2. Geriatrics

Question 1

What are some precipitating factors of acute confusional state (delirium)?

Answer 1

Predisposing factors:
- age > 65 years
- background of dementia
- significant injury e.g. NOF
- frailty or multimorbidity
- polypharmacy

Question 2

How can we manage delirium?

Answer 2

• treatment of underlying cause
• modification of the environment
• Haloperidol 0.5 mg may be used

In patients with Parkinson’s disease, lorazepam is preferred
or an atypical antipsychotic (e.g. quetiapine, clozapine) may be used

Question 3

Why can haloperidol not be used in PD?

Answer 3

D2 antagonist
Worsen PD e.g rigidity and risk of NMD

Question 4

What are the risk factors of developing Alzheimer’s?

Answer 4

• Increasing age
• Family history
• Mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1)
• Apoprotein E allele E4
• Caucasian
• Down’s syndrome

Question 5

What is the pathophysiology of Alzheimer’s?

Answer 5

Macroscopic:
widespread cerebral atrophy, especially
cortex and hippocampus

Microscopic:
- Plaques due to deposition of type A-Beta-amyloid protein
- Intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein due to hyperphosphorylation

Biochemical:
Deficit of acetylcholine from damage to an ascending forebrain projection

Question 6

How is Alzheimer’s managed in primary care?

Answer 6

Non-pharmacological management
- Group cognitive stimulation therapy

Pharmacological management
- Acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)

• Memantine (an NMDA receptor antagonist) is second line
• Review polypharmacy and reduce ACB
• Antipsychotics only if harming self or hallucinations/agitation causing severe distress, use for shortest period of time e.g 6 weeks

Managing non-cognitive symptoms
- NICE does not recommend antidepressants for mild to moderate depression in patients with dementia
- Assess BPSD symptoms

Question 7

What is a contraindication of Donepezil?

Answer 7

• Bradycardia
• Adverse effects include insomnia

Question 8

How can you distinguish between delirium and dementia?

Answer 8

Factors favouring delirium over dementia
- acute onset
- impairment of consciousness
- fluctuation of symptoms: worse at night, periods of normality
- abnormal perception (e.g hallucinations)
- agitation, fear
- delusions

Question 9

What should you not prescribe in Lewy Body Dementia?

Answer 9

Antipsychotics can worsen the motor features of the condition

Question 10

What investigations should you do for someone if you suspect dementia?

Answer 10

- Bloods to exclude reversible causes (e.g. Hypothyroidism) : FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels

- Neuroimaging to exclude other reversible conditions (e.g. subdural haematoma, normal pressure hydrocephalus)

- Memory clinic for tests e.g MMSE 24 out of 30

Question 11

On doing a polypharmacy review for a newly diagnosed dementia patient, what medications should you consider stopping?

Answer 11

Anticholinergic Cognitive Burden Scale

• Tricyclic antidepressants e.g amitriptylline
• Antiemetics e.g metoclopramide
• Analgesics e.g tramadol
• Sedatives e.g benzos
• Antihistamines e.g chlorphenamine

Question 12

What is the gold standard nemory test for dementia and what score would indicate dementia?

Answer 12

ADDENBROOKE’S COGNITIVE EXAM

ACEIII
<82 = dementia
82-88 = mild cognitive impairment

M-ACE
<21 = dementia
21-25 = MCI

Question 13

What are the three types of FTD and how do they each present differently?

Answer 13

Pick’s disease
- Personality change and impaired social conduct
- Focal gyral atrophy with a knife-blade appearance is characteristic

CPA (chronic progressive aphasia)
- Non fluent speech. Short utterances that are agrammatic
- Comprehension is relatively preserved.

Semantic dementia
- Fluent progressive aphasia
- The speech is fluent but empty and conveys little meaning
- Better short than long term memory

Question 14

What is the microscopic appearance of Pick’s disease?

Answer 14

• Pick bodies - spherical aggregations of tau protein (silver-staining)
• Gliosis
• Neurofibrillary tangles
• Senile plaques

Question 15

What are the common features of FTD?

Answer 15

Question 16

What is the pathophysiology of Lewy Body Dementia?

Answer 16

Alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas

Question 17

How is LBD diagnosed?

Answer 17

• Usually clinical
• Single-photon emission computed tomography (SPECT) (a.k.a DaTscan. Dopaminergic iodine-123-radiolabelled)

Question 18

How is LBD managed?

Answer 18

• Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine
• Avoid antipsychotics

Question 19

What is the inherited form of vascular dementia?

Answer 19

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)

Question 20

How should a diagnosis of vascular dementia be made?

Answer 20

NINDS-AIREN criteria

• Formal screen for cognitive impairment
• Medical review to exclude medication cause of cognitive decline
• MRI scan (may show infarcts and extensive white matter changes)

Question 21

How is vascular dementia managed?

Answer 21

• Aaddress cardiovascular risk factors to slow progression
• Non-pharmacological managemen tailored to the individual
• Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies
• NO evidence for statins or aspirin