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*Medicine: Geriatrics > Dementia > Flashcards

Flashcards in Dementia Deck (23)
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1

What is dementia?

  • clinical syndrome of at least ~6 months duration of chronic + progressive impairments in 2+ domains of cognitive function
  • principle abnormality is memory loss, severe enough to affect social or occupational life
  • impairment in one of following: language, visuospatial fxn, abstraction, calculation, personality or executive fxns 
  • "My Old Grandmother Converses Pretty Badly"
    • Memory, Orientation, Grasp, Communication, Personality, Behaviour
  • falls common in later stages
  • can lead to immobility, incontinence, dysphagia + total dependency for ADLs

2

Who does dementia affect?

  • females > males
  • 10-15% of 65 year olds
  • 30-50% of 85 year olds
  • 5th commonest cause of death

3

Dementia can be sub-classified into cortical and subcortical dementia depending on where the lesion is.

What are the classical features of cortical dementia? 

5 As

  • amnesia
  • aphasia
  • apraxia
  • agnosia 
  • acalculia

eg. Alzheimer's, frontotemporal dementia, Creutzfeldt-Jakob disease 

4

What are the classical features of subcortical dementia?

  • forgetfulness
  • slowing of thought process
  • impaired ability to manipulate acquired knowledge
  • apathy
  • depression
  • frontal lobe dysfunction
  • motor disability

eg. Huntington's, Parkinson's dementia, AIDS dementia complex

5

The most common type of dementia is Alzheimer's disease (55%).

What are key features of this type?

  • insidious onset, slow progression over years
  • risk factors: age, FHx, genetics, Down's, cerebrovasc disease, hyperlipidaemia
  • memory loss hallmark feature, starts w/ short-term memory
  • disorientation to time + place 
  • nominal dysphagia 
  • misplacing items/getting lost
  • apathy
  • decline in ADLs
  • personality change (loss of interest)

6

How is a diagnosis of Alzheimer's made?

  • MMSE + Blessed dementia scale
  • unremarkable physical examination
  • FBC -> rule out anaemia
  • metabolic panel -> rule out abnormal Na, Ca, glucose levels
  • TSH, Vitamin B12 (both can be associated w/ dementias)
  • urine drug screen -> rule out rec drug use
  • CT -> exclude SOLs, few changes evident in early AD
    • advanced disease: pronounced sulcal/gyral changes + global atrophy evident
  • MRI -> inc sensitivity over CT

7

Vascular dementia is the second most common (20%) cause of dementia. What is this caused by?

  • caused by chronic, reduced blood flow to brain 
  • due to blocked or diseased vascular system
  • usually result of stroke or series of strokes
  • if blood supply blocked longer than few secs, brain cells die, causing damage to cortex of brain - area associated w/ learning, memory and language

8

What is multi-infarct dementia?

  • most common type of vascular dementia
  • caused by mini strokes/TIAs
  • often go unnoticed
  • result in only temporary, partial blockages of blood supply
  • brief impairments in consciousness or sight
  • over time, more areas of brain damaged -> symptoms of dementia begin to appear

9

What are key diagnostic features of vascular dementia?

  • history of stroke(s)
  • difficulty solving problems
  • apathy
  • disinhibition
  • slowed processing of information
  • poor attention
  • retrieval memory deficit
  • frontal release reflexes - grasp, glabella tap, jaw-jerk
  • impaired gait and balance 

Often overlap between AD and VaD, memory may only be mildly affected in early stages of VaD unlike in AD. 

10

What is Lewy Body dementia (DLB) (15%)?

  • type of dementia closely associated w/ Alzheimer's and Parkinson's diseases (latter more so)
  • characterised anatomically by presence of Lewy bodies - accumulations of alpha-synuclein and ubiquitin protein in neurons
  • with DLB, loss of cholinergic neurons is thought to account for degradation of cognitive functioning, as in Alzheimer's disease while the loss of dopaminergic neurons is thought to account for degradation of motor control, as in Parkinson's disease

11

What are key characteristics of Lewy Body Dementia?

  • insidious onset, progression gradual
  • triad:
    • fluctuating cognitive impairment (confusion + lucid intervals)
    • recurrent visual hallucinations
    • motor features of parkinsonism
  • cognitive and behavioural impairments precede motor phenomena

12

What are characteristics of Parkinson's Disease with dementia?

