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1

What is Charles Bonnet Syndrome (CBS)?

Complex visual hallucinations in indivduals w/ acquired visual loss with insight and without cognitive impairment (10-60%)

[high incidence of non reporting + diagnosis of exclusion]

2

Common characteristics of CBS?

- Simple geometric shapes
- Complex shapes with reconisable forms (faces, objects)
- Tessellopsia (regular, overlapping patterns)
- Prosometamorphopsia (facial distorsion)
- Dendropsia (branching forms)
- Hyperchromatopsia (all objects appear coloured)
- Polyopia (multiple forms of one image)
- Micropsia (objects appear smaller than normal)
- Macropsia

3

General features of the nature of dementia presentation

- no implied aetiology
- insidious onset, progressive decline
- clear consciousness
- deficits in behaviour, attention, memory, language, visuospatial dys
- reversible/irreversible; indolent/rapid progress; multiple def/isolated def

4

1st and 2nd most common dementia forms?

1. AD
2. DLB (and PDD)

[there is also vasc. dement and FTD)

5

How to definitively diagnose dementia?

Brain tissue required (biopsy)

6

Features that should be preserved w/ ageing?

- Temporal Orientation

- Immediate Attention

- Vocabulary

- Visuospatial skills

- Judgement & Insight

7

Features that suffer mild decrements w/ ageing

- Sustained Attention
- Visual > Verbal recall

- Naming

- Response speed

- Flexibility

8

What is Mild Cognitive Impairement (MCI)?

Cognitive impairment that is insufficient to reach criterion of "dementia"

Amnestic/non-amnestic

10-15% annually convert to dementia

NB: rule out psyc/drug/other

9

Features of Depressive Pseudodementia (DPD)?

- apathy

- social withdrawal

- mutism

- incontinence

- lack of "sadness"

[depression is misdiagnosed as dementia in 8-15% of mentally declining pts]

NB: depression is present in 20-30% of demented pts

10

Clues of DPD?

- FHx
- subacute onset
- agitation/pacing
- precipitants
- poor memory
- poor effort
- spared language + praxis
- normal EEG/imaging

11

What is Balint's syndrome

[focal lesion]

Unable to perceive visual field as a whole:

- occulomotor apraxia
- optic ataxia
- visual stimultagnosia

12

What is Gerstmann's syndrome?

[focal lesion]

- dysgraphia/agraphia
- acalculia
- finger agnosia
- unable to distinguish R/L side of body

13

Types of anatomical classification of dementia pathology?

- subcortical
- cortical

14

Describe subcortical features of dementia?

- slow, inefficient
- apathy, mood, personality
- motor signs

[e.g. PDD, huntingtons, PSP, MS, Wilson's, HIV)

15

Describe cortical features of dementia?

- language
- praxis (visuospatial)
- disinhibition
- (memory)

[e.g. AD, FTD, DLC, CJD]

16

Describe feature of delirium?

Impaired stream of though and cognitive deficits

17

Diagnose:

Insidious amnesia, language impairment (anomia, paraphrasias, poor comprehension): ?

Lack of hygiene, personality change, poor comportment & planning: ?

Fluctuation, agitation, hallucinations, visuospatial dysfunction, Parkinsonism, neuroleptic sensitivity: ?

AD

FTD

DLB

18

Diagnose:

Memory loss, Ataxia, Incontinence: ?

Stepwise decline, focal/motor/gait signs: ?

Subacute or rapid decline,motor signs: ?

Normal Pressure Hydrocephalus (NPH)

Multi-Infarct Dementia (MID)

CJD/Autoimmune

19

Potential differentials for dementia symptoms?

- normal ageing
- psych disease (depress-pseudo dem, depression)
- drug
- focal neuro syndromes (aphasia, anomia, amnesia etc)
- acute confusional states (delirium)
- MCI (amnestic vs non-amnestic)
- MS
- Charles Bonnet Syndrome

20

Ddx of visual hallucinations?

- neurological (PD, LBD, epilepsy)
- psychiatric (schizophrenia)
- drugs
- sleep deprivation

21

Investigations for dementia symptoms?

- history
- neuro exam (dementia is a clinical diagnosis)
- biomarkers (CSF tau, CSF amyloid)
- EEG (slow wave activity in dementia due to increased delta waves)
- imaging (CT, MRI, PET, SPECT)
- brain biopsy (definitive)

22

Types of management for dementia?

Symptomatic treatment (no treatments that can halt progression)

23

Categories of dementia

- neurodegenerative
- traumatic/structural
- vascular
- metabolic
- toxic
- psychiatric

24

List some forms of neurodegenerative dementia?

- AD
- LBD
- PDD
- PSP/CBD
- FTLD

25

Forms of traumatic/structural dementia?

- subdural haematoma
- head injury (CTE, DAI, cerebral contusions)
- NPH (normal pressure hydrocephalus)
- neoplasm

26

Forms of vascular dementia?

- multi-infarct dementia
- cerebral amyloid angiopathy
- vasculitis (Wegner's)

27

Metabolic causes of dementia?

- hypoxia/hypercapnia
- uraemia
- hepatic encephalopathy
- thiamine/B12 deficiency
- hypoglycaemia

28

Toxic causes of dementia?

- medication (Anticholinergic, valproate)
- alcohol
- carbon monoxide

29

Psychiatric causes of dementia?

- schizophrenia
- depression (pseudodementia)
- bipolar disorder

30

How to differentiate normal ageing from dementia?

Normal ageing has:
- preserved temporal orientation
- preserved visuospatial skills
- preserved judgement
- can give immediate attention when asked