Memory Problems: Clinical Aspects and Management Flashcards by Aliya Hussain

What is dementia?

Progressive and irreversible global decline in cognition; there are 3 areas of life that are mainly affected:
• Cognition
• Behaviour
• Ability to perform ADLs

It is not one condition; it is a clinical syndrome, caused by many different disease processes

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Symptoms of dementia?

Memory problems

Behavioural change

Mood disturbance

Personality change

Psychosis

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Occurrence of dementia?

Increases with age but dementia is not caused by ageing itself; it does not just affect older people, e.g: Huntington’s disease

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Cognitive testing used as supportive evidence of a dementia diagnosis?

ACE-III - takes an average of 15 minutes and is the standard test in most psychiatry of old age departments

MoCA - shorter than ACE-III and is validated in many languages; it is also available in several versions, so repetitions of the test can be done

FAB (Frontal Assessment Battery)

Detailed neuropsychological testing (for specific patients)

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Components of a collateral / corroborative history?

Structured history

Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) - a series of Qs to ask a person close to the patient

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Other methods used to provide supportive evidence for a dementia diagnosis?

OT assessment - can do a cognitive performance test, where the patient is observed doing activities, e.g: washing, dressing; this estimates cognitive level and level of supervision required for daily living

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Differential diagnosis for cognitive impairment?

Dementia

Reversible causes of cognitive impairment (PVINDICATE)

Mild cognitive impairment

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Examples of reversible causes of cognitive impairment?

Delirium

Depression

Alcohol

Medications, e.g: tramadol

B12 or folate deficiency

Thyroid issues

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What is mild cognitive impairment?

Noticeable cognitive impairment with little deterioration of function, i.e: not a dementia yet

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Scores of a patient with mild cognitive impairment on cognitive testing/

Usually:
• ACE-III score of 80-89
• MoCA score of 24-26

NOTE - scores can vary

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Follow-up of mild cognitive impairment?

Repeat cognitive testing yearly (this can be repeated earlier)

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How to approach a consultation inv. giving a diagnosis of dementia?

BREAKING BAD NEWS

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Major features of Alzheimer’s disease?

SHORT-TERM memory loss

Dysphasia

Dyspraxia

Agnosia (inability to process sensory info)

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Ix for Alzheimer’s disease?

CT / MRI scan may show:
• Normal brain
• Medial temporal lobe atrophy
• Temporoparietal lobe atrophy

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Variants of Alzheimer’s disease?

Posterior cortical atrophy

Frontal

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Neuropathology of Alzheimer’s disease?

Intracellular neurofibrillary tangles and extracellular amyloid plaques

One of the 1st areas to be affected is the nucleus basalis of Meynert (main source of ACh for the cortex) in the basal forebrain; this disruption of cholinergic transmission partially explains how Alzheimer’s disease affects cognition

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Pharmacological management of Alzheimer’s disease?

Cholinesterase inhibitors - block the action of acetylcholinesterase, improving cholinergic transmission; licensed for use in MILD TO MODERATE Alzheimer’s disease:
• Donepezil
• Rivastigmine
• Galantamine

Memantine - blocking NMDA-type glutamate receptors (glutamate is the main excitatory NT in the brain and a theory is that neurones are damaged by glutamate over-activation in Alzheimer’s); licensed for use in MODERATE TO SEVERE disease
Check BP before prescribing, as it may cause hypertension

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Efficacy of cholinesterase inhibitors?

Do not affect underlying pathological processes in Alzheimer’s disease but they do slow cognitive decline, by increasing cholinergic transmission

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Side effects of cholinesterase inhibitors?

GI upset (diarrhoea and vomiting, often settles after the 1st few weeks)

Tiredness

Headache

Sleep disturbance

Bradycardia (CHECK PULSE before prescribing)

Side effects of memantine?

Normally well-tolerated, even by frail patients but may cause:
• Dizziness
• Confusion
• Agitation
• Sedation
• Headache
• Insomnia
• Hallucinations

Major features of vascular dementia?

The following symptoms are more common than in Alzheimer's disease:
• Dysphasia
• Dyscalculia
• Frontal lobe symptoms
• Affective symptoms

Others features that may be present are:
• Focal neurological signs
• Vascular risk factors
• Step-wise decline

Ix for vascular dementia?

CT / MRI scan shows small vessels disease and multiple lacunar infarcts

Method of clinically differentiating between Alzheimer’s disease and vascular dementia?

