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Neuroscience > 9.1 Dementia and Delirium > Flashcards

9.1 Dementia and Delirium Flashcards

1
Q

Describe the onset of Dementia

A

Dementia is a chronic, progressive disorder with insidious onset (wont know for a long time that they have it)

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2
Q

What are the 2 broad categories of symptoms in dementia?

A
  1. Cognitive symptoms

2. Non-cognitive symptoms

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3
Q

What are the cognitive symptoms in dementia?

A 
Impaired memory (temporal lobe involvement)
Impaired orientation (temporal lobe involvement)
Impaired learning capacity (temporal lobe involvement)
Impaired judgement (frontal lobe involvement)
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4
Q

What are the non-cognitive symptoms in dementia?

A 
Behaviour symptoms (agitation, aggression, wandering, sexual disinhibition)
Depression and anxiety
Psychotic symptoms (visual and auditory hallucinations; persecutory delusions)
Sleep symptoms (insomnia, daytime drowsiness due to decreased cortical activity)
(Hallucinations = false perceptions)
(Delusions = false beliefs)
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5
Q

How is dementia diagnosed?

A

Dementia is a diagnosis of exclusion - want to exclude organic causes of cognitive decline:
- Hypothyroidism
- Hypercalcaemia
- B12 deficiency
- Normal pressure hydrocephalus (abnormal gait, incontinence, confusion)
Also exclude delirium

Look for features of progressive cognitive decline, impairment of activities of daily living in a patient with a normal conscious level.

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6
Q

Comment on the consciousness of people with dementia and delirium.

A 
Dementia = normal conscious level
Delirium = conscious level is diminished with acute cognitive decline
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7
Q

What are the Macroscopic features seen in Alzheimer’s disease?

A 
Global cortical atrophy
Sulcal widening (due to gyri atrophy)
Enlarged ventricles (primarily lateral and third affected)
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8
Q

What are the Microscopic features seen in Alzheimer’s disease?

A

Plaques = composed of amyloid beta (APP > Amyloid Beta via beta + gamma secretase)

Tangles = Hyperphosphorylated Tau - cannot stabilise microtubules = neuronal death

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9
Q

Which neurones are predominantly affected in Alzheimer’s disease?

A

Cholinergic (treatments target this)
Noradrenergic
Serotonergic
Those expressing Somatostatin

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10
Q

What is Vascular dementia?

A

Cognitive impairment caused by cerebrovascular disease (multiple small strokes)

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11
Q

What are the risk factors for vascular dementia?

A 
Previous stroke/MI
Hypertension
Hypercholesterolaemia
Diabetes
Smoking
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12
Q

What is the presentation of vascular dementia like?

A

The presentation is stepwise (improvements seen then get worse), maybe with focal neurological features

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13
Q

How do we distinguish Lewy Body Dementia from Parkinson’s disease?

A

Dementia then movement disorder = Lewy body dementia

Movement disorder then dementia = Parkinson’s disease

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14
Q

What is the pathology behind Lewy Body Dementia?

A

Aggregation of alpha synuclein which form spherical intracytoplasmic inclusions. Main deposits are found across the brain:

  • Substantia nigra (think parkinsons)
  • Temporal lobe
  • Frontal lobe
  • Cingulate gyrus (just above corpus callosum - involved in motivation?)
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15
Q

What imaging techniques can be used in Lewy Body Dementia?

A

Can use antibodies to target the alpha-synuclein therefore labelling the alpha synuclein in the brain. The labelled alpha synuclein deposits can be seen using an MRI.

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16
Q

What is the presentation of Lewy Body Dementia?

A

Fluctuating cognition and alertness
Vivid visual hallucinations
Parkinsonian features (may cause repeated falls)

17
Q

Why are antipsychotics (dopamine antagonists) not prescribed to those with Lewy Body Dementia?

A

Can cause neuroleptic malignant syndrome - a psychiatric emergency

18
Q

What is the presentation of neuroleptic malignant syndrome?

