Older Person's Health - Dementia Flashcards
(26 cards)
Cognitive things that get better/ mainatin with age?
Crystallised intelligence - skills, ability, and knowledge over learned, well practised and familiar, accumulate over time
- Vocabulary
- General knowledge
Visuospatial (simple)
Memory (Non-declarative):
* Procedural – memory how to do things e.g. ride bike
* Recognition – ability to retrieve information when given a cue
* Temporal order – memory for correct time or sequence of past events
Cognitive things that get WORSE with age?
Fluid cognition - innate ability to learn new information, problem solve (reduces from 3 rd decade, 0.02SD per year)
* Processing speed
* Psychomotor ability
* Complex attention: Selective and divided
* Verbal fluency
* Executive function
* Visual-construction
Declarative memory
* Episodic – “specific events to self”
* Semantic – “general knowledge/facts”
Risk factors for MCI?
- Apolipoprotein E allele
- Age
- Male
- Low SES
- Vascular risk factors
- Family history cognitive impairment
- Sedentary
- Comorbidities
Conversions from MCI
Amnestic MCI 5-16% per year conversion to Alzheimer dementia
Conversion rate to “normal cognition” 30 – 50%
Factors associated with conversion:
* Single cognitive domain
* Normal hippocampal volume
* Depression
* Anticholinergic burden
* Higher cognitive scores
* Absence of apolipoprotein E
Correctable factors -> MCI
Medical Conditions:
* thyroid,
* BP
* BSLs
* OSA
* NPH
* AF
Meds
* anticholinergics,
*sleeping tablets,
Psych
Vitamin def
Sensory loss
Infection
Who should do genetic tests for dementia in?
Young ppl with dementia.
Familial AD
* Autosomal dominant inheritance
* Early onset < 65 years old
* APP (Ch21), PSEN1, PSEN2 mutation account for 70% early onset AD
MCI due to AD citeria with biomarkers
What should you always do before prescribing cholinesterase inhibitor
ECG - Contraindicated in bradycardia/conduction issues, long QTc.
Main cholinesterase inhibitors
- Donepezil (tablet)
- Galantamine (tablet)
- Rivastigmine (tablet or patch)
main AE Cholinesterase inhibitors
- Contraindicated in bradycardia/conduction issues, long QTc.
- Risk with syncope, falls, fractures
- GI side effects most common
AE of memantine
May worsen delusions and hallucinations
What is Aducanumab?
(Aduhelm)
- Amyloid beta-directed monoclonal antibody
- Controversially FDA approved June 2021
- 30-40% Amyloid-related imaging abnormalities (ARIA), some serious
% of dementia post single/ recurrent strokes
~ 10% after single
> 30% with recurrent
Increased risk with:
* age
* previous stroke
* large volume stroke
* aphasia
* Left hemisphere lesion
* haemorrhagic stroke
Radiologic changes in cerebral small vessel disease
- Subcortical infarcts
- White matter hyperintensities (MRI) or hypodensities (CT)
- Microbleed MRI
- Atrophy
Main cognitive issues in cerebral small vessel disease
Subcortical pathology interrupts frontostriatal circuits. Deficits in:
* Attention
* Information processing
* Executive function –poor problem solving/initiation (apathy)
Apathy - often misinterpreted as depression
Pseudobulbar affect
Gait disorder
(Memory often relatively intact – problem with retrieval rather than encoding i.e recall improves with prompt)
Treatment for vascular CI
Hypertension:
* Tight control to prevent vascular disease BUT
* Hypotension accelerates cognitive decline in established small vessel disease
- Exercise improves cognition post stroke
- No evidence for antiplatelets or statins in cognitive improvement
- Some role of cholinesterase inhibitor in improving cognitive function and ADLS
Cerebral amyloid angiopathy
- Aβ protein in cortical and leptomeningeal blood vessel walls
- Hereditary (AD) and sporadic forms
Lobar, cortical, cortical-subcortical haemorrhage in > 55 years old
* No other causes of haemorrhage
* Microbleeds and cortical superficial siderosis
- Advanced CAA exhibit cognitive impairment
- Antiplatelets and anticoagulation increases bleeding risk
Clin features CADASIL
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
- Migraine with aura
- Lacunar syndrome stroke
- Subcortical features: pseudobulbar affect, gait dyspraxia, urinary incontinence, dementia
- Mood disorder (depression and apathy)
- Acute encephalopathy
- Seizures
Core clinical features DLB
- Fluctuating cognitive impairment
- Visual hallucinations
- REM sleep behavior disorder
- Parkinsonism: at least 1 of rigidity, bradykinesia or tremor
DLB/PDD treatment
Avoid antipsychotics: 2-3x mortality
* If absolutely necessary, low dose Quetiapine
Cholinesterase inhibitor - improve fluctuations, apathy, anxiety, hallucinations, sleep (single RCT)
~1/3 modest response of motor symptoms to L-dopa – worth a trial if parkinsonism is significant ( rigidity and bradykinesia)
Most common dementia < 60 yo?
Actually alcohol, but after that
FTD
- Mean age 62 years with normal distribution: less common >70yrs
Associations with FTD
Motor neuron disease ~15%
FHx: ~ 40% genetic with autosomal dominant pattern family history (most causing Tau mutations)
Causes of rapidly progressing dementia?
Creutzfeldt Jacob Disease - basically only cause
Diagnosis CJD
- Cerebellar, extrapyramidal, extraocular, myoclonus, akinetic mutism
AND
- EEG
OR
- 14-3-3 CSF (positive predictive value 95% if dementia <2 years)- contact infection control prior to LP
OR
- Ribbon sign MRI
