Geriatrics - Dementia Flashcards
(40 cards)
What is the definition of dementia?
Dementia is a global loss of cognitive ability in a previously unimpaired person beyond what might be expected in normal ageing.
What are the diagnostic criteria needed for a diagnosis of dementia?
DSM IV states that the following criteria are required for a diagnosis of dementia:
1) Evidence of impairment of memory (amnesia) + at least one of
- language impairment
- apraxia
- agnosia
- impairment of executive function
2) Impairment of functioning
3) No other medical or psychiatric explanation
4) Present for at least 6 months
What is “mild cognitive impairment”?
Mild cognitive impairment (MCI) is a term that is often used non specifically and as such is not helpful diagnostically. It is applied when there is evidence of memory decline on formal memory tests (e.g. MMSE) WITHOUT any other clinical features of dementia.
Mild memory problems may indicate the early start of dementia but can be associated with other conditions such as depression, anxiety, stress or physical problems.
What is the link between MCI and dementia?
Approximately 10-15% of patients with MCI develop dementia every year.
It is important to note that many patients will report subjective memory loss, but unless there is objective evidence of decline in memory the diagnosis of MCI cannot be made.
What is the epidemiology of dementia?
The prevalence of dementia is 5% in the over 60s and 20% in the over 90s. The key risk factor for developing dementia is advancing age.
2/3s of patients with dementia are women.
How is dementia classified?
There are several classification systems for dementia. These aim to group disorders that have common features, such as which part of the brain is affected:
- Cortical dementia = dementia causing problems with memory, language, thinking and social problems
- Subcortical dementia = dementia causing problems with emotions, movement, and memory problems
- Progressive dementia = dementia that deteriorates over time
- Primary dementia = dementia that is not due to another cause
- Secondary dementia = dementias that occur due to physical injury or disease
Diseases often fit into several classifications -
e.g. Alzheimer’s disease is a primary, progressive cortical dementia.
Sometimes more than one of these can co-exist in the same patient - e.g. a patient with fixed cognitive impairment secondary to brain injury can go on to develop superimposed primary Alzheimer’s disease.
Name some degenerative causes of dementia?
Alzheimer's disease Frontotemporal dementia Lewy body dementia Parkinsons disease Huntington's disease PSP
Give some vascular causes of dementia?
Multi-infarct dementia Cerebral infarcts Binswanger's disease CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) Vasculitis (e.g. lupus)
What metabolic disorders can cause dementia?
Alcohol related Heavy metal poisoning Drug intoxication HYPOthyroidism B12 and folate deficiency Paraneoplastic Inherited metabolic disorders (e.g. Wilson's disease)
What is the most common type of dementia?
Alzheimer’s disease accounts for 62% of all cases of dementia. The risk of developing AD increases with age. Approx 98% of patients with AD are aged over 65 years.
How common is dementia with Parkinson’s disease?
Dementia affects up to 30% of patients with Parkinson’s disease.
The symptoms and signs are similar to those found in dementia with Lewy bodies.
Parkinson’s disease dementia presents in patients who have had a diagnosis of PD for more than 2 years.
What is mixed dementia?
This is the 3rd most common type of dementia and refers to a combination of AD and vascular dementia.
A key feature of vascular dementia is that it progresses in a stepwise fashion, as opposed to AD which is a progressive decline.
What is Lewy Body dementia?
Lewy body dementia affects 25000 people in the UK. Many symptoms are similar to those found in AD - e.g. memory deterioration, poor attention, communication difficulties. Patients with LBD often show Parkinsonism and hallucinations.
What is a key early signs of frontotemporal dementia?
FTD is a rare form of dementia that actually describes a variety of conditions. It includes Picks disease.
It is more common in adults < 65 years old. The early signs are personality and behavioural changes as opposed to memory decline.
How does dementia progress?
The progression of dementia can be divided into 3 phases (this is most typical of AD):
1) Early: difficulty embracing change, repetition of questions, short term memory loss
2) Middle: needs prompting, difficulty with daily tasks, failure to recognise people
3) Late: decline in speech, aggression, weight loss, incontinence
What is the role of genetics in dementia? How does this affect inheritance of dementia?
The majority of dementias result from a combination of multiple genetic contributions.
Lifestyle and environmental factors are often important and may play a role in how genes are expressed (genotype) and how the patient presents clinically (phenotype).
Whilst the son or daughter of a patient with dementia is at an increased risk of developing the disease, the complex interaction between multiple genes and the environment means that the heritability of dementia is unpredictable.
There are rare forms of dementia where the responsible genes have been identified - e.g. early onset AD.
What is early onset AD?
This is a subtype of AD that is rare compared with late onset AD. It is autosomal dominant and has 3 genes associated with it:
i) Amyloid precursor protein
ii) Presenilin gene 1
iii) Presenilin gene 2
If one of these genes is present then the disease is developed aged 30-40 years. If 2 or more close relatives develop AD before the age of 60, a patient should be considered for genetic screening.
What is late onset AD?
Late onset AD is the most common form of AD and develops in the over 65s.
Its development is linked to the apolipoprotein E gene (APO-E). There are 3 types: APO-E2, APO-E3, and APO-E4. Everyone has 2 copies of the gene which can be the same or different.
APO-E4 is associated with a higher risk of AD. About 25% of people inherit a single gene and this will increase their risk of AD by 4 times. 2% of the population will inherit 2 copies of the gene which will increase their risk of AD by 10 times.
APO-E3 gene is inherited in a double form by 60% of the population, and of these 50% will develop AD by their late 80s.
APO-E2 is mildly protective against AD.
What genes are associated with vascular dementia?
Single gene defects are associated with rare variants of this form of dementia:
- Notch3 gene is linked with CADASIL
- variation of the APP gene causes heritable cerebral haemorrhage with amyloidosis (HCHWA)
High cholesterol, diabetes and hypertension all contribute to the development of vascular dementia and have a genetic component as well.
What risk factors are associated with dementia?
Smoking: increases risk of mental decline
Alcohol (M)
Atherosclerosis (M)
Hypercholesterolaemia: raised LDL cholesterol increases risk of vascular dementia (M)
Age
Genetics
MCI
Some of these are modifiable (M).
What are the 3 forms of AD?
1) Early onset (rare) - fewer than 10% of AD patients. Associated with the development of myoclonus
2) Late onset (most common) - symptoms begin after 65
3) Familial (rare)
What are the features of the late stage of AD?
Remember that AD progresses in 3 stages or phases. The late phase is characterised by:
- increasing dependence on others for care
- inability to recognise familiar objects or even relatives
- increasing frailty
- poor appetite, dysphagia and even weight loss
- incontinence
- restlessness and agitation
What are the features of the early phase of AD?
- minor changes in abilities or behaviours, often only realised in hindsight
- loss of recent memory, repetition or questions, slow at grasping ideas
- unwilling to embrace change and difficulty dealing with money
How does AD progress clinically?
Symptoms evident during the early stages of AD are short term memory loss with disorientation and errors of judgement.
As the disease progresses:
- sufferers develop difficulty with daily functioning
- language skills decline
- there may be behavioural change with wandering
- often requirement with ADLs
End stages of the illness occur in the last 1-2 years of life:
- patients need intensive levels of care
- communication is severely impaired
- sufferers become incontinent
- swallowing becomes difficult
Most common cause of death is from infections such as pneumonia.
