Dementia Flashcards
(53 cards)
1
Q
What are the types of dementia?
A
- Alzheimer’s dementia
- Vascular dementia
- Lewy Body Dementia (+ Parkinson’s dementia)
- Fronto-temporal dementia
- Pseudo-dementia - secondary to depression
- Other types: Korsakoff’s, Huntington’s
2
Q
What are differentials of dementia?
A
- Traumatic brain injury - acute onset of deficits, more focal, well defined and less progressive
- Huntington’s - progressive cognitive deficits, choreic movements, FH + early onset
- Normal pressure hydrocephalus - additional signs such as magnetic gait and incontinence
3
Q
How is mild dementia classified?
A
- A degree of memory loss interfering with everyday activities
- Difficulty learning of new material
- Difficulty in registering new information
- MMSE 20-24
- Able to manage independent life
4
Q
How is moderate dementia classified?
A
- A degree of memory loss which represents a serious handicap to independent living
- Only very familiar material is retained
- New information is retained only occasionally and very briefly
- MMSE 10-20
- Need help with ADLs
5
Q
How is severe dementia classified?
A
- A degree of memory loss characterised by complete inability to retain information
- Only fragments of previously learned info remain
- Unable to learn new information
- MMSE <10
- Completely dependent for ADLs
6
Q
What are the additional symptoms for dementia?
A
- Decline in emotional control or motivation - emotional lability, irritability
- Apathy
- Coarsening of social behaviour
7
Q
What is the exclusion criteria for dementia?
A
- Absence of delirium
- Symptoms present for at least 6 months
- No clouding of consciousness
- Should be irreversible
8
Q
What are the investigations for dementia?
A
- Urinalysis: no WBC, proteins or blood (check for UTI which could be causing delirium and contributing to confusion)
- Bloods (part of confusion screen to check for inflammatory markers - delirium)
- CT or MRI brain scan (help detect haemorrhages/clots, space-occupying lesions, areas of lobar atrophy)
9
Q
What test is used when other differentials have been ruled out for dementia?
A
ACE III (Addenbrook’s Cognitive Examination) which allows a comprehensive assessment of various aspects of cognition:
- Memory
- Attention
- Fluency
- Visuospatial skills
- Language
A score below 82 is highly suggestive of dementia
10
Q
What are some other cognitive tests for dementia and depression in dementia?
A
- MOCA
- MMSE
- Frontal assessment battery
Depression:
- Hospital Anxiety and Depression Score
- Beck’s Depression Inventory
11
Q
What are the instruments to assess functional and psychological symptoms of dementia?
A
- Functional assessment: functional activities questionnaire, activities of daily living questionnaire, Bristol functional assessment
- Psychological assessment: neuropsychiatric inventory (NPI)
- Care giver strain: MBRC caregiver strain instrument
12
Q
What is the clinical presentation of dementia?
A
- Aphasia (language impairment)
- Agnosia (inability to interpret sensations/recognise things)
- Apraxia (difficulty performing motor functions)
- Lexical anomia (knowing how to use an object but unable to name it)
- Decrease of motivation and drive - apathy and lack of spontaneity
- Rate of progression - slow
- Investigation: CT/MRI brain - cerebral atrophy, particularly if shown to increase over time
13
Q
Describe the features of Alzheimer’s Dementia
A
- Difficulty focusing
- Poor memory
- Visual hallucinations
- Disorganised speech
- Depression
- Early onset - autosomal dominant (50% chance), Down’s syndrome patients are at increased risk
14
Q
Describe the features of vascular dementia
A
- Single infarct dementia - dependent on area
- Multi-infarct dementia
- Subcortical dementia - small vessel disease: personality changes, slowness of thought, affective symptoms, executive skills (planning or organising, making decisions or solving problems)
- Stepwise progression
15
Q
What are the symptoms of temporal lobe impairment?
A
- Difficulty understanding words
- Short term memory
- Semantic memory (factual knowledge)
- Inability to categorise object
- Identification and verbalisation
- Visuo-spatial neglect
- Agnosia
- Dysphasia
16
Q
What are the symptoms of parietal lobe impairment?
A
- Anomia (object identification)
- Dysgraphia (difficulty writing/drawing)
- Agnosia
- L-R disorientation
- Dyscalculia
- Apraxia
- Visuo-spatial neglect e.g. clock, cube
- Tactile perception
17
Q
What are the symptoms of frontal lobe impairment?
A
- Loss of spontaneity
- Loss of cognitive flexibility
- Conceptualisation
- Poor concentration/sensitivity to interference
- Poor impulse control
- Difficulty with problem solving
- Expressed language
- Behaviour
18
Q
What are the features of Lewy Body Dementia?
