Dementia

Question 1

Define Dementia

Answer 1

Chronic or progressive syndrome of brain disease leading to disturbance of multiple higher cortical functions

• including memory, orientation, comprehension, calculation, learning capacity, language and judgement
• sufficient to impair personal ADLs

Question 2

Risk factors for dementia

Answer 2

Age
Female
Genetics
Lifestyle - smoking, alcohol, obesity, cholesterol, hypertension, cerebrovascular disease
Psychosocial - no physical activity, depression

Question 3

Features of dementia

Answer 3

Timeline - who noticed decline, when, what differences
Collateral hx
Symptoms - memory, decision making, language, degree of insight
Current family support
Any recent changes or bereavement
Risks - wandering, cooking, driving, neglect, alcohol, smoking
Significant co-morbidities
Self care ability - managing finances

Question 4

Clinical cognitive assessment

Answer 4

Attention and orientation
o Alertness and cooperation
o Time, place, person
o Spell world backwards, months of the year backwards
Memory
Language
o Naming objects, comprehension, repetition, reading, writing
Executive and frontal lobe function
o Letter and category fluency (name as many words starting with P)
o Impulsivity
o Personality change
o Primitive reflexes 0 e.g. palmar-mental reflex
Apraxia
o Mimicking tasks (brush teeth, comb hair), hand gestures
Visuospatial ability
o Topographic disorientation, neglect
o Copy drawing of cube, clock face

Question 5

Ix for dementia

Answer 5

Physical exam
- other causes - infection
- focal neurology - vascular dementia
Bloods - U+Es, B12, folate, TFTs
ECG, CXR, EEG, MSU
Neuro-imaging
- CT/MRI - cerebral atrophy in late stages

Question 6

Mx of dementia

Answer 6

MDT – psychiatrist, GP, occupational therapist, support worker etc
Support – Alzheimer’s society, age UK
Psychological interventions – cognitive stimulation therapy, cognitive rehab
Comorbidities
o Vascular risk modification
o Avoid polypharmacy (anticholinergics, TCAs, antihistamines, opiates)
o Depression screen
Risk assessment - driving, carer strain
Future planning – follow up, power of attorney, will
Social care involvement
Legal framework – capacity, DOLS

Question 7

Define mild cognitive imapriment

Answer 7

Evidence of objective cognitive decline
Not an official diagnosis
10-10% conversion to dementia per year

Question 8

Pathophysiology of Alzheimer’s

Answer 8

Deposition of amyloid plaques and neurofibrillary tangles (tau proteins)

Question 9

Symptoms of Alzheimer’s

Answer 9

Short term memory loss
Problems with language - shrinking vocab
Disorientation
Mood swings
Apraxia with fine motor tasks

Question 10

Mx of Alzheimer’s

Answer 10

Diagnosed on hx, cognitive assessment and ruling out other disease
Mediations - acetylcholinesterase inhibitors, memantine

Question 11

Features of vascular dementia

Answer 11

Stepwise cognitive decline with progressive vascular occlusions
Symptoms mainly include cognitive decline and memory impairment
Some focal neurology maybe present
Brain imaging shows cerebrovascular disease

Question 12

Features of Lewy body dementia

Answer 12

Abnormal deposits of alpha-synuclein (Lewy bodies) in the brain
Symptoms of parkinsonism, impaired cognition, sleep disorders, visual hallucinations, fluctuations in attention, slowness of movement, mood changes
REM sleep behaviour disorder – acting out dreams due to loss of normal muscle paralysis during REM sleep
DLB – cognitive symptoms arise before or with Parkinson’s symptoms
PDD – Parkinson’s is well established before cognitive symptoms

Question 13

Features of frontotemporal dementia

Answer 13

Changes in behaviour, social conduct, impulsivity, loss of comprehension
MRI shows frontal and/or temporal lobe atrophy in later disease

Question 14

Core features of delirium

Answer 14

Cognitive impairment
Rapid onset
Fluctuating severity

Question 15

Risk factors for delirium

Answer 15

Over 65s
Dementia
Polypharmacy
Functional/sensory impairment
Malnutrition

Question 16

Precipitating factors for delirium

Answer 16

Acute illness
Drugs
Electrolyte disturbance
New environment
Constipation
Dehydration
Post-op period

Question 17

Types of delirium

Answer 17

o Hyperactive – increased fall risk, may require antipsychotic (avoid if possible)
o Hypoactive – often mistaken for depression or missed
o Mixed – fluctuating

Question 18

Diagnosis of delirium

Answer 18

Confusion Assessment
- delirium should be suspected with the presence of Features 1 and 2 and 3/4
1) Acute Onset and Fluctuating Course – collateral history required for baseline
2) Inattention
3) Disorganized Thinking
4) Altered Level of Consciousness
4AT tool – score out of 12
o Alertness – normal (0) abnormal, markedly drowsy, agitated, hyperactive (4)
o AMT – age, D.O.B., place, current year (0 – no mistakes, 1 – 1 mistake, 2 – 2 or more mistakes)
o Attention – months of the year backwards (0 – 7 or more months, 1 – doesn’t reach 7 months, 2 – untestable)
o Acute change/fluctuating course (0 – no, 4 – yes)

Question 19

Prevention and mx of delirum

Answer 19

Minimise environmental disruption
Good nursing care
Medication review
Ensure availability of glasses and hearing aid if needed
Orientation clock
Side room
Medication last resort – low dose lorazepam/haloperidol

Question 20

Complications of dementia

Answer 20

Increased mortality at 6 months

Risk of accelerated cognitive decline

Question 21

Define cognitive impairment

Answer 21

Disturbance of higher cortical functions including memory, thinking, judgement, language, perception and awareness

Question 22

Confusion Assessment Method for Delirium

Answer 22

Acute onset and fluctuating course
Inattention
Disorganised thinking
Altered level of consioucsless