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Flashcards in Dementia Deck (82):
1

Definition (4)

Acquired
General
Progressive impairment of cognitive function
Impaired activity of daily living

2

Cognitive functions impaired

Memory
Recall
Orientation
Language
Abstraction

3

Prevalence at 60yo and doubling time

1% at 60, doubles every 5 years

4

Prevalence at 85yo

30-50%

5

Categories of dementia (Vitamin D Vest)

Primary degenerative
Vascular
Infectious
Trauma
Rheumatological
Neoplastic
Vitamin, Intracranial tumor, Trauma, Anoxia, Metabolic, Infection, NPH, Degenerative, Huntingtons, Vascular, Endocrine, SOL, Toxic

6

Reversible causes of dementia

Alcohol (withdrawal, intoxication)
Medications (benzodiazepines, anticholinergics)
Heavy metal toxicity
Hepatic/renal failure
Wilsons
Vit B12
Hypo/hyperglycemia
Cortisol
Thyroid
Normal pressure encephalus
Depression
Intracranial tumor
Subdural hematoma

7

Common differentials

MCI
Delirium
Depression
Alzheimers
Vascular dementia
Lewy body dementia

8

Uncommon differentials

Amnesia
Aphasia
FTD
Parkinsons
Huntingtons
Brain tumors
Cushings
Hypothyroid
+PTH
SLE
Syphillis
Wilsons
TB
Lyme disease
CJD

9

Primary neurodegenerative causes (4) with key clinical features

Alzheimers- Anterograde amnesia, aphasia, apraxia, agnosia, disturbance in executive function
Dementia with lewy body- visual halluncinations, parkinsonism, fluctuating cognition
Frontotemporal dementia- behavioural / language presentation
Huntingtons disease- chorea

10

Vascular causes of dementia with key clinical features

Multi-infarct dementia->acute onset, stepwise, focal neurological signs, dysexecutive
Vasculitis->systemic S&S of vasculitis

11

Infectious causes (6) with key clinical features

HIV
Syphillis->ataxia, myoclonu, tabes dorsalis
Chronic encephalitis
Chronic meningitis->F,H,N, meningismus, localising neurological defects
Abscess->+ICP, localising neuro signs
CJD->rapidly progressive, myoclonus

12

Traumatic causes

DAI, subdural, epidural hematoma->history, +ICP, papilloedema, localising neuro signs

13

Neoplastic causes

Mass effect, edema, hemorrhage, seizure->+ICP, localising signs, systemic symptoms of cancer

14

Emergency consideration for suspected dementia

Delirium

15

Initial test to order when delirium not ruled out

FBC, UEC, fasting blood glucose, urinalysis MCS, UDS

16

Importance of herpes simplex

Most common cause of sporadic encephalitis

17

How does HSV encephalitis present

Acute febrile illness
Altered mental status
Headache, seizure, focal neurology

18

What to give in all cases of suspected HSV encephalitis

Aciclovir

19

History

Psychiatric evaluation
Premorbid function
Geriatric giants
Changes in cognition, function, personality, language, skills, behaviour
Abrupt, step wise, gradual->vascular
Acute->infection, metabolic, lesion, medication, stroke, hydrocephalus
Rapid decline->delirium
Gait abnormalities, urinary incontinence
Change in ability to manage ADLs, and instrumental activities
Family history
Drug and alcohol
Past medical history
Stroke risk factors->hx, TIA, hypertension, cholesterol, diabetes, CAD, AF
Parkinson's disease inquiry
Transient neurological->gait, incontinence

20

What are the activities of daily living (6)

Eating
Bathing
Dressing
Toileting
Transferring
Continence

21

What are the instrumental activities of daily living (8)

Housework
Cooking
Cleaning
Shopping
Finances
Telephone
Transport

22

Cognitive assessment tool and score when indicates an abnormal result

MMSE

23

Components of MMSE

Orientation
Registration
Attention and calculation
Recall
Language

24

Components of language assessment (6)

