Dementia

Question 1

What is pseudodementia and what is its main distinguishing feature?

Answer 1

Severe depression mimicking dementia - key differentiator is global memory loss rather than short-term memory loss

Question 2

What are the factors suggesting depression over dementia?

Answer 2

Short history, rapid onset
Biological symptoms (weight loss, sleep disturbance)
Patient worried about poor memory
Global memory loss (instead of recent memory loss)
Reluctant to take tests and disappointed with results
Mini-mental test score can be variable but often normal

Question 3

What are the 6 cognitive domains that decline is seen in dementia?

Answer 3

Learning and Memory
Language
Executive function
Complex attention
Perceptual-motor
Social cognition

Question 4

What are the 3 conditions for cognitive impairment to be specifically dementia?

Answer 4

Cognitive deficits interfere with independent everyday activities
Cognitive deficits do not occur in the context of delirium
Cognitive deficits are not better explained by another mental disorder (e.g. depression, psychosis)

Question 5

What are the 5 types of dementia?

Answer 5

(most common to least common)
Alzheimers 
Lewy body
Vascular
Frontotemporal
Others (Parkinson's, Huntington's) or mixed dementia

Question 6

What are the 4 key sections of a dementia history?

Answer 6

Timeline (gradual, progressive vs stepwise vs acute)
Ability to do ADLs/finances/manage house
Language skills
Visuospatial

Question 7

What are the 5 cognitive tests you can do at the bedside for dementia

Answer 7

AMTS (abbreviated mental test score)
MMSE (mini mental state exam)
MOCA (montreal cognitive assessment)
ACE (addenbrooke’s cognitive examination)
RUDAS (rowland universal dementia assessment scale)

Question 8

What is the maximum score for the AMTS and what threshold indicates cognitive impairment?

Answer 8

10

below 7

Question 9

What differentials would you have in a potential case of dementia?

Answer 9

Delirium

Question 10

What are the distinguishing features of delirium vs dementia?

Answer 10

Rapid onset
Acute medical cause
Clouding of consciousness
Visual perceptual disturbances
Risk factors - age >65, cognitive impairment, current hip fracture, severe illness

Question 11

What are the features of vascular dementia?

Answer 11

Acute onset/stepwise progressive (can be insidious)
Cardiovascular risk factors (TIA/CVA/hypertension/diabetes/hypercholesterolaemia)
Cognitive symptoms - impaired attention and frontal features
Fluctuations in performance
Night time confusion
Personality and insight relatively preserved
Potential focal neurological signs
Emotional lability, pseudobulbar palsy, gait disturbance, incontinence

Question 12

What are the features of Lewy-body dementia?

Answer 12

Lewy bodies present
Visual hallucinations
REM behavioural sleep disorder
Autonomic dysfunction (postural hypotension)
Neuroleptic sensitivity

Question 13

What is the difference in Lewy body distribution between lewy-body dementia and parkinson’s?

Answer 13

LBD - more widespread and involve cortical regions

Parkinson’s - confined to substantia nigra

Question 14

What are the features of fronto-temporal dementia?

Answer 14

Personality change
Loss of social awareness and insight
Disinhibition, impulsivity
Apathy, inertia, apontaneity
Mental rigidity, inflexibility
Personal neglect and declining self-care
Stereotypic behaviours and rituals
Change in eating habits and food preference
Loss of empathy and mentalising ability

Question 15

What other differentials that can be dementia?

Answer 15

Creutzfelt-Jakob Disease
Alcoholic dementia
Neurosyphilis
Normal pressure hydrocephalus
HIV
Vitamin deficiencies
Tumours
Huntington's

Question 16

What is the aim of investigations when suspecting dementia?

Answer 16

Main aim is to rule out reversible/acute causes
Potentially assess progression too (neuroimaging)
Memory clinic for MDT approach

Question 17

What does the memory clinic do for patients with dementia?

Answer 17

Assessment and diagnosis of dementia
Management of anti-dementia medication and BPSD (behavioural and psychiatric disorders in dementia)
Post-diagnostic support
Research for trials

Question 18

What is the main medication for Alzheimer’s dementia?

Answer 18

Cholinesterase inhibitors (AChEi) (donepezil, galantamine, rivastigmine)

Memantine (second-line) - non-competitive glutamate receptor antagonist

Question 19

What are the treatment guidelines for 3 main dementias?

Answer 19

Alzheimer’s - AChEi +/- memantine (mild to moderate), memantine (intolerant/refractory to AChEi) or severe disease
LBD
Frontotemporal - AChEi
Vascular - none, only start AChEi if co-morbid Alzheimer’s or LBD
Don’t stop treatment because of disease severity alone

Question 20

What is mild cognitive impairment?

Answer 20

Dementia-like syndrome but not severe enough to be classified as dementia

Question 21

What are the features of mild cognitive impairment syndrome?

Answer 21

Cognitively impaired but not having a significant effect on their daily life
Still able to function independently
Dementia-esque

Question 22

What are the 4 things a patient needs to do in able to demonstrate capacity?

Answer 22

Understand
Retain
Use/weigh
Communicate decision