Dementia

Question 1

Define mild cognitive impairment

Answer 1

• Focal cognitive impairment
• Not severe enough to interfere with daily life and function

Question 2

What is dementia?

Answer 2

A syndrome characterised by:

• Progressive global cognitive deficits
• Compared to baseline
• Significant impairment of normal functioning
• Definite Dx: symptoms lasting 6+ months
• Tentative Dx: symptoms lasting less than 6 months

Question 3

What is included in the routine dementia screen?

Answer 3

• TFTs
• Vit B₁₂; folate
• FBC; ESR; CRP: anaemia and vasculitis
• LFTs; U+Es
• Glucose
• CT head
• Neurosyphilis test

Question 4

What are the cognitive deficits seen in dementia?

Answer 4

• Memory impairment
• Impaired executive function
• Dysphagia
• Agnosia
• Apraxia (loss of motor function)
• Personality disintegration

Question 5

What is executive function?

Answer 5

A set of cognitive processes that enable planning, organisation, and completion of tasks.

e.g. Problem solving, abstraction, reasoning, decision making, judgement, planning, organisation, processing

Question 6

Name four risk factors for Dementia

Answer 6

• Older age
• Mild cognitive impairment
• Intellectual difficulties
• Genetics; FHx of young-onset dementia
• CVD risk factors; stroke
• Parkinson’s disease
• Depression; Alcohol abuse
• Low educational attainment; low social engagement/support

Question 7

Name four protective factors for Dementia

Answer 7

• Diet: Vitamin E and C
• Exercise
• Mental and social activity
• More complex work ➔ reduced hippocampal atrophy

Question 8

What are the common causes of dementia?

Answer 8

• Alzheimer’s disease (50-60%)
• Vascular dementia (20-25%)
• Mixed dementia
• Lewy body dementia (10-15%)
• Frontal-temporal dementia (7%)
• Other e.g. CJD, AIDS dementia, Alcohol dementia (3%)

Question 9

List three behavioural and psychological symptoms of dementia (BPSD)

Answer 9

• Psychosis: delusions and/or hallucinations
• Agitation; emotional lability
• Depression; anxiety
• Withdrawal; apathy
• Disinhibition: social or sexually inappropriate behaviour
• Motor disturbance: wandering; restlessness
• Sleep cycle disturbance; insomnia
• Echolalia (tendency to repeat phrases or questions)

Question 10

What differential diagnoses must be excluded for a diagnosis of dementia?

Answer 10

• Delirium
• Depression

Question 11

Name three reversible causes of dementia

Answer 11

• Subdural haematoma
• Normal pressure hydrocephalus
• Chronic alcohol misuse
• Metabolic
  
  • Vitamin B12 deficiency
  • Hypothyroidism
  • Hypoglycaemia
• Neurosyphilis

Question 12

What is the characteristic of fronto-temporal cortical dementia?

Answer 12

Prominent personality change

May manifest as frontal lobe syndrome: damage of higher functioning processes ^eg. motivation, planning, behaviour

Question 13

What is Alzheimer’s disease?

Answer 13

• Commonest form of dementia
• Degenerative disease of the brain
• Prominent cognitive and behavioural impairment.
• Significantly interferes with social and occupational function

Question 14

List three risk factors for Alzheimer’s disease

Answer 14

• Increasing age
• FHx of AD or early-onset AD
• Down’s syndrome
• FHx of Down’s syndrome
• Previous head injury
• Hypothyroidism
• Parkinson’s disease

Question 15

What is the association between Alzheimer’s disease and Down’s syndrome

Answer 15

Chromosome 21:

• AD: gene for amyloid precursor protein ➔ amyloid plaques
• DS: Down’s syndrome have an extra Chromosome 21 ➔ accelerated production of amyloid plaques ➔ earlier dementia

Question 16

What are the three symptomatic domains of Alzheimer’s disease?