Name two objects
Repeat "no ifs, ands, or buts"
Follow a three stage command
Read and obey the following
Write a sentence
Copy the design

25

Physical examination- what to test and what it may mean

General: vitals, BP, hearing and vision
CN->vascular may have visual field defects. Ataxia, nystagmus and lateral gaze palsy may suggest alcohol
Motor->vascular and hemiparesis
Sensory->peripheral neuropathy may indicate vitamin, toxic metabolic
Co-ordination and gait->vitamin B12, NPH, vascular
Reflexes-> may have primitive, asymetric in vascular, myoclonus in CJD
CV->hypertension, dysrhythmias, PVD, vascular disease, CHF

26

What are the geriatric giants in history

Confusion, incontinence, falls, polypharmacy
Memory and safety
Behavioural

27

Behaviour issues in dementia

Mood
Anxiety
Psychosis
Suicide
Personality
Aggression

28

Safety issues in dementia

Wandering
Leaving electrical items on
Losing objects
Leaving doors unlocked

29

Laboratory investigations

UEC, glucose
FBC w. differential
TSH
Vit B12
Folate
ESR
CRP
Urinalysis
Urine MCS
CXR

30

Other tests to consider based on history

HIV
Urine toxicology
Collage vascular
Urinalysis for heavy metals
Syphyllis serology
CSF
FDG-PET

31

Imaging

CT or MRI

32

Definition of alzheimers

Progressive chronic neurocognitive decline

33

Define aphasia

Language disturbance

34

Define apraxia

Inability to perform motor tasks despite normal motor function

35

Define agnosia

Difficulty recognising objects despite intact sensory modality

36

Epidemiology of AD

60-70% of all dementias
5% of 80
More common in women

37

Gender preference in AD

More common in women

38

How is early onset AD inherited, genes involved and how common

Autosomal dominant->APP, presenilin 1 and 2

39

Pathophysiology of AD- two theories

Amyloid hypothesis->excess interneuronal amyloid (abeta) as overproduction/reduced clearance of beta amyloid->dense amyloid as plaques. Cause inflammation, microglial activation, complement cascade->neuritic plaques leading to cell death.
Tau-protein theory->tau protein accumulation as neurofibrillary tangles.

40

Gross pathology of AD

Cortical atrophy +in frontal, parietal, temporal lobes

41

Microscopic pathology of AD

Senile plaques
Loss of synapses
Hyperphosphorylate tau
Neurofibrillary tangles
Loss of cholinergic neurons

42

Biochemical pathology of AD

50-90% reduction in choline acetyltransferase

43

Risk factors for AD (6)

Age
Family history
Down syndrome
Genetics
Cerebrovascular disease
Hyperlipidemia
(Weak= brain injury, obesity, low IQ, female, depression, female, DM)

44

Clinical presentation catgories (3)

Cognitive
Psychiatric
Motor

45

Cognitive impairment in AD

Impaired memory, language, abstract, executive

46

Psychiatric manifestations in AD

Mood
Psychosis
Apathy

47

Motor manifestations in AD

Occurs late-->Parkinsonism

48

Key diagnostic factors in AD (9)

Presence of risk factors
Memory loss
Disorientation
Nominal aphasia
Misplacing/getting lost
Apathy
Decline in ADL, IADL
Personality change
Unremarkable physical examination

49

Investigations for AD (9)

Bedside cognitive assessment
FBC
ESR
Glucose
TSH
Vit B12 and folate
Metabolic panel
UDS
CT, MRI

50

DSM 5 criteria for AD

Memory impairment + one >
aphasia, apraxia, agnosia, disturbed executive function
Gradual and progressive
Not due to general medical condition, psychiatric illness or other neurological illness or substance use

51

Findings on MRI of AD (3)

Cortical atrophy, +in hipocampua
Dilitation of lateral ventricles
Widened cortical sulci

52

Management overview of AD

Supportive
Environmental control
Cholinesterase inhibitors
Symptomatic management