  • typical motor symptoms of PD present, precede cognitive impairment and are severe - so motor symptoms come first!
  • diagnosed when cognitive symptoms begin a year after the onset of parkinson symptoms

13

What are key characteristics of frontotemporal dementia (5%)?

  • onset often early (35-75), insidious and slow
  • either behavioural, personality or language difficulties dominate
  • eg. Pick's disease
  • slovenly appearance, impatience, irritability
  • argumentative, lewd, tactless remarks, child-like + impulsive
  • loss of empathy and concern for others
  • progressive loss of language fluency or comprehension
  • in FTD, changes in personality, language, habits, and activity generally precede the development of memory impairment, disorientation, or apraxias
  • progressive self-neglect
  • insight lost early
  • neuroimaging shows frontal and/or temporal atrophy

14

What are other causes of dementia (5)% that have not been yet mentioned?

  • hypothyroidism
  • vit B12 deficiency
  • Wernicke-Korsakoff's syndrome
  • normal pressure hydrocephalus
  • neurosyphyllis
  • AIDS
  • Huntington's disease
  • progressive supranuclear palsy
  • creutzfeldt-jakob disease

15

What are the differences between delirium and dementia?

16

What are some differential diagnoses for apparent dementia in the elderly?

  • delirium
  • drugs
  • depression
  • normal age-associated memory changes
  • mild cognitive impairment
  • communication difficulties due to deafness, poor vision, language deficits
  • schizophrenia
  • manias

17

The diagnosis of dementia is primarily clinical - a history is therefore crucial and this should include a collateral history.

What will the history need to document?

  • onset, time course + duration of symptoms
  • presence or absence of fluctuations
  • functional status
  • current + past medical problems
  • medications
  • FHx of dementia
  • safety issues (eg. driving, wandering, kitchen safety)
  • alcohol use
  • evidence of depression (present in 20-40%)
  • presence of hallucinations, delusions or other psychiatric symptoms 
  • personality change
  • agitation
  • review of support systems and carer stress
  • there may be neurological signs and primitive reflexes (snout, palmomental and grasp) 

18

Aggrevators of dementia must always be looked for and treated appropriately. 

What might these include?

'DEMENTIA'

  • Drugs
  • Emotional illness
  • Metabolic disorders
  • Eye + ear problems
  • Nutritional disorders
  • Tumours/trauma
  • Infections
  • Alcohol/Anaemia

19

The mini-mental state examinaiton also can be used to assess for dementia. 

What does the MMSE involve?

20

What is the difference between the progression of deterioration in AD and VaD?

  • AD - progressive deteroriation common
  • VaD - step-wise deterioration

 

21

What is meant by 'sundowning'?

 It's also known as “late-day confusion.” If someone you care for has dementia, their confusion and agitation may get worse in the late afternoon and evening. In comparison, their symptoms may be less pronounced earlier in the day.

22

Management depends on the severity of dementia, whether the patient lives alone and comprises a multi-disciplinary, multi-agency package of care. The care needs to be well-coordinated and to evolve as the needs of the patient and carer change. 

What are the options for non-pharmacological treatment of dementia?

  • coping strategies + psychological techniques
  • optimize hearing, vision + improve gen health
  • treat other conditions impairing cognition (eg. anaemia, HF)
  • treat depression (SSRIs > TCAs)
  • treat risk factors (hypertension, constipation, anaemia)
  • encourage physical + mental activity, incl social activities
  • suggest simple interventions to improve coping (eg. lists, calenders)
  • treat specific symptoms + behaviours (by avoiding precipitants, creating home-like environment, distraction + reassurance)
  • support care givers + enquire about their burden
  • educate families about disease + how to cope w/ manifestations, as well as ethico-legal issues
  • simplify medication (provide dosett boxes)
  • palliative care in the terminal stages

23

What is the pharmacological treatment of dementia?

  • Acetylcholinesterase inhibitors (AChEI)
    • provide symptomatic relief through one-off increment in cognition
    • underlying disease continues to progress at same rate
    • Donepezil - for AD
    • Galantamine
    • Rivastigmine - LBD
       
  • Memantine (NMDA blocker) - mod-severe AD, sometimes added to AChEI
  • Trazadone (antidepressant), antipsychotics and benzodiazepines - used for agitation, anxiety and irritability