Answer 16

• Cognitive
• Functional: ADLs
• Neuropsychiatric
  
  • Mood/affect disturbances
  • Aggression
  • Anxiety
  • Psychosis
  • Sleep disturbances

Question 17

Describe the memory problems in Alzheimer’s disease

Answer 17

• Early impairment of immediate and short-term memory
  
  • Due to atrophy of the hippocampus.
• Long-term (remote) memory declines with progression
• Common to also have disorientation of time and place

Question 18

List three early symptoms of Alzheimer’s disease

Answer 18

• Impaired immediate and short-term memory
• Disorientation of time and place
• Muddled efficacy with ADLs
• Spatial dysfunction
• Behavioural: Wandering, irritability

Question 19

List three middle symptoms of Alzheimer’s disease

Answer 19

• Intellectual and personality deterioration
• Aphasia
• Apraxia
• Agnosia (inability to process sensory information)
• Impaired executive function
• Impaired visuospatial skills: getting lost, impaired driving

Question 20

List three late symptoms of Alzheimer’s disease

Answer 20

• Fully dependent
• Physical deterioration
• Incontinence
• Gait abnormalities
• Spasticity Seizures (3%)
• Tremors
• Extrapyramidal signs

Question 21

How does early-onset Alzheimer’s disease differ from typical AD?

Answer 21

• More aphasia and apraxia
• Rapid course with severe intellectual decline
• Poor survival rate

Question 22

Request four investigations for Alzheimer’s disease

Answer 22

• Cognitive testing: Clock drawing test, MMSE
• FBC
• TFTs
• Haematinics: B₁₂; folate
• Neurosyphilis screen
• LFT, U+Es, TSH, HIV
• CT head:
  
  • Cortical atrophy esp in medial temporal lobes (hippocampus), ventricular enlargement

Question 23

Outline the management of Alzheimer’s disease

Answer 23

• Promoting cognition, independence and wellbeing:
  
  • Group cognitive stimulation therapy
  • Cognitive rehabilitation; occupational therapy
• Medication:
  
  • AChEi: donepezil; galantamine; rivastigmine
  • Memantine

Question 24

What are the indications for Memantine?

Answer 24

• Moderate Alzheimer’s disease
  
  • AChEi contraindicated or not tolerated
• Severe Alzheimer’s disease

Question 25

Name three risk factors for Vascular dementia

Answer 25

* Male * PMH or FHx of cardiovascular disease * CV risk: smoking, diabetes, HTN, hyperlipidaemia

Question 26

List three characteristics suggestive of Vascular dementia

Answer 26

* Sudden onset * Stepwise deterioration * Cardiovascular risk factors

Question 27

How can the presentation of vascular dementia be categorised?

Answer 27

* Cognitive deficits following a single stroke * Deficits depend on site of infarct * Multi-infarct dementia * Stepwise deterioration in cognitive function * Relative stability between strokes * Binwangers disease: progressive small-vessel disease * Gradual intellectual decline * Generalised slowing * Motor problems

Question 28

List four presenting features of Vascular dementia

Answer 28

* Acute onset; may follow a stroke * Early: * Emotional and personality changes * Cognitive deficits - fluctuate * Behavioural slowing and anxiety * Depression with affective lability and confusion, esp at night * Physical signs of arteriovascular disease * Neurological impairment

Question 29

Outline the management of Vascular dementia

Answer 29

* **Manage modifiable risk factors**: * Diet; exercise * Smoking cessation; reduce alcohol intake * Medication: * Aspirin * Clopidogrel * Statins * ACEi * Anti-hyperglycaemics if needed

Question 30

When may a CXR be indicated when investigating dementia?

Answer 30

Indication of **malignancy**, esp of small-cell lung cancer Paraneoplastic syndromes resembling neurological deficits in dementia

Question 31

Name one infectious cause of reversible dementia

Answer 31

* HIV * **Syphilis** * TB * Meningitis

Question 32

Outline pathophysiology of Lewy body dementia

Answer 32

Accumulation of Lewy bodies (alpha-synuclein and ubiquitin) in the cerebrum and substantia nigra.

Question 33

Name two characteristic clinical features of Lewy body dementia

Answer 33

* **Fluctuating cognitive impairment** * **Spontaneous parkinsonism** * **Vivid visual hallucinations** * *Additional: REM sleep disturbance - treated with clonazepam*

Question 34

Why should antipsychotics be avoided in Lewy body dementia?

Answer 34

Antipsychotics can: * **Precipitate irreversible parkinsonism** * Preceipitate autonomic dysregulation * similar to neuroleptic malignant syndrome * Reduce consciousness * Increases mortality rates (2-3x)

Question 35

Differentiate dementia from delirium

Answer 35

Delirium has altered consciousness and attention Dementia: * Gradual onset (months to years); progressive * Normal consciousness; late perceptional disturbances * Normal sleep-wake cycle Delirium: * Acute onset (hours to weeks); fluctuating course * Impaired consciousness; perceptional disturbances often * Disrupted sleep-wake cycle.