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1

Week 236 - Alzheimers: What is the ICD10 diagnostic criteria for dementia?

• Acquired impairment in memory for at least 6 months plus impairment in one of the following cognitive domains-
- Executive functioning
- Language
- Praxis (learned motor tasks)
- Gnosis (ability to recognize objects, faces)

These impairments must be severe enough to interfere with work, social activities and relationships.

2

Week 236 - Alzheimers: What is mild cognitive impairment?

Cognitive decline that is greater than we would expect for age but which does not notably interfere with activities of daily living.

3

Week 236 - Alzheimers: What are the risk factors for developing alzheimers?

• Age
• Female
• Genetics
• Head injury
• Environmental (eg. oxidative stress)

4

Week 236 - Alzheimers: What are the risk factors for developing vascular dementia?

• Smoking
• Diabetes
• High cholesterol
• Hypertension
• Male

5

Week 236 - Alzheimers: How are Parkinson's dementia and Lewy body dementia related and how do they differ?

• Parkinsons dementia
- Prominent motor features and motor symptoms predate dementia by at least 6 months.

• Lewy body dementia
- Parkinsonia motor features are mild and onset of memory and motor features are more closely related in time.

6

Week 236 - Alzheimers: What is the presentation of vascular dementia?

• Sudden onset
• Stepwise progression
• Mood/behaviour change
• Insight preserved

7

Week 236 - Alzheimers: What is the presentation of Lewy body dementia?

• Fluctuating cognition
• Vivid visual hallucinations
• Mild parkinsonian features
• Repeated falls

8

Week 236 - Alzheimers: What is Pick's disease?

• A type of fronto-temporal dementia

9

Week 236 - Alzheimers: How does fronto-temporal dementia present?

• Apathy, reduced motivation, self neglect.
• Disinhibited, decreased social awareness, lack of judgement.
• Change in personality
• Memory loss is variable
• Language difficulties are prominent

10

Week 236 - Alzheimers: How can depression be misinterpreted as dementia?

• They may get psychotic features.
• Impaired attention and concentration may lead to subjective complaints of memory loss.

11

Week 236 - Alzheimers: What are some of the causes of secondary dementia?

• HIV, CJD
• Inflammatory - SLE,MS
• Renal failure - Vit def.
• Hypothyroidism
• Alcohol
• Traumatic eg SDH

12

Week 236 - Alzheimers: What is Korsakoff's dementia?

• A secondary cause of dementia that is related to a history of alcohol dependence.
• Caused by Vitamin B1 deficiency (thiamine)
• Follows acute Wernicke's encephalopathy.
- Ataxia, opthalmoplegia, nystagmus, confusion.

13

Week 236 - Alzheimers: What are the genetics underlying the early onset of Alzheimers (

• Presenilin gene 2 (chromosome 1)
• Presenilin gene 1 (chromosome 14)
• Beta amyloid precursor protein gene (chromosome 21)

14

Week 236 - Alzheimers: What are the genetics underlying late onset alzheimers? (>65yrs)

• Apolopoprotein E gene (chromosome 19)

15

Week 236 - Alzheimers: What is the medical treatment in alzheimers and Lewy body dementia?

• Mild-moderate dementia consider anti-cholinesterase.
• Moderate-advance dementia consider memantine.

16

Week 236 - Alzheimers: What is the medical management for vascular dementia?

Treatment of cardiovascular risks.
- Low dose aspirin, statin, management of BP, blood glucose.
- Lifestyle advice re smoking, low fat diet.

17

Week 236 - Alzheimers: What drugs are anti-cholinesterase's? What are they used to treat?

• Mild-moderate dementia. (Due to alzheimers or Lewy body)
• Aricept - Donepezil
• Exelon - Rivastigmine
• Reminyl - Galantamine

18

Week 236 - Alzheimers: Memantine is used in the treatment of moderate-severe dementia caused by alzheimers or Lewy bodies. What is it and what is its mechanism of action?

• NMDA antagonist.
• Blocks NMDA receptors and so blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction.

19

Week 236 - Alzheimers: What are some of the behavioural and psychiatric features of dementia?

• Agitation and agression.
• Restlessness and wandering.
• Depression, anxiety, sleep disturbance.
• Delusions/hallucinations.
• Disinhibition.

20

Week 236 - Alzheimers: What are the key for points for understanding whether someone has capacity?

Can the person-
• Understand information relevant to the decision.
• Retain that information.
• Use/weigh that info when making a decision.
• Communicate decision.

21

Week 236 - Alzheimers: What are the driving rules with dementia?

• Patient must notify DVLA
• Doctor may advise against driving
• DVLA 12 month license may renew
• On road test
• Patient must inform insurance company

22

Week 236 - Alzheimers: What are the macroscopic pathology findings of alzheimers?

• Cerebral atrophy
• Ventricular dilatation

23

Week 236 - Alzheimers: What are the three microscopic features of alzheimers disease?

• Amyloid plaques between neurones.
• Amyloid deposited in cerebral blood vessel walls.
• Neurofibrillary tangles - made up of the tau protein.

24

Week 236 - Alzheimers: What are the two hypotheses behind alzheimers disease?

• Cholinergic

• Glutamergic

25

Week 236 - Alzheimers: What is the cholinergic hypothesis of alzheimers?

• Acetylcholine is vital in memory and cognition.
• Pathological processes result in an extensive deficit of cholinergic neurotransmission.

26

Week 236 - Alzheimers: What is the glutamergic hypothesis of Alzheimers?

• Neuronal damage linked to over-activation of NMDA receptors by glutamate.

27

Week 236 - Alzheimers: High levels of which neurotransmitter are 'excitotoxic'? It is the major mechanism of neuronal death in which conditions?

• Glutamate
• Stroke, epilepsy, Huntingtons Disease, Alcohol withdrawal, Alzheimers (Hypothesis).

28

Week 236 - Alzheimers: Where is acetylcholine made?

Basal forebrain
- Projections to the cortex and hippocampus.

29

Week 236 - Alzheimers: What are the three main types of memory? (Temporally)

• Short-term memory - Sensory processing
• Working-memory - Info is held whilst you work out what to do with it.
• Long-term memory - Turn working memory into 'permanent'

30

Week 236 - Alzheimers: What are the two types of memory? (Functionally)

• Declarative (explicit)
- Semantic (concepts)
- Episodic (autobiographical)
- Medial temporal lobe, hypothalamus, thalamus.

• Non-declarative (implicit memory)
- Procedural memory, skills, habits - striatum
- Motor learning - cerebellum
- Emotional conditioning - amygdala