Geriatrics

Question 1

64-year-old man with 8 month hx decline with memory, confusion, swearing, answering door naked, mom had similar - diagnosis?

Answer 1

Fronto-temporal dementia

Question 2

What are the three types of fronto-temporal lobe degeneration?

Answer 2

1 Frontotemporal dementia (Pick’s disease)
2 Progressive non fluent aphasia (chronic progressive aphasia, CPA)
3 Semantic dementia

Question 3

Common features of frontotemporal lobar dementias

Answer 3

1 Onset before 65
2 Insidious onset
3 Relatively preserved memory and visuospatial skills
4 Personality change and social conduct problems

Question 4

What is Pick’s disease clinical features?

Answer 4

personality change
impaired social conduct
hyperorality
disinhibition
increased appetite
perseveration behaviours

Question 5

Macroscopic changes seen in Pick’s disease

Answer 5

Focal gyral atrophy with a knife-blade appearance
Atrophy of the frontal and temporal lobes

Question 6

Microscopic changes seen in Pick’s disease

Answer 6

1 Pick bodies - spherical aggregations of tau protein (silver-staining)
2 Gliosis
3 Neurofibrillary tangles
4 Senile plaques

Question 7

Management of Pick’s disease

Answer 7

NICE do not recommend AChE inhibitors or memantine

Question 8

CPA =chronic progressive apshasia features

Answer 8

non fluent speech.
short utterances that are agrammatic
Comprehension preserved

Question 9

Semantic dementia features

Answer 9

fluent progressive aphasia
speech is fluent but empty
conveys little meaning
memory better for recent events

Question 10

72-year-old man 4-month history of varying confusion and sleep disturbance, visual hallucinations, struggled to draw a clock face and could not count down from 20 to 1 currently on atorvastatin, amlodipine, apixaban - ?cause

Answer 10

Lewy Body Dementia

Question 11

Lewy Body Dementia Features

Answer 11

1 progressive cognitive impairment
- occurs before parkinsonism but within one year
-fluctuating cognition
-early impairments in attention and executive function rather than just memory loss
2 parkinsonism
3 visual hallucinations
(delusions and non-visual hallucinations possible)

Question 12

Lewy Body Diagnosis

Answer 12

usually clinical
SPECT

Question 13

Lewy Body Management

Answer 13

• acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
• memantine
• neurolpetics (anti-psychotics) can cause irreversible parkinsonism

Question 14

Factors favouring delirium over dementia

Answer 14

-acute onset
-impairment of consciousness
-fluctuation of symptoms: worse at night, periods of normality
-abnormal perception (e.g. illusions and hallucinations)
-agitation, fear
-delusions

Question 15

Relative contraindication of donazepil?
Side effect

Answer 15

-Sick Sinus Syndrome - bradycardia which occurs through vagus stimulation
(cholinesterase inhibitor)
-insomnia

Question 16

Alzheimer’s non-pharmacological treatment

Answer 16

-activities to promote wellbeing
-group cognitive stimulation therapy
-group reminiscence therapy and cognitive rehabilitation

Question 17

Alzheimers Pharmacological management

Answer 17

First line: acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
Second line: memantine
-if intolerant or CI to first line
-add on in mod-severe disease
-monotherapy in Alzheimers

Question 18

Managing non-cognitive symptoms in Alzhemeirs

Answer 18

-anti-depressants not routinely recommended in mild-mod
-antipsychotics if distress or harm

Question 19

Medication which should be stopped in dementia?

Answer 19

tricyclic anti-depressant (amitryptiline)

Question 20

Assesment tools which can be used for dementia diagnosis

and which should not be used

Answer 20

-10-point cognitive screener (10-CS)
-6-Item cognitive impairment test (6CIT)

-abbreviated mental test score (AMTS)
-general practitioner assessment of cognition (GPCOG)
-mini-mental state examination (MMSE)

Question 21

Investigations in dementia

Answer 21

-blood tests to rule out reversible
-imaging to rule out reversible and give subtype diagnosis

Question 22

72-year-old man attends his GP surgery with a 4-month history of confusion and sleep disturbance. His wife says the severity of his confusion varies between days but is also concerned that he is ‘seeing things’ such as people and animals around the house. His medications include apixaban 5mg, amlodipine 5mg, and atorvastatin 20mg. There is no history of recent infection. Observations are within normal limits and there is no motor or speech disturbance. However, he struggled to draw a clock face and could not count down from 20 to 1 correctly. A urine dip was normal.