53

Supportive management of AD

Carer support
Home safety evaluation
OT assessment
Driving, shopping, finances
Self care
Written instructions and explanations for carers
Calenders, clocks, charts for orientation
Lighting
Exercise
AHD

54

Environmental control measures for AD

Identification bracelets
Tagging devices with GPS

55

Cholinesterase inhibitor goals, when to start, first line

To slow the decline
Begin when mild AD diagnosed
Donepezil 5mg OD or rivastigmine OR Galantaine

56

Symptomatic management AD- mood, psychosis, insomnia, behavioural

Antidepressant->sertraline, citalopram, escitalopram
Agitation, wandering, psychosis->risperidone, olanzepine, quetiapine, aripiprazole
Insomnia->sleep hygeine
Behavioural->environmental and behavioural modification

57

When should you consider mirtazepine

If poor appetite and insomnia

58

When antipsychotics not to be used in dementia

Evidence of vascular dementia

59

When antipsychottic treatment should be stopped

Evidence of worsening neurology

60

What environmental factors should you consider with exacerbation of psychosis and confusion

Poor lighting
Disorientation
Isolation

61

MOA of donepezil

Decrease breakdown of ACh- alleviating the relative deficiency

62

Donepezil CI and cautions, pregnancy and breastfeeding

CI in active peptic ulcer and GI/ureteric obstruction
Caution in hx peptic ulcer, heart block/bradyA, parkinsons, asthma, COPD

63

Common side effects of donepezil (10)

Nausea, abdominal pain
Urinary frequency, diarrhea
Insomnia, fatigue, depression, drowsy
Sweating, hypertension

64

Counselling use of donepezil

Initial dose 5mg
May cause dizzy/drowsy, if it does do not use heavy machinery
Omit one or more if adverse effects
If interrupted treatment, start back at low dose to minimise risk of severe vomiting

65

Key diagnostic factors in Lewy body dementia

Presence of risk factors (old age, male)
Cognitive impariment
Fluctuations in mental state
Visual hallucinations
Depression
EPS
REM sleep disturbance
Severe antipsychotic sensitivity
Others- auditory, falls and syncope, delusions

66

Etiology and pathogenesis of LBD

protein alpha-synuclein, a cytoplasmic protein associated with synaptic vesicles

67

Epidemiology of LBD

15-25% of all dementias

68

Treatment of lewy body dementia

Donepezil

69

Prognosis of lewy body dementia

3-5 years

70

Key diagnostic factors in FTD

Coarsening of personality, social behaviour and habits
Progressive loss of language fluency/comprehension
Memory impairment, disorientation, apraxias
Self neglect, abandonment of work, activity and social contacts

71

Two variants of FTD

Behavioural
Language

72

Which FTD variant is more common

Bahavioural

73

Language variants of FTD

Progressive non fluent aphasia
Semantic dementia

74

Features of progressive non-fluent aphasia

non fluent, laboured speech, anomia, preserved single word comprehentions, word finding deficit, impaired repetition

75

Features of semantic dementia

fluent, normal rate, impaired single word comprehension, intact repetition, use of words of generalisation (things) or supraordinate categories (animal for dog)

76

What are supraordinate categories

Use of animal for dog

77

Two histology types of FTD

Frontal lobe degeneration with microvacuolar change
Pick type with astrocytic gliosis +/- ballooned cells and inclusion bodies

78

Epidemiology of FTD

10% of all dementias

79

Core features in FTD

Insidious decline and gradual
Early decline in social interpersonal conduct
Early impairment of regulation of personal conduct
Early emotional blunting
Early loss of insight

80

Supportive features in FTD

Behavioural
Language
Motor

81

Motor features of FTD

Primitive reflexes
Incontinence
Akinesia
Rigid
Tremor
Low and labile blood pressure

82

Management of FTD

Supportive care
Treat irritability with benzodiazepine
Treat any concurrent illness
Home assistance, respite
Treat mania etc with valproate
Organise and manage end of life care