dementia

Question 1

how many people in the world live with dementia?

Answer 1

46 million

Question 2

commonest cause of dementia?

Answer 2

Alzheimer’s disease

- characterised by progressive cognitive, social and functional impairment

Question 3

Cure for dementia?

Answer 3

non currently

• Acetylcholinesterase inhibitors having modest symptomatic benefit in early stages (MMSE = 1)
• diagnosis in life is only probable but it’s changing

Question 4

types of dementia

Answer 4

familial autosomal dominant
alzheimer's disease
vascular dementia
Dementia with lewy bodies/parkinson's disease
Frontotemporal dementia

Question 5

what is the main condition that can present as dementia?

Answer 5

depression

Question 6

deficiencies of what B vitamins can lead to potentially reversable cognitive deficits?

Answer 6

• 1, 6, 12 - especially B12

Question 7

Disease course of dementia

Answer 7

• follows a heterogenous course (has several causes)
• In old age the disease presentation is of multiple comorbidities
• Lots of mixed and uncertain pictures
• Younger patients are more typical
• Clinical history; function of the patient and how they change is paramount

Question 8

how is dementia diagnosed

Answer 8

• history taking

- lots of variation in scans

Question 9

Things to check when interviewing dementia patients?

Answer 9

• memory
• language
• numerical skills
• executive skills
• visuospatial skills
• neglect phenomena
• visual perception
• route finding and landmark identification
• personality and social conduct
• sexual behaviour
• eating
• mood
• motivation/apathy
• anxiety
• delusions
• activities of daily living

Question 10

what is dementia?

Answer 10

severe loss of memory and other cognitive abilities which leads to impaired daily function

Question 11

what investigations do you do for dementia?

Answer 11

• neuropsychology
• Bloods
• MRI
• PET

Question 12

Example of cognitive test used on the wards

Answer 12

MMSE ( mini mental state examination)

+/- ACE III (15 mins and more memory focused)

Question 13

things to look at in blood for dementia

Answer 13

• FBC
• inflammatory markers
• Thyroid function
• Biochemistry and renal function
• Glucose
• B12 and folate
• Clotting
• Syphilis serology
• HIV
• Caeruloplasmin

Question 14

what kind of MRI do you do to image the brain in dementia and what can they show?

Answer 14

sMRI

In those with alzheimer’s disease we can see narrow gyri and wider sulci and dilated/enlarged ventricles. There is medial temporal volume loss and the hippocampus is shrunken and replaced with CSF

Question 15

what is the newer type of dementia imaging and what do they show us?

Answer 15

florbetapir in vivo and amyloid post-mortem PET scans

Increased post- mortem beta amyloid present with those with alzheimer’s

Question 16

Other things that present like dementia

Answer 16

• Depression
• Delirium
• Idiopathic

Question 17

features of alzheimer’s dementia

Answer 17

• subtle, insidious amnestic/non amnestic presentation

Question 18

features of vascular dementia

Answer 18

• related to cerebrovascular disease with a classical stepwise deterioration +/- multiple infarcts/strokes

Question 19

features of dementia with Lewy bodies

Answer 19

• cognitive impairment before/within 1 year of Parkinsonian symptoms, visual hallucinations and fluctuating cognition

Question 20

features of frontotemporal dementia

Answer 20

• behavioral variant FTD, semantic dementia (cant match words with images), progressive non-fluent aphasia (Broca’s aphasia)

Question 21

obs by family members for alzheimers?

Answer 21

patient:

• repeats the same questions each day
• makes mistakes with respect to taking medication
• increasingly irritable
• will rewatch things without realising

Question 22

what does the head turning sign indicate during an examination?

Answer 22

• patient is unsure
• patient is looking for verification
• indicates cognititve impairment
• accompanied by episodic memory

Question 23

tests to assess brain function in alzheimers

Answer 23

• MMSE

- ACE

Question 24

what is episodic memory?

Answer 24

• memory for particular episodes in life

- dependent on the medial temporal lobes; inc hippocampus

Question 25

when can a definitive diagnosis of alzheimer's be made definitively?

Answer 25

- post mortem | - previously only a probable diagnosis but this is changing with new ways of looking at in-vivo pathology

Question 26

biomarkers in alzheimers

Answer 26

- low CSF B amyloid - high CSF tau - high B amyloid in brain

Question 27

what is the commonest cause of neurodegenerative disease?

Answer 27

alzheimers - typically involves initial episodic memory deficits secondary to dysfunction of medial temporal lobe structures (entorhinal cortex and hippocampus)

Question 28

what is rapidly progressing dementia?

Answer 28

another type of dementia

Question 29

do patients with dementia with lewy bodies always show parkinsonian symptoms?

Answer 29

not always | Symptoms of dementia can show before parkinson symptoms

Question 30

what decreases hallucinations in lewy body dementia?

Answer 30

cholinesterase inhibitor rivastigmine

Question 31

features of lewy body dementia

Answer 31

- Associated with fluctuating cognition - Often visual hallucinations (people/animals) - REM sleep disorder (shouting/talking at night) - High risk of falls - Development of symptoms associated with parkinson's disease

Question 32

what causes dementia with lewy bodies

Answer 32

aggregation of alpha synuclein

Question 33

What can we see on scans for a patient with dementia of lewy bodies?

Answer 33

MRI: Preserved hippocampus volume and medial temporal lobe volume (different to AD) DaTscan: Less dopamine transporters in caudate and putamen

Question 34

What observations can we make from a blood test and an MRI for FTD

Answer 34

Normal blood test results MRI: - volume loss in temporal lobe and frontal opercula - may be more on right side to suggest FTLD

Question 35

What are symptoms of frontotemporal lobe dementia?

Answer 35

Broca's aphasia- comprehension intact but speech production impaired - unable to speak properly - behavioral changes- more rude - self neglect/ loss of hygiene - unable to yawn on command - difficulty copying hand gestures - neurological examinations NAD