Hachinski Ischaemic Score (HIS):
• Abrupt onset - 2 points
• Step-wise deterioration - 1
• Fluctuating course - 2 
• Nocturnal confusion - 1
• Preservation of personality - 1
• Depression - 1
• Somatic complaints - 1
• Emotional incontinence - 1
• Hx of hypertension - 1
• Hx of stroke - 2
• Assoc. atherosclerosis - 1
• Focal neurological symptoms - 2
• Focal neurological signs - 2

Score of 4 or less indicates Alzheimer’s disease
Score of 7 or more indicates vascular dementia

3 syndromes of FTD and the major features of each?

1. Behavioural variant FTD -
 changes in social behaviour and conduct:
• Loss of social awareness
• Disinhibition
• Poor impulse control 
• Apathy

Primary Progressive Aphasia (PPA):
• Effortful, non-fluent speech
Semantic dementia - loss of semantic understanding leads to:
• Impaired word comprehension
• Speech remains fluent and grammatically faultless

Ix for FTD?

CT / MRI scan shows frontotemporal atrophy SPECT shows a reduced frontotemporal tracer uptake (SPECT is mainly useful for FTD diagnosis)

``` Most likely to cause semantic dementia of the following: • Vascular dementia • Alzheimer's disease • FTD • Alcohol-related brain damage • Lewy Body Dementia ``` ?

FTD

Major features and criteria for Lewy Body Dementia (DLB)?

Commonly, there is early reduced attention ``` 2 of the following are required: • Visual hallucinations • FLUCTUATING COGNITION • REM sleep behaviour disorder • Parkinsonism (not >1 year before onset of dementia) • +ve DAT scan ```

What is dementia in Parkinson's disease (DPD)?

Must have had Parkinson's disease for at least 1 year Clinical features of this and DLB are the same but the neuropathology differs

Differentiating DPD and DLB from one another?

Distinguished clinically by the timing of the symptoms: • In DLB, the cognitive impairment occurs before or around the same time as the movement disorder • In DPD, movement disorder is present for at least a year prior to onset of cognitive impairment

Ix for DPD?

+ve DAT scan

Compare the appearance of a normal vs abnormal DAT scan?

Normal DAT scan - caudate nucleus, putamen and globus pallidus together look like a comma Abnormal DAT scan - the above basal ganglia together look like a full stop

Treatment of DLB?

Rivastigmine (a specific cholinesterase inhibitor) NOTE - despite being used for Alzheimer's disease, DLB and DPD, cholinesterase inhibitors actually have a more prominent effect in DLB and DPD

Treatment of DPD?

Rivastigmine

Post-diagnostic support for those with dementia?

Management should begin ASAP following diagnosis, although this is often a time of uncertainty Encourage advance planning and inc. practical and legal advice, e.g: driving, Power of Attorney Some patient requires post-diagnostic counselling

Consequences of dementia, as it progresses?

Behavioural and psychiatric aspects become more prominent Increase physical co-morbidity Decreased ability to perform ADLs and reduced independence May require institutional care

Treatment of slow cognitive decline?

Treat Behavioural and Psychological Symptoms of Dementia (BPAD)

What are the BPSD?

Hallucinations Delusions Insomnia Anxiety, agitation, aggression, depression

Initial management of dementia?

Antecedents, behaviours and consequences Review physical symptoms and examination Ensure comfort, e.g: avoid thirst, hunger, discomfort; ensure sensory aids are worn Environment, activities, exercise Sleep Ensure hygiene is maintained Educate any carer

Mx of depression in dementia?

Anti-depressants +/- adjuncts

Mx of anxiety in dementia?

Anti-depressants and BZDs

Mx of visual hallucinations in dementia?

Cholinesterase inhibitors Anti-psychotics

Mx of other psychotic symptoms in dementia?

Anti-psychotics NOTE - never use anti-psychotic in LBD

Mx of insomnia in dementia

Melatonin Z drugs BZDs Sedating anti-depressants

Mx of agitation and aggression in dementia?

BZDs Anti-psychotics Sedating anti-depressants Cholinesterase inhibitors Memantine Pregabalin

Important point about Mx of issues in dementia?

Only treat these issue if they are causing the patient distress

Does a diagnosis of dementia stop driving?

Discuss this at diagnosis; for some patients, it does stop them from continuing with driving but for others it does not IT MUST BE REPORTED TO THE DVLA REGARDLESS Doctor makes the decision as to whether the patient can continue driving while Ix are ongoing

Methods of checking whether a dementia patient is safe to drive, if unsure during history?

Rookwood Driving Battery (carried out by OT) On road test