacity Advocate
Where do disputes regarding best interests go?
Court of Protection
Which situations must always be referred to the Court of Protection?
- Sterilisation (for contraceptive purposes)
- Donation or organs/tissue
- Withdrawal of nutrition and hydration from P in PVS or min conscious
What factors can affect a P’s capacity?
Shock
Panic
Extreme tiredness
Medications
Alcohol
What age are Ps presumed to have sufficient capacity?
16+
What happens if P is under 16?
Capacity is assessed to determine whether they have enough intelligence, competence & understanding to fully appreciate their treatment = Gillick competence
Who has parental responsibility?
Child’s mother
Child’s father (if married to mother or on the birth certificate)
Person with residence order for the child
Local authority designated to care for the child
Local authority or person with emergency protection order for the child
When can a parent’s refusal of treatment be overruled?
If court deems it in the best interests of the child
When can treatment proceed without consent?
When it is vital and where awaiting parental consent / court ruling would place the child at risk.
When can refusal of treatment by a child P be overruled by Court of Protection?
When it may lead to their death or severe permanent injury
Which is the most common dementia?
Alzheimer’s
What are the RF for Alzheimer’s?
Age
Caucasian ethnicity
Family history
What aspects of cognition to Alzheimer’s Ps have?
Memory issues = normally first symtom
Orientation problems
Visuospatial (judging distances and navigation)
Speech
Problem solving & decision making
What are the risk factors for vascular dementia?
CVD - inc obesity, hyperlipidaemia, diabetes, HT, smoking, coronary artery disease, AF, stroke or TIA.
What are Lewy bodies?
Abnormal protein deposits in the neurons.
What features of dementia suggest LBD?
Visual hallucinations
Spontaneous fluctuations in cognition
Parkinsonism (tremor, slow movement, rigidity)
What is a decline in cognitive function greater than expected for a healthy person of that age, but that does not meet the definition of dementia, known as?
Mild cognitive impairment (MCI)
How does MCI differ from dementia in terms of progression?
Dementia is a progressive disease - MCI is not necessarily progressive.
What % of Ps progress from MCI to dementia?
10% each year
Is MCI treatable?
If it is caused by a treatable underlying condition - may be possible to reduce or reverse the symptoms of MCI
How does MCI differ from dementia in terms of symptoms?
Share many symptoms - however MCI is typically less severe and may affect fewer cognitive domains
How does MCI differ from dementia in terms of daily living?
MCI - can typically still manage day-to-day tasks independently (may need help with complex or unfamiliar tasks)
Dementia - Ps have trouble with everyday tasks
Name three types of delirium.
Hyperactive
Hypoactive
Mixed state (hypo & hyper periods)
What are the risk factors for delirium?
Recent surgery
Narcotic medications
Underlying disease inc dementia, constipation, pneumonia, UTI
Chronic fatugue
How can you prevent delirium?
Orientation
Comfortable Ps
Reduce extra noise and stimulation
Glasses, hearing aids on
Good daily routine - food, water, toilet
Keep mobile
Maintain healthy sleep
Try to avoid opiate meds
Which medications increase the chances of delirium?
Opiods
Hypnotivs
Those which increase anticholinergic burden
How is delirium linked to falls?
Ps with delirium are x6 likely to fall
What is the name of specialist dementia nurses?
Admiral nurses
Which is the NMDA antagonist licensed for used in AD?
Memantine
What is the triangle of care?
Involving the carer in the patient’s treatment as much as possible
What is a general term for a patient making healthcare decisions and planning for the future?
Advanced Care Planning
What is the name of the legal tool where P appoints one or more people to make decisions for them, if they no longer have capacity?
Lasting Power of Attorney
What is the legal document where a P can record decisions about future healthcare when they lack capacity?
Advanced Decision
What is the document where a P sets out preferences and priorities about their health care for the future - but is NOT legally binding?
Advanced Statement
Which document contains guidance for healthcare staff on previous clinical discussions and decisions, should a P lack capacity or be unable to communictae?
Treatment Escalation Plans
