Dementia and delirium

Question 1

Which type of dementia is associated with visual hallucinations

Answer 1

LBD

Question 2

3 types of delirium.

Which is the most common type

Answer 2

1. Hypoactive (most common)
2. Hyperactive
3. Mixed

Question 3

ICD-10 fo delirium

5 criteria

Answer 3

1. Impairment of consciousness and attention
2. Global disturbance in cognition
3. Psychomotor disturbance
4. Disturbance of sleep-wake cycle
5. Emotional disturbance

Question 4

How is the sleep-wake cycle and concentration affected in dementia vs delirium

Answer 4

Delirium: very disrupted

Dementia: normal

Question 5

How is psychomotor activity affected in dementia vs delirium

Answer 5

Delirium: usually abnormal

Dementia: usually normal

Question 6

Most common causes of delirium

Answer 6

PINCH ME

• pain
• infection
• neoplasm
• constipation
• hydration/ hypoxia
• medication
• environment

Question 7

Which 4 infections are commonly associated with delirium

Answer 7

1. UTI
2. Pneumonia
3. Meningitis
4. Encephalitis

Question 8

Common medication causes of delirium

Answer 8

• BZDs, narcotics
• Anticholinergics, Antiparkinsons (L-DOPA)
• Steroids
• Warfarin
• 1st gen antihistamines

Question 9

How is delirium managed

Answer 9

1. treat underlying cause
2. provide appropriate environment
3. low dose antipsychotics if necessary

Question 10

ICD-10 for dementia

Answer 10

1. Evidence of memory decline and cognitive decline
2. Preserved awareness of environment
3. Decline in emotional control, motivation or change in social behaviour

Question 11

What 4 features are examples of a decline in emotional control, motivation or change in behaviour

^in someone with dementia

Answer 11

1. Emotional lability
2. Irritability
3. Apathy
4. Coarsening of social behaviour

Question 12

For a confident diagnosis of dementia,

how long should decline in memory and cognition have lasted

Answer 12

At least 6 months

Question 13

Name 3 main reversible causes of dementia

Answer 13

1. Raised ICP (eg normal pressure hydrocephalus, tumours, haematoma)
2. B12/folate deficiency
3. Endocrine problems (Cushing’s, Hypothyroidism)

Question 14

How is a CT scan useful in dementia

Answer 14

Identify hippocampal atrophy

Question 15

How is an MRI useful in dementia

Answer 15

Identify posterior vascular pathology (eg in vascular dementia)

Question 16

How is a SPECT scan useful in dementia

Answer 16

Differentiate between different types of dementia

Doperminergic cell loss seen in DLB and Parkinsons

Question 17

MMSE score

Normal
Severe

Answer 17

25-30

<10

Question 18

Pathophysiology of Alzheimer’s

Answer 18

Degeneration of cholinergic neurons

in nucleus basalis of Meynert

Question 19

Microscopic features of brain in Alzheimer’s

Answer 19

• neurofibrillary tangles

- beta-amyloid plaque formation

Question 20

Macroscopic features of brain in Alzheimer’s

Answer 20

• hippocampus atrophy
• widened sulci
• enlarged ventricles

Question 21

What age is considered early onset Alzheimer’s

Answer 21

<65yo

Question 22

Features of early onset Alzheimer’s

Answer 22

• <65yo
• rapid onset and progression
• aphasia
• agraphia (cannot write)
• alexia (cannot read)
• acalculia (cannot do maths)
• apraxia

Question 23

Pathophysiology of vascular dementia

Answer 23

Multiple small strokes/ atherosclerosis in small vessels

Question 24

Symptoms of vascular dementia

Answer 24

• emotional and personality changes (earlier onset)
• STEPWISE deterioration
• confusion
• late-onset memory loss

Question 25

What type of neuro signs might someone with vascular dementia have

Answer 25

UMN signs - spasticity - extensor plantar response

Question 26

Pathophysiology of Lewy Body dementia

Answer 26

Deposition of Lewy Bodies in neurons of brainstem, substantia nigra, neocortex

Question 27

Symptoms of Lewy Body dementia

Answer 27

- FLUCTUATIONS in cognition from day to day - Visual hallucinations - Parkinsonism (tremor, rigidity, bradykinesia)

Question 28

Pathophysiology of frontotemporal dementia

Answer 28

Atrophy of frontal and temporal lobes of brain

Question 29

Symptoms of frontotemporal dementia

Answer 29

- language difficulties (earlier onset compared to other types of dementia) - personality changes - worsened social behaviour - losing insight early on (but preserved memory)

Question 30

What bloods to do in a patient with suspected dementia (to rule out other causes of similar presentations)

Answer 30

B12/ folate TFTs (might be severe hypothyroidism) ACTH levels (Cushing’s) Ca (cerebral mets) Also rule out depression Note: check HbA1c levels as it accelerates vascular dementia

Question 31

Types of Alzheimer’s drugs

Answer 31

1. Ach-esterase inhibitors (eg Rivastigmine, Donepezil, Galantamine) 2. NMDA receptor antagonists (eg Mementine)

Question 31

Side effects of Ach-eterase inhibitors

Answer 31

- increases QTc interval - urinary incontinence - GI problems - sleep disturbance Specific to Donepezil Headache Anaemia, thrombocytopenia

Question 31

Types of Parkinson’s/ LBD drugs

Answer 31

1. Same as Alzheimer’s (Ach-esters season inhibitors, Memantine) 2. Clonazepam/ melatonin for REM steel disorder 3. Quetiapine/ aripriprazole for hallucinations

Question 31

Risks in giving antipsychotics in LBD

Answer 31

Neuroleptic sensitivity reactions eg sedation, cognitive decline Neuroleptic malignant syndrome eg high fever, confusion, muscle rigidity, tachycardia Worsening of extrapyramidal features

Question 32

Types of vascular dementia drugs

Answer 32

Anticoagulants + BP drugs | Ach-esterase inhibitors don’t work

Question 33

How is short vs long term memory loss affected In Alzheimer’s vs vascular dementia

Answer 33

Alzheimer’s has problems with short term memory but long term memory is preserved Vascular dementia has problems with both types of memory