Dementia

Question 1

What is the diagnostic criteria for dementia?

DSMIV criteria

Answer 1

Impairment of memory +1 of the following:
Aphasia
Agnoisa
Apraxia
Executive dysfunction 

Impairment in functioning

Present for at least 6 months

No other medical or psychiatric explanation

Question 2

What are the dementia subtypes?

Answer 2

Alzheimers 
Vascular
Mixed 
Lewy-body 
Frontotemptoral 
Parkinson's
Other

Question 3

How common are each subtype?

Answer 3

Alzheimers - 62%
Vascular - 17% 
Mixed - 10%
Lewy-body - 4%
Frontotemptoral - 2%
Parkinson's - 2% 
Other - 3%

Question 4

Describe the pathophysiology of vascular dementia briefly

Answer 4

Ishaemia multiple cortical infarcts

Question 5

Describe the pathophysiology of AD briefly

Answer 5

atrophy
plaques (beta amyloid)
Tangles (tau proteins) Decreased neurotransmitters

Question 6

What are the modifiable RFs for dementia?

Answer 6

smoking 
atherosclerosis 
alcohol
high cholesterol
obesity 
low standard education

Question 7

What are the non modifiable RFs

Answer 7

genetics
Age
Mild cognitive impairment

Question 8

What is the function of the frontal lobe?

Answer 8

Voluntary motor
speaking
behaviour
personality

Question 9

What is the function of the parietal lobe?

Answer 9

Sensory information
sequencing
proprioception
calculation

Question 10

What is the function of the temporal lobe?

Answer 10

attention
verbal memory
visual memory
learning

Question 11

What percentage of over 65s have dementia?

Answer 11

5%

Question 12

What percentage of over 80s have dementia?

Answer 12

20%

Question 13

How many people in the UK currently have dementia ?

Answer 13

estimated 820 000

Question 14

How does the brain appear macroscopically in AD?

Answer 14

brain appears atrophic - particularly hippocampus

enlargement of ventricles

Question 15

How does the brain appear microscopically in AD?

Answer 15

reduced neurotransmitter function

presence of neurofibrillary tangles and amyloid plaques caused by abnormal protein deposition

Question 16

Which three genes are mutated in rare forms of early onset dementia?

Answer 16

APP
PSEN 1
PSEN 2

Question 17

What gene is implicated in later-onset AD?

Answer 17

APOE

Question 18

What is the second most common form of dementia?

Answer 18

Vascular dementia

Question 19

Causes of VD?

Answer 19

problems with bloods supply to the brain such as atherosclerosis or stroke

Question 20

What are the further subtypes of VD?

Answer 20

multi-infarct dementia - caused by small strokes in the cortex of the brain

subcortical vascular dementia - caused by damage to small vessels deeper within the brain

post stroke dementia

Question 21

Which lifestyle factors increase the risk of developing pathological changes in VaD?

Answer 21

smoking
high fat diet
diabetes
HTN

Question 22

What is mixed dementia?

Answer 22

mixed picture of AD and VaD

Question 23

What are the featured of lewy body dementia?

Answer 23

fluctuation in cognition
early visual hallucinations
parkinsonism

Question 24

What is the disease process of lewy body dementia?

Answer 24

abnormal protein structures, called lewy bodies build up in the brian cortex and basal ganglia causing disruption to neurotransmitter function

Question 25

How are LBD and PD different?

Answer 25

similar pathological basis but are differentiated depending on the sequence of symptom development In LBD cognitive dysfunction presents within 2 years of motor function, in PDD it presents later

Question 26

What are the features of frontotemporal dementia

Answer 26

changes in behaviour, emotion and language before memory is affected

Question 27

what causes FTD?

Answer 27

degeneration of frontal and temporal lobes

Question 28

What percentage of cases are inherited?

Answer 28

50%

Question 29

what are the other subtypes of dementia?

Answer 29

Huntington's Alcohol related dementia Progressive supranuclear palsy (PSP) HIV related cognitive impairment

Question 30

what is a mild cognitive impairment (MCI)?

Answer 30

relatively new concept used to describe impairment of memory greater than expected with normal ageing but not significant to affect an individuals function significantly enough to suggest dementia

Question 31

what does having MCI increase your risk of

Answer 31

dementia

Question 32

Reversible causes of MCI?

Answer 32

reversible - depression and physical illness

Question 33

What are the stages of dementia? (easy)

Answer 33

Early Mid End

Question 34

Features of early stage dementia?

Answer 34

memory loss slower to grasp new ideas errors of judgement

Question 35

Features of mid stage dementia?

Answer 35

difficulty with daily tasks decline in language behaviour change

Question 36

Features of end stage dementia?

Answer 36

increased care needed communication impaired incontinence swallowing difficulties

Question 37

What are the key differentials?

Answer 37

mood disorders - depression metabolic - hypothyroidism, vit B12 deficiency trauma - subdural haematoma poisons - heavy metals, recreational drugs nutrition - thiamine deficiency medication - multiple e.g. steroids, anti-depressants Other - normal pressure hydrocephalus

Question 38

How is dementia managed? Cognitive

Answer 38

Cognitive - pharmacological (AD) - -> AchE-1 - -> NDMA antagonists these slow the progression of cognitive decline in vascular dementia reducing risk factors such as high BP, cholesterol Behavioural and psychological - pharmacological - non pharmacological - -> MDT support - -> orientation - -> complementary therapies

Question 39

Describe history taking in patients with dementia

Answer 39

elicit the difficulties patient has been having and link these to areas of brain affected speed and pattern of progression will help to determine dementia subtype Collateral history important - when was patient last 'normal'? PMH, DH, FH, SH important too

Question 40

Which investigations would you order for a suspected dementia patient?

Answer 40

Bloods - FBC, vit B and folate, ESR, renal and liver function, glucose and lipids Baseline ECG Imaging - to exclude reversible causes - CT head first line, MRI and HMPoA-SPECT provide more detail

Question 41

Describe examination of patient with suspected dementia?

Answer 41

physical exam including cardio and neuro mental state exam - MMSE, MoCA, ACE-R

Question 42

what needs to be discussed when dementia is diagnosed?

Answer 42

driving advanced care planning legal issues - lasting power of attorney

Question 43

How is dementia managed? behavioural and psychological

Answer 43

Behavioural and psychological - pharmacological - -> anti-psychotics and acetylcholinesterase's can be prescribed by specialists - non pharmacological - -> MDT support - -> orientation and reassurance - -> complementary therapies