Lecture 14- Dementia and delirium

Question 1

Dementia summary

Answer 1

Dementia is a syndrome (usually progressive) characterised by an appreciable deterioration in cognition resulting in behavioural problems and impairment in the activities of daily living. Decline in cognition is extensive, often affecting multiple domains of intellectual functioning

• Alzheimer’s most common (50-70%)
  
  • Women>men
• Vascular dementia (25%)
• Lewy body (15%_
• Frontotemporal dementia
• AIDS-dementia complex

Question 2

pathophysiology of alzheimers dementia

Answer 2

• Global atrophy of brain lobes
  
  • Mostly frontal, parietal and temporal lobes
• Sulcus widening
• Enlarged 3^rd and 4^th interventricular space

Question 3

2 theories for AD

Answer 3

amyloid hypothesis

abnormal aggregation of Tau protein

Question 4

The amyloid hypothesis – 1st theory

Answer 4

Question 5

Abnormal aggregation of the Tau protein- 2^nd theory

Answer 5

• Tau is a microtubule associated protein that stabilises microtubules in the cell
• Tau accumulates into intraneuronal masses known as neurofibrillary tangles and as dystrophic neurites
• Abundance of tangles roughly proportion to the severity of clinical disease and cognitive decline

Question 6

AD RF

Answer 6

• Head injury
• High serum cholesterol and fats
• Lifestyle factors: smoking, midlife obesity and diet high in sat fats

Question 7

AD history: questions to ask

Answer 7

• Ask RF (inc family history of down syndrome)
• Memory loss –> loss of recent first
• Disorientation to time and place (misplacing items/getting lost)
• Nominal dysphasia à proper name sand low-frequency words decline first
• Apathy
• Decline in ADLs
• Personality/ mood change

Question 8

Management of AD

Answer 8

• Carer support (OT, community services, ID bracelets)
• Pharmacological
  
  • Cholinesterase inhibitors
  • Antidepressants
  • Antipsychotics (controversial)

Question 9

Vascular dementia pathophysiology

Answer 9

• Common endpoint of many vascular pathologies intracranially
  
  • Infarction
  • Leukaoraisois –> disease of white matter also called subcortical leukoencephalopathy
  • Haemorrhage
  • Alzheimer’s disease –> although not classified as a vascular pathology, AD has a strong vascular risk- factor spectrum

Question 10

vascualt dementia : history questions to ask

Answer 10

• History of stroke
• Difficulty solving problems
• Apathy
• Disinhibition
• Slow processing
• Poor attention
• Retrieval memory deficit
• Risk factors similar to IHD

Question 11

Management of VD

Answer 11

Basically reducing risk of further sclerotic/embolic effects

• Antiplatelet therapy/Anticoagulation
• Lifestyle modification
• BP control if HTN
• Statin therapy if elevated LDL cholesterol
• Optimisation of glycaemic control if diabetic
• Carotid endarterectomy if carotid stenosis >70%
• Cholinesterase inhibitors or memantine if concomitant AD

Question 12

Lewy body dementia pathophysiology

*

Answer 12

• Accumulation of lewy bodies in vulnerable sites of the CNS
  
  • substantia nigra
  • temorpal lobe
  • frontal lobe
  • cingulate gyrus

Question 13

what are lewy bodies

Answer 13

• Lewy bodies are composed of protein alpha-synuclein, a cytoplasmic protein associated with synaptic vesicles. Other proteins include neurofilament and ubiquitin
• The distribution and density of Lewy bodies are thought to be correlated with clinical syndromes
• Co-existing AD pathology is common

Question 14

Parkinson’s or Lewy body dementia?

