13. Cognitive Impairment

Question 1

What are the features of dementia?

Answer 1

Amnesia
Aphasia
Apraxia
Agnosia

Question 2

What are the types of dementia?

Answer 2

Alzheimer’s disease
Vascular
Lewy body
Frontotemporal

Question 3

What is the differential for dementia?

Answer 3

Space occupying lesion in the brain
Chronic infection
Vasculitis
Heavy metal
Alcohol
Prolonged delirium
Depression

Question 4

What does vascular dementia depend on?

Answer 4

Cumulative effects of many small strokes

Whether a functional area was involved in the stroke eg. Broca’s

Question 5

How is dementia diagnosed?

Answer 5

History from collateral
Examination to rule out focal neuropathy
Imaging to rule out space occupying lesion
Bedside cognitive assessment
Exclude mimics

Question 6

Which tests may be used in a bedside cognitive assessment?

Answer 6

MMSE
MOCA
RUDAS
ACE 3

Question 7

What are the differences between the bedside cognitive assessment tests?

Answer 7

MMSE has a strong focus on memory
MOCA assesses frontal lobe function
Both require the patient to have a certain level of education so this is overcome with RUDAS

Question 8

What questions are important to ask when taking a history for dementia?

Answer 8

What daily activities have been affected?
Rapid forgetting
Word finding difficulties
Safety issues: falls, getting lost
Withdrawal from social activity and apathy
Weight loss
Personality changes

Question 9

What investigations should be done into dementia?

Answer 9

MRI of brain (rule out, medial temporal lobe atrophy in alzheimers)
B12/folate, TFTs and routine bloods
ECG (baseline)
PET scan shows how much glucose used by different parts of the brain
LP (amyloid:tau)

Question 10

What is the pharmacological treatment of dementia?

Answer 10

Remove meds that impair cognition: anti-cholinergics and opiates
Cholinesterase inhibitors stop ACh breakdown
NMDA receptor antagonist
Avoid alcohol, control BP and comorbidities

Question 11

Name 3 cholinesterase inhibitors

Answer 11

Donepezil
Rivastigmine
Galantamine

Question 12

Name an NMDA receptor antagonist

Answer 12

Memantine

Question 13

What factors affect the prognosis of a patient with alzheimers?

Answer 13

Weight loss
Functional loss
recurrent infections
swallow impairment

Question 14

What are the risks for vascular dementia?

Answer 14

Diabetes
Hypertension
High cholesterol, obesity
Smoking
A. fib

Question 15

What are the features of Lewy body dementia?

Answer 15

Visual hallucinations
Fluctuating cognition
Parkinsonism

Question 16

What is delirium?

Answer 16

Mental confusion when medically unwell
Fluctuates with time of day
Attention is mainly affected

Question 17

Does hyper or hypo active delirium have the best prognosis?

Answer 17

Hyperactive as it is more easily noticed

Question 18

What are the features of hyperactive delirium?

Answer 18

Visual hallucinations
Hyper alert
Distractable

Question 19

What are the features of hypoactive delirium?

Answer 19

Apathy or impaired interaction

Question 20

What are the risk factors for delirium?

Answer 20

Age
Dementia
Parkinson's disease
Stroke
Frailty
Liver disease
Polypharmacy
Alcoholic

Question 21

What is the treatment for delirium?

Answer 21

Treat underlying condition
Stop anti-cholinergics
Manage acute safety issues
Single room with stability of care