A 
mnemonic = FEVER 
F = Fever
E = Encephalopathy (confusion)
V = Vital signs instability (tachycardia, tachypnoea (v. sensitive sign), fluctuating BP)
E = Elevated creatine phosphokinase
R = Rigidity (caused by dopamine antagonism)
19
Q

What is Frontotemporal dementia?

A

Also known as Pick’s dementia - due to picks deposits
It is the second most common cause of early onset dementia
Frontal and temporal lobe atrophy is seen

20
Q

What are the symptoms of Frontotemporal dementia?

A

Symptoms mostly due to frontal lobe dysfunction:

  • Behavioural disinhibition
  • Inappropriate social behaviour
  • Loss of motivation without depression (caused by damage to anterior cingulate cortex)
  • Repetivie/ritualistic behaviours (repeating what people are saying)
  • Expressive aphasia
21
Q

What is the pathological process behind AIDS dementia?

A

Entry of HIV infected macrophages into the brain is thought to lead to indirect damage to neurones.

22
Q

What is the onset of AIDS dementia like?

A

Insidious onset but rapid progression once established

23
Q

What are the clinical features of AIDS dementia?

A

Related to global damage but also some manifestations of cerebellar involvement:

  • Cognitive impairment
  • Psychomotor retardation (slow thoughts and movements)
  • Tremor
  • Ataxia
  • Dysarthria - slurred speech
  • Incontinence
24
Q

What is the management of demenita?

A

Use of the bio-psycho-social model

  • Drugs = acetylcholinesterase inhibitors and NMDA antagonists
  • Psychological = pretty much none available
  • Social = Sensitive explanation of diagnosis, give results of any special investigations, inform patient they can no longer drive (need to inform DVLA), sort finances (will, power of attorney), day care and respite care, nursing home placement
25
Q

Give the name of a acetylcholinesterase inhibitor and its use…

A

Donepezil,
Rivastigimine,
Galantamine.
In dementia there is less acetylcholine neurotransmitter available therefore want to reduce its breakdown. Modest efficacy for mild to moderate Alzheimer’s disease.

26
Q

Give the name of a NMDA antagonist and its use…

A

Memantine

Useful for treating agitation - reduces overstimulation of glutamate activity.

27
Q

What is Delirium?

A

Sometimes called ‘acute confusional state’. Often reversible, due to organic cause.
Associated with a variety of insults to the brain which may cause neuronal damage and inflammation.

28
Q

How is dementia related to delirium?

A

Dementia can predispose to episodes of delirium

29
Q

What are the features of delirium?

A

Rapid onset of confusion
Clouded consciousness (may be drowsy)
Fluctuating course (e.g. worse in morning, better in afternoon)
Maybe transient visual hallucinations
Often exaggerated emotional responses (e.g. aggression)

30
Q

What are the 2 types of Delirium?

A
  1. Hypoactive

2. Hyperactive

31
Q

How do those with Hypoactive Delirium present?

A

Withdrawn (dont want to talk, eat etc…)
Quiet
Sleepy (usually awake all night so tired in the day)

Due to this presentation they are more likely to be missed / confused with something else.

32
Q

How do those with Hyperactive Delirium present?

A

Restless
Agitated
Aggressive

33
Q

How may people with Delirium present generally?

A

Mood may fluctuate
Persecutory delusions
Symptoms worse at the start and end of the day (due to cortisol levels??)

34
Q

What are some causes of Delirium?

A

Nutritional - vitamin deficiencies
Intracranial - strokes, TIA, epilepsy, infection…
Extracranial infections - UTI, pneumonia
Iatrogenic - infections (sepsis), drugs
Alcohol - intoxication, withdrawal (delirium tremens - caused by changes in GABA and NMDA receptors)
Endocrine - Thyroid, Pancreas
Metabolic - Hypoxia, Renal (electrolytes), Hepatic

35
Q

What is the management of Delirium?

A

Find and treat the underlying cause

36
Q

What is the prognosis of delirium?

A

Increased risk of dementia
Associated with mortality (toxic insult to brain)
Patients often have lengthy hospital stays and have a high risk of re-admission

Neuroscience (13 decks)

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