Dementia and major neurocognitive disorders

Question 1

What is a major neurocognitive disorder?

Answer 1

Dementia - new name

Question 2

Gender more affected by dementia and maybe why

Answer 2

• Females more than males
• Females are more likely to be carers for those with dementia = depression and isolated = risk factor for dementia (visicous cycle)

Question 3

What is dementia?

Answer 3

• Substantial cognitive decline from previous level in 1 or more domains
• Sufficient enough to interfere with daily function
• Cognitive deficits do not exclusively occur in context of delirium
• Not another cause from mental disorder eg depression, scizophrenia

Question 4

Neurocognitive domains

Answer 4

• Perceptual-motor function
• Language
• Learning and memory
• Social cognition
• Complex attention
• Executive function

Question 5

Tests for executive function

Answer 5

• Category fluency - name all animals, all words beginning with A
• Tap test - tests for inhibition, if I tap once tap, if i tap twice don’t tap
• Conceptualisation - what is similar between apple and orange
• Clock drawing - how detailed?
• Abstract thinking - what does ‘fought like a lion mean’
• Judgement - if you see a smoking house what do you do?

Question 6

Tests for visualspatial awareness

Answer 6

• Hemineglect - draw clock
• Test praxis - tell me how to use a hammer, comb, scissors
• Intersecting pentagon draw

Question 7

Perceptual motor test

Answer 7

• Copy designs
• Show movement and copy movement

Question 8

Language tests

Answer 8

• Impaired word finding?
• Impaired fluency?
• Hesitant speech?

Question 9

4 most common types, in order, of dementia

Answer 9

1. Alzheimers 50-75%
2. Vascular 20-30%
3. Dementia with Lewy bodies 10-25%
4. Frontotemporal 10-15%

Question 10

What is lewy body dementia sometimes meaning?

Answer 10

• Dementia with Lewy Bodies OR
• Parkinsons dementia

Question 11

RF for dementia

Answer 11

• Physical inactivity
• Smoking
• Excessive alcohol consumption
• Air pollution
• Head injury - eg ex boxers
• Infrequent social contact
• Low eduction
• HTN
• Obesity
• Diabetes
• Depression
• Hearing impairement

Question 12

Pathophysiology of Alzheimers

Answer 12

• Extracellular amyloid plaques
• Formed by amyloid beta
• Intracellular neurofibrillary tangles - from tau proteins

Question 13

Normal role of tau

Answer 13

• Stabilise microtubules in neurones
• Microtubules help nutrients travel around neurone

Question 14

Amyoid plaques and contribution to disease

Answer 14

Removing them does not reduce clinical progression
Are they waste product of already damaged thing?

Question 15

Subtypes of amyloid beta

Answer 15

40
42
38

Question 16

What happens in alzheimers?

Answer 16

• Apoptosis of neurones = widespread cortical atrophy
• Increase in some neurotransmitters
• Decrease in others eg Ach

Question 17

Symptoms of Alzheimers

Answer 17

• confusion with time and location
• Poor judgement
• Withdrawal from social activities
• Difficulty with words
• Problem solving difficulty
• Difficult to complete regular tasks
• Misplacing items
• General memory loss
• Difficulty with words
• Random emotions
• Trouble with images and spaces

Question 18

Biomarkers of Alzheimers

Answer 18

• CSF - Decreased amyloid beta 42, decreased 42:40 ratio, increased P and T tau, increased neurofilament light chain
• Plasma - increased T tau, increased neurofilament light chain

Question 19

Imaging for biomarkers of Alzheimers

Answer 19

• Amyloid and Tau PET scan
• FDG PET scan for neuroinflammation (hypometabolism)
• MRI brain - atrophy

Question 20

Vascular dementia RF

Answer 20

• Diabetes
• HTN
• Previous stroke?
• Atherosclerosis?
• MI

Question 21

Imaging for vascular dementia

Answer 21

CT or MRI head - show areas of ischaemia

Question 22

Signs/symptoms of vascular dementia

Answer 22

• Gait (scizzoring, shuffling, parkinson like) and bladder problems - frontal lobe affected
• Fluctuating
• Emotional fluctuations but personality ok
• Stepwise decline - ok for a while then drop off

Question 23

Dementia with lewy body - who

Answer 23

Males affected more than females (unlike others)

Question 24

Pathophysiology of DLB

Answer 24

• Alpha synuclein accumulates

Question 25

Symptoms specific to DLB

Answer 25

* REM sleep disorder - act out dreams * Anosmia - years * Constipation * Visual hallucinations and delusions * Fluctuations in day - risk accidentally diagnosing delirium * VERY sensitive to neuroleptics * Autonomic dysfunction - urination problems, postural hypotension

Question 26

Difference between DLB and parkinson dementia

Answer 26

* For parkinson dementia, have parkinson symptoms for 1 year before get dementia like symptoms * DLB - cognitive decline is first

Question 27

DLB sensitive to neuroleptics consequence

Answer 27

* If give haloperidol if agitated if suspect extreme delirium = neuroleptic malignant syndrome = BAD * As already deficient in dopamine

Question 28

Neuroleptic malignant syndrome signs

Answer 28

* fever * Altered mental state * Rigidity * Autonomic dysfunction

Question 29

Parkinsonism features of DLB

Answer 29

* Rigidity * Bradykinesia * Tremors * Freezing

Question 30

Diagnosis aid for DLB

Answer 30

* DAT scan - dopamine active transporter scan, nuclear scan showing dopamine transport in specific areas of brain

Question 31

Frontotemporal dementia can affect

Answer 31

* Frontl lobe * Temporal lobe * Both

Question 32

behavioural varient FTD symptoms

Answer 32

* Changes to social behaviour * Loss empathy * Apathy * Disinhibition * Lack insigns

Question 33

Semantic FTD

Answer 33

* Loss ability to remember meaning of words, faces and objects * Impaired object naming * But fluent speech

Question 34

Progressive non fluent aphasia dementia

Answer 34

* Difficult speech, takes more effort * Can understand objects and words fine

Question 35

3 types of FTD

Answer 35

* Behavioural variant * Semantic * Progressive non fluent aphasia

Question 36

What is FTD associated with?

Answer 36

* Younger age onset * Genetic components unlike others (+sporadic mutations too) * Motor neurone disease + amyotrophic lateral sclerosis

Question 37

Proteins in FTD

Answer 37

* Tau * TDP (TAR DNA binding protein) * FUS (fused in sarcoma)

Question 38

What are TDP and FUS involved in?

Answer 38

Intranuclear - involved in RNA metabolism More familial componement to FTD

Question 39

Management of dementia

Answer 39

* Donepezil * Rivastigmine * Galantamine * Memantine Ach esterase inhibitors

Question 40

Management of dementia depends on...

Answer 40

Reisberg stage of disease - end stage need to think about DNACPR and advanced care planning

Question 41

How much dementia preventable?

Answer 41

40% other 60 is non-modifiable RF

Question 42

What do we need to rule out in agitated, aggressive pt?

Answer 42

* Pain * Constipation * Retention * Emotional distress * Sleep deprivation * Medication induced?

Question 43

Management for aggressive pt with dementia - non pharm

Answer 43

* Music and aroma therapy * Physical therapy * Lighting

Question 44

Pharmacological management for dementia aggressive pt (only LAST resort)

Answer 44

* Benzodiazepines eg Lorazepam * Mood stabilisers * Antipsychotics - haloperidol, risperidone (BUT these can make things worse so be careful)