Alzheimer’s disease
Chronic subdural haematoma
Frontotemporal dementia
Lewy body dementia
Vascular dementia

Answer 22

Lewy body dementia typically presents with fluctuating cognition in contrast to other forms of dementia

Question 23

You are a doctor working on an elderly care ward. You are asked to perform a cognitive assessment of Mavis, an 81-year-old woman who is suspected of having dementia.

You complete and Addenbrooke’s Cognitive Exam-3 (ACE-3) exam with Mavis. Out of 100, she scores 68. There is a global deficit in all domains tested in the ACE-3.

Given the above, information which condition do you suspect?

Alzheimer’s dementia
Frontotemporal dementia
Vascular dementia
Mild cognitive impairment
Parkinson’s dementia

Answer 23

-ACE-3 is sensitive and specific for the detection of dementia.
-score of 82 or less strongly suggests dementia
-People with Alzheimer’s dementia show a global deficit in all of the domains
-later deficits seen in memory and attention = damage to the medial temporal lobe

• frontotemporal dementia = deficits in fluency and language
  -vasc dementia - no consistent pattern
  -ACE-3 score of 82-88 suggests MCI ( mild cognitive impairment)
  -Parkinson’s dementia often show deficits in the visuospatial domain as well as memory and attention.

Question 24

A 72-year-old man who has recently been diagnosed with vascular dementia seeks advice on how to treat his new diagnosis.

He has a past medical history of high cholesterol, atrial fibrillation and currently smokes 10 cigarettes per day.

What is the best intervention?

Atorvastatin
Daily aspirin
Donepezil
Memantine
Smoking cessation

Answer 24

Tight control of vascular risk factors, rather than antidementia medication, is recommended by NICE in vascular dementia

Question 25

You perform a home visit on an 85-year-old woman, whose daughter is concerned by increased confusion in the last 2 days. Her past medical history includes mild cognitive impairment, ischaemic heart disease and diverticular disease. When you arrive, she reports feeling well. She says she has had no recent problems with her health. However, you suspect she might be an unreliable historian as she is slightly confused in time and place. On examination she has mild lower abdominal discomfort. On deep palpation, you feel a fullness in the left iliac fossa. Observations all lie in the normal range. What is the most likely cause of this woman's confusion? Acute diverticulitis Brain metastases from a colonic tumour Constipation Progression to Alzheimer's dementia Urine infection

Answer 25

Constipation is a very common cause of increased confusion in elderly patients

Question 26

Acute confusional state - predisposing factors

Answer 26

infection: particularly urinary tract infections metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration change of environment any significant cardiovascular, respiratory, neurological or endocrine condition severe pain alcohol withdrawal constipation

Question 27

Acute confusional state - features

Answer 27

memory disturbances (loss of short term > long term) may be very agitated or withdrawn disorientation mood change visual hallucinations disturbed sleep cycle poor attention

Question 28

Management of acute confusional state

Answer 28

-underlying cause -environment -if pharmacological therapy is required and no Parkinson’s disease is present: haloperidol 0.5 mg may be used first-line or olanzapine -in Parkinson’s disease - lorazepam is preferred if urgent treatment is required, or an atypical antipsychotic (e.g. quetiapine, clozapine) -careful reduction of the Parkinson medication may be helpful - olanzapine is not for delirium

Question 29

A GP receives a shared care document from the dementia specialist team, asking him to take over the prescribing of donepezil for a patient with Alzheimers disease. Which other medication if present on the patients repeat prescription may represent the strongest potential contraindication to donepezil? Tiotropium Verapamil Omeprazole Trimethoprim Glyceryltrinitrate spray