A
- Sleep disturbances - nightmares, aggressive, movements, disturbed sleep cycle, REM sleep behaviour disorder
- Cognitive fluctuations - hallucinations, delirium etc that comes and goes
- Features of PD
- Autonomic dysregulation
- Variable cognition
- Psychotropic medication hypersensitivity
- Urinary incontinence
- Cognition (visuo-spatial difficulties, language impairment, dyspraxia)
- Hyposmia (reduced smell)
19
Q
What is REM sleep behaviour disorder?
A
- Not confused upon waking up
- Exhibit dream enacted behaviours
- Does not cause excessive daytime sleepiness
- Clonazepam is effective for this
20
Q
What is the difference between LBD and PDD?
A
- LBD - memory difficulties and psychotic symptoms develop 1 year before motor difficulties (initially similar to AD, then develop motor symptoms)
- PDD - memory difficulties and psychotic symptoms develop 1 year after motor difficulties
21
Q
How do you diagnose LBD?
A
- Progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational functions or with usual daily activities
- Prominent or persistent memory impairment may not occur in the early stages but it usually evident with progression
- Deficits on tests of attention, executive function and visuoperceptual ability may be especially prominent and occur early
22
Q
What are the 3 types of Fronto-Temporal dementia?
A
- Pick’s disease
- Primary progressive aphasia - non-fluent aphasia
- Semantic dementia - loss of semantic memory, most often in verbal domain e.g. loss of word meaning
23
Q
What are the symptoms of the behavioural variant of FTD?
A
- Disinhibition
- Apathy (but not sad)
- Lose empathy
- Repetitive, compulsive or ritualised behaviours
- Changes in eating habits
- Executive function difficulties
24
Q
What is dysexecutive function?
A
- Dysfunction in frontal part of the brain - can present with cognitive, behavioural or emotional symptoms
- Causes: brain tumour, stroke, head injury, FTD, AD, vascular dementia, schizophrenia, personality disorder and ADHD
- Assess with FAB
25
Describe acetylcholinesterase inhibitors for dementia
- Cholinesterase inhibitors - donezapil, galantamine
- Butyryl-cholinesterase inhibitors - rivastigmine
- Rivastigmine better choice for LBD + PD (oral or patch)
- If moderate to severe dementia use galantamine
- No medication can help with vascular dementia
26
Describe glutamate receptor antagonists for dementia
- NMDA receptor blockers - memantine (generally used only if AChE doesn’t work)
- Glutamate thought to cause toxicity due to hyperexcitation of neurones
- Memantine inhibits neutron excitation by inhibiting glutamate receptors
27
What is the pharmacological treatment for vascular dementia?
- Vascular risk prevention
- Aspirin
- Statins
28
What is the pharmacological treatment for LBD?
Rivastigmine
- If there is swallowing difficulties are present, can give a patch
- Increased risk of neuroleptic sensitivity - if necessary quetiapine is best
29
What are the interactions of dementia medications?
- Memantine renally excreted so avoid in renal impairment or if taking medications that are renally excreted
- Donezapil and galantamine metabolised by liver enzymes (CD26 + C3A4). Enzyme inducers e.g. carbamazepine may reduce levels of these.
- ACh drugs decrease effect of AChE-I
- Cholinomimetrics and AChE-I increase each other’s effects
- Beta blockers and AChE-I increase each other’s effects
- Memantine and glutamate receptor antagonists (ketamine, amantadine, dextromethorphan) increase each other’s effects and risk of pharmacotoxic psychosis
30
What are the side effects of AChE-I?
- Bradycardia
31
What tests should be done before starting AChE-I and NMDA receptor antagonists?
- ECG - assess HR, presence of conduction abnormalities and QTc interval
- Cholinesterase inhibitors are contraindicated for patients with bradykinesia, LBBB + prolonged QTc interval
- U+E - memantine can cause acute renal failure
32
What are the behavioural and psychological symptoms of dementia?
- Hallucinations
- Delusions
- Anxiety
- Marked agitation
- Associated aggressive behaviour
- Behaviour changes: aggression, agitation, wandering, hoarding, sexual disinhibition, apathy and disruptive vocal activity e.g. shouting
33
What are the pharmacological choices of treatment for dementia?
1. AChE-I
2. Memantine
3. Mood stabiliser- sodium valproate/pregabalin
4. Antidepressant - trazodone/mirtazapine/sertraline
5. Antipsychotics - last resort, preferably quetiapine
34
When would you offer antipsychotics to dementia patients?
- At risk of harming themselves or others OR
| - Experiencing agitation, hallucinations or delusion that are causing them severe distress
35
What are the psychological managements for dementia?
