Geriatrics: Dementia and delirium Flashcards
In advanced dementia what is preferred method of feeding?
Prefer hand held feeding over tube as there is increased tube related complications such as blockage and dislodgement. Furthermore, causes discomfort to the patient.
Increases chance of aspiration pneumonia as it decreases the lower esophageal sphincter, making GERD more common.
What is the range of pathogy for vascular dementia?
- Diffuse confluent age related WM changes/subcortical ateriosclerotic encephalopathy (SAE)
- Multi-lacunar state
- Multiple (territorial infarcts)
- Strategic cortical-subcortical or watershed lesions
- Cortical laminar necrosis (granular cortical atrophy)
- Delayed post-ischemic demyelination
- Hippocampal sclerosis
What are the physiologic changes of the brain with aging?
- Decreased brain volume and metabolic rate: decline in episodic memory
- Decreased dopamine levels –> decline in cognitive and motor performance
- Decreased serotonin and brain derived neurotrophic factor –> decreased synaptic plasticity and neurogenesis
- Increased monoamine oxidase –> liberate free radicals
- Increased BBB permeability –> increased inflammatory response and structural damage
- Arteriosclerosis: increased vascular resistance and decreased perfusion pressure
What is the diagnostic criteria for probable lewy body dementia?
Central feature: dementia (+FDG biomarker evidence)
Deficits on tests of attention, executive function and visuospatial ability
Core features (>2 probabele, 1 possible)
Fluctuation of cognition (attention and alertness)
Recurrent visual hallucinations
Spontaneous parkinsonism
Suggestive features (>1 + core features: probable, >1 possible)
Severe neuroleptic sensitivity
REM sleep behavioural disorder (violent)
What is the neuroimaging findings in dementia with lewy bodies/parkinsons disease dementia)
Cerebral blood flow and metabolism: general reduction, most marked in occipital: quite similar to AD
Focal deficits favor vascular dementia rather than DLB
Dopaminergic imaging most important marker
FP-CIT: tracers bind to the presynaptic dopamine transporter
Abnormal striatal uptake (decreased binding in BG)
Putaminal before caudate abnormality
May be asymmetric initially
Amyloid imaging: may have cortical uptake similar to AD in 40-80% in DLB subjects, less so in PDD
What are the 3 types of primary progressive aphasia?
- Semantic dementia (SD): fluent but circumlocution, frequent asking about meaning
- Progressive non fluent aphasia (PNFA): non fluent, effortful, grammer problems and anomia
- Logopenic aphasia (LA): slowed speech, frequent pauses, anomia, no grammer problem
What is the international consensus criteria for behavioural variant FTD (frontotemporal dementia)?
> 3 symptoms
* Early behavioural disinhibition
* Early apathy or inertia
* Early loss of sympathy or empathy
* Early preservative, stereotyped or compulsive/ritualistic behaviour
* Hyperorality and dietary changes
* Neuropsychological profile: executive/generation deficits with relative sparing of memory and visuospatial functions
Progressive deterioration
* Imaging results consistent with bvFTD (>1)
* Frontal and/or anterior temporal atrophy on MRI/CT
* Frontal and/or anterior temporal hypoperfusion or hypometabolism on PET/SPECT
What are the types of dementia?
- Alzheimers disease (most common)
- Vascular dementia (2nd most common)
- Lewy bodies dementia (alpha synuclein)
- Frontotemporal dementia (abnormal forms of the proteins tau and TDP-43)
- Mixed dementia (multiple forms)
What are recently approved drugs for AD?
Aducanumab: amyloid beta directed monoclonal antibody
Lecanemab
Transcription of the amyloid protien is abnormal (normally very fluid in the BBB) –> becomes sticky if there is mutation. This results in leakage of tau proteins
What genes are involved in familial AD?
Genes in sporadic form?
Familial AD: APP, PSEN1, PSEN2
Sporadic form: ApoE
What can be used to treat communicating hydrocephalus?
Ventriculoperitoneal shunt to help with CSF drainage
What is the triad of normal pressure hydrocepahlus?
Gait disturbance, urinary incontinence –> dementia
What are some medication related causes of delirium?
What investigations including imaging done for cognitive decline?
TFT, Vit b12, folate, VDRL
Plain CT
Pittsburgh compound B scan (PET scan) used for geriatrics cognitive assessment (not PET scan FDG) which is used to detect amyloid position
SPECT scan: regional blood flow (vascular dementia post stroke)
What are the biomarkers for AD?
beta-amyloid 42 (decreased)
tau (increased)
phospho-tau (increased)
What are characteristics of Lewy bodies dementia?
REM sleep aggressiveness, disorientation
Visual hallucination (give quetiapine 50mg)
No hippocampal atrophy
Hypometabolism occipital, parietal in PET scan
PIB PET amyloid deposition is low
Other symptoms: neuroleptic hypersensitivity (drowsiness, confusion, abrupt worseninig of parkinsonism, postural hypotension, or neuroleptic malignant syndrome)
LBD affects cerebral cortex more (more executive functions over motor function)
What imaging feature seen for normal pressure hydrocephalus?
If frontal horn is 1/3 of the maximum length of the skull than it is ventriculomegaly
Frontal sulci is not shrunken therefore not cerebral atrophy (will be generalized sunken sulci)
Geriatric cerebral atrophy
dx?
Frontotemporal dementia