Answer 29

important S/E of acetylcholinesterase inhibitors is bradycardia or SAB/AVB (donepezil, rivastigmine and galantamine)

Question 30

A 70-year-old man comes to the GP surgery with his wife because she is growing increasingly concerned about his health. Five years ago he began to suffer from periods of confusion and sleepiness that seemed to come and go at random. More recently he has also developed a unilateral tremor in his right hand. Upon questioning, his wife tells you that she has slept in a separate bed for the last 30 years because her husband suffers from bad nightmares. What is the most likely diagnosis? Alzheimer's disease Dementia with Lewy bodies Frontal lobe dementia Parkinson's disease dementia Vascular dementia

Answer 30

Dementia with Lewy bodies

Question 31

A elderly lady patient presents with arthritic pains. At the end of the consultation she tells you she has been to see a doctor at the memory clinic who diagnosed her with Alzheimer's dementia. She cannot remember why she was not given any tablets to help with this. Which of the following would represent a relative contraindication to donepezil prescription? Patient on warfarin Mild Alzheimer's dementia Stage II renal impairment Resting bradycardia Mini-mental state examination (MMSE) score of 18

Question 32

A 75-year-old lady is admitted in an acute confusional state secondary to a urinary tract infection. Despite antibiotic therapy, reassurance and environmental modification she remains agitated. You are considering prescribing haloperidol. Which one of the following conditions may be significantly worsened if haloperidol is prescribed? Myasthenia gravis Parkinson's disease Essential tremor Epilepsy Depression

Answer 32

Parkinson's disease: already a deficit of dopamine in the basal ganglia -Haloperidol is a first-generation (typical) antipsychotic that works primarily by antagonising D2 dopamine receptors in the brain. - would worsen motor symptoms and possibly precipitating neuroleptic malignant syndrome

Question 33

An 86-year-old gentleman comes to see you with his daughter for a medication review. His memory has been declining recently and he was referred to memory clinic three months ago, where he was diagnosed with Alzheimer's dementia. His other medical history includes chronic back pain secondary to osteoporosis, ischaemic heart disease and atrial fibrillation. Which one of the following medications should you consider stopping? Amitriptyline Rivaroxaban Atorvastatin Alendronic acid Aspirin

Answer 33

Amitriptyline

Question 34

A 79-year-old man with a known history of mixed type dementia (Alzheimer's and vascular) is assessed in memory clinic as his family have noticed a further deterioration in his memory and cognition. His mini-mental state score is 12 and as such he is commenced on memantine. Which of the following best describes the mechanism of action of memantine? Serotonin receptor agonist Dopamine receptor antagonist Acetylcholinesterase inhibitor Butyrylcholinesterase and acetylcholinesterase inhibitor NMDA antagonist

Answer 34

NMDA receptor antagonist

Question 35

A 64-year-old man is seen in the memory clinic with an 8-month history of cognitive decline. His wife tells you that he has difficulty remembering basic tasks and is becoming more confused and forgetful than usual. She has also noticed a change in his personality and has caught him swearing more frequently and answering the door naked on multiple occasions. His mother had a similar reputation for being 'too outspoken' in her twilight years. He reports smoking 20 cigarettes/day and drinks 1 glass of wine each evening. What is the most likely diagnosis? Alzheimer's dementia Creutzfeldt-Jakob disease Frontotemporal dementia Lewy body dementia Vascular dementia

Answer 35

Frontotemporal dementia

Question 36

A 78-year-old man attends memory clinic with his daughter. He has a past medical history of hypertension and he is an ex-smoker. His daughter describes him being stable for many months, then noticing a sudden decline. This has occurred on multiple occasions. Montreal cognitive assessment (MoCA) score is 18/30 and physical examination is unremarkable. He denies visual or auditory hallucinations. What is the most likely underlying diagnosis? Alzheimer's dementia Frontotemporal dementia Lewy body dementia Parkinson's dementia Vascular dementia

Answer 36

Stepwise deterioration in cognitive function? - think vascular dementia