- Cognitive stimulation therapy
- CBT
- Reminiscence therapy
- Aromatherapy
- Sensory stimulation
- Music therapy
36
What physiotherapy and OT interventions can be done for dementia patients?
Therapy staff working with the memory assessment team will complete a community risk assessment, checking for things like:
- Wandering
- Falls
- Fire
- Self neglect
37
What are the risk reduction strategies for dementia patients?
- Door sensors and locators
- Telemonitoring
- Adaptations at entrance + steps inside house
- Contact fire brigade - assess and install fire retardant equipment and furnishings, can cut off gas to oven
- Food + fluid charts, weight charts
- Nutritional supplements via GP
- Carers
38
What can a health and welfare LPA make decisions about?
- Your daily routine e.g. washing, dressing, earring
- Medical care
- Moving into care home
- Life-sustaining treatment
Can only be used when unable to make own decisions.
39
What can a property and financial LPA make decisions about?
- Managing a bank or building society account
- Paying bills
- Collecting benefits or a pension
- Selling your home
Can be used as soon as it’s registered, with your permission
40
What is advanced care planning?
- Should be discussed post diagnosis with patient and carer as would empower them to play a part in their future care should they lose capacity
- Includes formal documentation of decisions to do with resuscitation, preferred place of care, death
- The topic of a will should be broached with the patient as it is good practice to arrange for this when so-called testamentary capacity is present
41
What can happen to your attorney to end your LPA?
- Loses mental capacity
- Divorces you or ends your civil partnership if they’re your husband, wife or partner
- Becomes bankrupt or they’re subject to Debt Relief Order (DRO) - if they’re property snd financial affairs LPA
- Is removed by Court of Protection
- Dies
42
What are the mandatory parts of dementia screening in an individual with memory loss?
- History taking
- Cognitive testing
- Neuropsychological assessments can highlight cognitive deficit
- Imaging is never diagnostic but could help settle the diagnosis and show cerebrovascular issues
- SPECT to differentiate between AD and FTD
43
Describe the progression of Alzheimer's Dementia
- Gradual decline in cognitive impairment
- More common in women
- Hallucinations may occur, but in late stages
- Decrease in facial expression develops later in the disease
- Physical deterioration usually at late stage
44
Describe the progression of LBD
- Face shows very little emotion from early in disease process
- More common in men
- Visual hallucinations occur early
- Fluctuating cognitive impairment
- Early problems with balance
45
What are the core features of LBD?
- Fluctuating cognition (mimics delirium)
- Recurrent well-formed visual hallucinations
- Spontaneous features of Parkinsonism
46
What are the suggestive features of LBD?
- REM sleep behaviour disorder
- Severe neuroleptic sensitivity
- Low dopamine transporter uptake in basal ganglia on SPECT/PET
47
What is the pathology of LBD?
- Lewy bodies - protein deposits inside neurons
- Cholinergic neurons - acetylcholine
- Substantia nigra - initiate movement/motor function (dopaminergic)
- Alpha synuclein gets misfolded within the neurons and aggregates to form Lewy bodies
48
What are the key features of dementia?
- Decline in memory
- Decline in other cognitive domains (planning, organizing, thinking, judgement, language, orientation, recognition)
- WITH functional impairments e.g. self-care, struggling to find the words for things
49
What are the diagnostic criteria for dementia?
- Cognitive impairment
- Clouding of consciousness i.e. reduced clarity of awareness of the environment, with reduced ability to focus, sustain or shift attention
- Psychomotor disturbances - usually hyper- or hypo-activity
- Disturbance of sleep or sleep-wake cycle
- Caused by underlying cerebral or systemic disease
50
What is mild cognitive impairment?
- A disorder in cognitive function for most of the time for at least 2 weeks
- The disorder is exemplified by difficulties in any of the following areas: new learning, memory, concentration, thinking, language
- Abnormality or decline in performance on neuropsychological tests (or quantified cognitive assessments)
- BUT not sufficient to meet dementia criteria - no major impact in functioning
- Patients with MCI at increased risk of going on to develop dementia
51
What are the features of FTD?
- Often younger age onset
- Slow onset with steady deterioration
- Predominance of frontal lobe involvement evidenced by 2 or more of the following: emotional blunting, coarsening of social behaviour, disinhibition, apathy or restlessness and aphasia
- Relative preservation
52
What are the risks in older adult care?
```
Suicide/SH, Self-neglect, Susceptibility to illness
Abuse, Aggression
Wandering
Falls, Fire
Exploitation
Non-compliance with medication
Driving, Drugs and alcohol
```
53
What is assessed in the Frontal Assessment Battery?
- Similarities
- Lexical fluency
- Motor series 'Luria test'
- Conflicting instructions
- Go-no-go
- Prehension behaviour