Answer 14

Question 15

lewy body dementia history taking

Answer 15

History

• Risk factor = old age
• Cognitive fluctuations
• Hallucinations, typically visual and complex; up to 80% of patients
• Motor symptoms → Parkinsonian features present in >85% of patients
• Vivid dreams are accompanied by loss of associated atonia of REM sleep; ‘acting out’ dreams
• Depression
• Repeated falls/syncope
• Urinary incontinence
• Constipation

Question 16

management of lewy body dementia

Question 17

Frontotemporal dementia

Aetiology

Answer 17

• Focal neurodegeneration of the frontal or temporal lobes of the brain
• Strong family history

Question 19

frontotemporal dementia pathophysiology

Answer 19

Pathophysiology

Definitive diagnosis depends on the pathological examination of brain tissue, and identification of patterns of neuronal injury and characteristic intra-neuronal and glial cell inclusions. Specific accumulations found:

• FTD-tau
• FTD-U (ubiquitin)

Question 20

classification of FTD

Answer 20

3 behavioural presentations of FTD

• Apathetic
• Disinhibited
• Stereotypic

Can be overlapping

Distinction between behavioural FTD vs Primary progressive aphasia

Question 21

History FTD

Answer 21

• Coarsening of personality, social behaviour, and habits
• Progressive loss of language fluency or comprehension
• Development of memory impairment, disorientation, or apraxias
• Progressive self-neglect and abandonment of work, activities, and social contacts
• Age at onset peak in mid-50s
• FHx
• Altered eating habits

Question 22

Management of FTD

Answer 22

*not standard dementia medication*

Dependent on patient need:

• Acute irritability, restlessness, agitation, or aggression → benzos
• Home-assistance, respite care
• Compulsions → SSRIs
• Sleeping disturbance → Mirtazapine 1st line
• Distractibility → amantadine
• Gluttony → topiramate

Question 23

AIDs dementia complex pathophysiology

Answer 23

• As patients with HIV infection live longer thanks to modern treatments, their chance of developing AIDS associated dementia is increasing
• HIV-infected macrophages enter the brain, causing indirect damage to neurones
• Insidious onset, but rapid progression once established

Question 24

Clinical features of AIDs dementia complex

Answer 24

• Related to global damage but also some manifestations of cerebellar involvement:
  
  • Cognitive impairment
  • Psychomotor retardation (slow thoughts and movements, also seen in depression)
  • Tremor Ataxia Dysarthria Incontinence

Question 25

**Prognosis of dementia**

Answer 25

Question 26

dementia investigations

Answer 26

* Mini-mental state exam * dementia screen * FBC (anaemia) * U&E (deranged sodium, calcium, glucose) * TSH --\> hyper/hypothryodisms * serum vitamin B12 * Urine drug screen * CT head * MRI brain * ECG in vascular dementia * Routine syphilis testing is not necessary but should be done if a risk is identified in the history

Question 27

* Mini-Mental State Exam

Answer 27

Question 28

define delirium

Answer 28

Question 29

why is delirium important to recognise

Answer 29

Patients who develop delirium also have longer length of stay and more likely to develop hospital acquire complications such as falls and pressure sores * Increased mortality

Question 30

**Types of delirium**

Answer 30

* **Hyperactive** – easier to spot * Agitated * Restless * Inappropriate behaviour * **Hypoactive** * Lethargy * Reduced conc * Increased appetite * **Mixed-** hyperactive and hypoactive

Question 31

**Screening for delirium**

Answer 31

Question 32

delirium assessment- what is the underlying cause

Answer 32

* history and examiantion * collateral history is very important * investgiations tailored to individual

Question 33

**Potential underlying causes**

Answer 33

**THINK** * Trauma (head injury, intracranial event) * Hypoxia (PE\< CCF, MI, COPD, pneumonia) * Increasing age/frailty * Neck of femur fracture * SmoKer or alcohol withdrawal **DELIRIUM** * Drugs (new stopped /started, side effects, drug interactions) * Environment- especially ward moves * Lack of sleep * Imbalanced electrolytes (renal failure, Na+, Ca2+, glucose, liver function) * Retention (urinary and constipation) * Infection/sepsis * Uncontrolled pain * Medial conditions (Dementia, Parkinson’s disease)

Question 34

**Management of delirium**

Answer 34

* Minimise/treat precipitating factors * Encourage normal day/nigh cycle * Allow wandering if safe * Consider DOLs (deprivation of liberties safeguard) * Involve family/loved ones * For challenging behaviour * Distraction techniques * Medications last resort

Question 35

**Prognosis of delirium**

Answer 35

*‘Reversible cause of confusion’*

Question 36

compare dementia and delirium

Answer 36