Dementia/dementing illnesses

Question 1

Important questions to ask when evaluating patients with symptoms of cognitive impairment

Answer 1

Are the patients symptoms abnormal?
Memory deficits only, or other cognitive impairments in addition?
Is the problem progressive?
Is the cause potentially reversible?
Do the history, physical, and test results suggest a specific primary dementing illness (AD, DLB, FTD, vascular dementia)?

Question 2

What evidence on history makes a memory problem less likely to be dementia?

Answer 2

If the patient is able to report the specific incident in great detail, without help from family members

Question 3

Definition of dementia

Answer 3

Acquired, persistent decline of intellectual function that causes impaired functioning in the absence of underlying psychiatric disease or clouded sensorium

Question 4

Definition of delirium

Answer 4

Acute, transient, fluctuating confusional state characterized by inattention, sensory misperception, or disorganized thinking

Question 5

Signs of pseudodementia

Answer 5

SIGECAPS (depressive symptoms of sleep changes, loss of interest, guilt, energy loss, cognitive changes, appetite, psychomotor, suicidal thoughts)

Question 6

Tests to look for potentially reversible causes of dementis

Answer 6

Blood: electrolytes, BUN/Cr, glucose, Ca, LFTs, CBC, ESR, B12, folate, TSH

Urine: UA
Imaging: head CT or MRI (if exam abnormalities)

Question 7

Presentation of Alzheimer’s disease

Answer 7

Highly variable. Presents in older age (>75) with widespread cognitive deficits in multiple domains, with memory loss usually as the first symptom

Question 8

Drugs for Alzheimer’s

Answer 8

AChE inhibitors:
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
NMDA antagonis:
Memantine (Namenda)

Question 9

Clinical features of dementia with Lewy bodies

Answer 9

Rigidity and parkinsonism early in course
Visual hallucinations early in course
Marked fluctuations in cognition or alertness
REM sleep behavior disorder

Question 10

Treatment of DLB

Answer 10

Cholinesterase inhibitors for cognitive improvement
CAUTION with antipsychotics (DLP pts extremely sensitive)
Carbi-Levo NOT as helpful as in parkinsons

Question 11

Presentation of frontotemporal dementia

Answer 11

Progressive behavioral disturbance or progressive language difficulties, typically in younger patients (before 65)