What is dementia?
A syndrome of global impairment and deterioration in cognition, leading to decline in functioning, in clear consciousness.
What is the ICD-10 criteria for dementia?
- A decline in memory (verbal + non-verbal)
- Decline in other cognitive abilities
- Awareness of environment preserved (no delirium)
- Decline in emotional control, motivation or a change in social behaviour
- Symptoms present for > 6 months
What is the DSM-IV criteria for Alzheimer's?
- Memory impairment + (at least 1; aphasia, apraxia, agnosia, executive dysfunction)
- Causing significant impairment in social + occupational functioning
- Gradual + continuing cognitive decline
What are the different dementia types?
- Alzheimer's disease 50-60%
- Vascular dementia 15-20%
- Dementia w/ Lewy bodies 10-15%
- Frontotemperal 4-6% (but younger onset)
What are the prevelance trends of dementia?
- Prevelance rates approximately double every 5 years (between 60-90)
- Overall prevalence 65+ (7-10%)
What are non-cognitive features of dementia?
- Depression, anxiety
- Psychosis, hallucinations
- Agitation, wandering, aggression, anxiety, shouting, day-night reversal
- Personality change
- Apathy, disinhibition
What are risk factors for Alzheimer's?
- Female, Age
- Vascular risk factors (diabetes, hypertension, AF)
- Family history
- Apo E4 allele status
- Head trauma
Which particular structure in the brain will show atrophy upon MRI/CT scan of an Alzheimer's patient?
Which part of the clinical history is important when assessing Alzheimer's?
- History of presenting complaint
- Past medical history
- Family history
- Collateral history
- Cognitive test + physical exam
What is the pathophysiology of Alzheimer's?
- Neuronal cell death, particularly cholinergic
Amyloid plaques made up of B-amyloid
Neurofibrillary tangles - Hyperphosphorylated Tau
What is vascular dementia?
Vascular dementia is the outcome of blocked or minimized flow of blood to the brain, denying the brain cells of crucial oxygen and nutrients.
What is large vessel disease?
- Type of vasc dementia
- Strategic single infarct (Eg thalamus)
- Multiple coritcal grey matter infarcts (MID)
- 20-30% post-stroke develop dementia (not immediately after the stroke)
What is small vessel disease?
- Multiple lacunar infarcts (white matter)
- Occlusion of single deep perforating artery
Is episodic memory deficit more severe in Alzheimer's or Vascular dementia?
Alzheimer's has more severe episodic memory loss.
In vascular dementia, they can remember things that have happened but have more disorientation adapting to new situations
What are risk factors for vascular dementia?
- High cholesterol
- Previous MI
- Recent TIA
When are the following two conditions diagnosed?
- Parkinson's Dementia
- Dementia w/ Lewy Bodies
- Parksinon's diagnosed if parkinsonian symptoms have existed for at least 12 months prior to dementia
- Dementia Lewy Bodies if both motor and cognitive symptoms develop within 12 months, or cognitive prior to motor
What is the pathophysiology of dementia w/ Lewy bodies?
Neuronal inclusions, abnormally phosphorylated neurofilaments, ubiquitin + a-synuclein
- Found in paralimbic, neocortical areas, brainstem. Marked decrease of ACh
- Lewy neurites (degenerated neurites)
- Amyloid plaques
What are clinical features of dementia w/ Lewy bodies?
- Fluctuating cognitive performance + level of consciousness
- Visual hallucinations (60%)
- Parkinsonism (70%)
- Falls (30%)
- V sensitive to antipsychotics
- REM sleep disorder (vivid dreams)
What is Parkinson's disease dementia?
Dementia that is a direct pathophysiological consequence of Parkinson's Disease
How many of Parkinson's disease patients will eventually develop dementia?
What are the important non-motor symptoms of Parkinson's Disease?
- REM sleep disorder
Describe key points regarding Frontotemporal dementia AKA Pick's disease
- Accounts for 20% of pre-senile dementia (before 65)
- Onset 45-65
- 40% of ppl w/ FTD show tau inclusions or 'Pick bodies'
- Atrophy of frontal and anterior temporal lobes
The two language subtypes of frontotemporal dementia are semantic and progressive non-fluent aphasia, what are they?
Semantic - difficulty finding right word, lost understanding of words, talking vaguely
- Progressive non-fluent aphasia - difficulty finding right word, telegraphic speech, wrong grammar, opposite words
What consists of the behavioural variants of frontotemporal dementia?
- Alteration in personality + social conduct
- Disinhibiton or apathy, related to serotonin?
- Perseveration. Utilisation behaviour.
What is the link between alcohol and dementia?
Unclear if alcohol causes dementia but increases prevalence. Alcohol related to risk factors such as vascular causes and head injury.
How are Wernicke's and Korsakov's linked?
Wernicke's is an acute syndrome (impaired consciousness, ataxia, opthalmoplegia). Due to dietary thiamine deficiency.
Korsakov's develops if still lack of thiamine/Vit B, profound amnesia for new learning but good attention/working memory. Confabulation.
What is the screening pathway for dementia?
- History + collateral history
- Examination, investigation (MMSE, ACE-III)
- Blood tests - FBC, U&Es
- Liver + thyroid function tests; glucose, B12, folate
- Calcium, C-reactive protein
- Neuro exam
- Syphilis serology, autoantibody screen, serum cholesterol
- MRI or CT head
In terms of long term care what does the psychiatrist do? How is this different from the role of the community psychiatric nurse?
- Overall management strategy
- Medical management
- Complex decisions
Community psychiatric nurse monitors mental state + risks, supports/educate patient and carers.
What does the occupational therapist do?
- Assess home environment
- Living skills (ie safety in kitchen)
- Provide aids/adaptations
What does the psychologist do?