Dementia

Question 1

What is the dsm 5 criteria for dementia (major neurocognitive disorder)

Answer 1

A. Significant cognitive decline from previous level of performance in ≥1 cognitive
domains based on:

• Concern of the individual, a knowledgeable informant or the clinician that there has been
  significant decline in cognitive function
  AND
• A substantial impairment in cognitive performance (ideally documented by standardised testing)

B. Cognitive deficits interfere with independence in ADLs (at a minimum requiring assistance with complex instrumental
ADLs e.g. paying bills, managing medications)

C. Cognitive deficits do not occur exclusively in the context of delirium

D. Cognitive deficits not better explained by another medical disorder (e.g. major depressive disorder, schizophrenia)

Question 2

What are the 6 neurocognitive domains

Answer 2

• Complex attention: ability to focus on multiple things at once/ choose to ignore distractions
• Executive function: plan, organise set of tasks, sequencing
• Learning/memory: working, procedural
• Language: word finding, naming objects, grammar, syntax,
• Perceptual-motor: coordinate body by combining senses + motor skills
• Social cognition: contol desires to act on impulses, express empathy, recognise social cues, read facial expessions, motivate ourselves

Question 3

What are the differentials for gradual cognitive decline and the different types of dementia

Answer 3

Alzheimers - most common - memory, language and visuospatial defects (depth perception, recognise faces/objects, locating pathways).
- walking, continence, personality and social fx are preserved until later stages

Vascular - stepwise fashion - CV risk factors , mood disturbances common, psychosis can be see in later stages

Lewy Body
- fluctuating confusion, parkinsonism, visual hallucinations

Frontotemporal Dementia
- progressive decline in interpersonal skills, changes in food preference, more childlike amusement, obsession/rituals.
- progressive decline understanding, retrieving, words/ names, inability to recognise
- poor articulation of speech sound, impaired comprehension of sentences and impact on literacy skills
Memory problems later in presentation

OTHER
- Traumatic Brain injury
- HIV
- Huntingtons disease
- Stroke
- severe depression

Question 4

What is the hx/ questions to ask someone with suspected dementia

Answer 4

BEHAVIOURAL SX OF DEMENTIA (treat with 2nd gen antipsychotics)
- agitation, aggression
- delusions, hallucinations,
- depression
- anxiety
- disinhibition
- wandering

o When did it begin?
o How has it progressed?
o What are the current difficulties?
?CONFUSION
? Personality changes

ADLS
o Assessment of cook, clean wash yourself - ?leaving elements, taps on

• INCONTINENCE
• Mobility - FALLS

SAFETY Are you still driving ?problems, accidents

MEMORY
- issues remembering things ? peoples names? appointments , medications or paying bills

• MOOD, NEUROVEG SYMPTOMS INC ANHEDONIA

PMH - RISK FACTORS
ORIENTATION

Question 5

what are the risk factors for dementia

Answer 5

RISK FACTORS
- family hx,
- CVS risk factors
(HTN, cholesterol, diabetes, obesity, smoking),
- poor education
- polypharmacy
o PMHx: Parkinson’s, stroke.

Question 6

What is the assessment of cognition 3 questions / areas

Answer 6

Orientation
- Person, place, time
- Prime minister of NZ? US president?

Attention
- Subtract 7 from 100 and continue subtracting until asked to stop
- Spell the word “world” backwards

Memory
- Remember 3 words that will be asked later in the interview

Question 7

What are the differentials (DSM wise for cognitive decline in older person

Answer 7

• Major neurocognitive disorders (dementia)
• Mild neurocognitive disorders (requires compensatory strategies/ accommodation to maintain independence and ADLS
• Delirium (time course/ cause)
• Pseudodementia of depression
• Neurocognitive disorder not otherwise specified

-Late onset psychotic illness

Question 8

Management -safety considerations for dementia and investigations

Answer 8

Safety
- Cooking, taking lifesaving meds, wandering/getting lost
- Place of management - home vs. residential care vs. hospital level care

• Hospitalisation - if acute risk to patients or others
• Environmental risks e.g. driving, leaving stove on

Investigations
Collateral History
- Formal cognitive testing - MMSE <25, MoCA <26, ACE-R <83
- Fully physical examination
- Baseline bloods inc. FBC, U&Es, TFTs, syphilis screen

Question 9

Biological treatments for dementia and side effects

Answer 9

• Calming agents: haloperidol, sometimes benzodiazepines
• Cholinesterase inhibitors - increasing evidence in efficacy for mild/moderate dementia
• Examples - donepezil, galantamine, rivastigmine
• Side Effects - nausea, weight loss, agitation, bradycardia
• Treatment of behavioural/psychological
  symptoms of dementia - low dose atypical antipsychotics
  e.g. risperidone, olanzapine,
  aripiprazole
• Address comorbidities and polypharmacy
• stop drugs that worsen confusion
  eg. benzo, anticonvulsant, opioids, levodopa. anti

Question 10

What are the psycho social treatment of dementia

Answer 10

Psychological
- Therapeutic relationship
- Psychoeducation
- Cognitive stimulation therapy - structured group treatment for mild-moderate dementia activities for enhancement of mental and social functioning

Social
- Driving assessment
- Functional assessment - OT for equipment , coping strategies (diaries, alarms)
- Needs assessment - NASC for home help,
Financial - carer finance
Legal - assess capacity - EPOA , PPR, welfare guardian, acp.
- Support groups - Alzheimer’s society, Dementia NZ

Question 11

What is the framework for communicating with dementia patient

Answer 11

Validate: acknowledge the person’s behaviour as a personal expression, not simply a symptom of dementia.

Emotional connection: understand the emotional context behind the behaviour.

Reassurance: Anything from presence and a calming voice, to a gentle hand on their arm.

Redirection instead of correction

Activity: being occupied is a great anxiety-reliever! This can help to reduce agitation and give the person a feeling of purpose.

Question 12

explain dx of dementia in laypersons term

Answer 12

• You came here today because you or others were worried about your changes in your memory / personality / ability to carry out tasks that you were previously able to
• From what others and yourself has noticed it appears you might have been having a decline in your memory / ability for some time which is consistent with the early signs of dementia
• Dementia is caused by physical changes in the brain, such as the buildup of abnormal proteins or damage to brain cells, and there are many different types of dementia, each with their own unique characteristics and causes.
• Dementia can happen to anyone but people over the age of 65 are at greater risk. Other conditions eg . Previous head injury, infection, heart disease, some mental health conditions and long term alcohol use increase risk for developing dementia
• While there is currently no cure for dementia, there are treatments and strategies that can help manage symptoms and improve quality of life.
• These can include medicines like cholinesterase inhibitors which help some people with memory and thought symptoms early into the disease. It is important to optimize your heart health and get into regular routines. We also have other medications that can help patients with worrying thoughts or hallucinations.
• Other things that help are mind and memory include exercises at home or structured group therapy Cognitive stimulation therapy (CST) is a structured group treatment developed for people with mild to moderate dementia. It consists of 14 sessions with a range of activities and discussions aimed at general enhancement of mental and social functioning.
• An early diagnosis is important for accessing services that can support you being safely independent and develop an advanced care plan so that your wishes are know if you become more unwell. This can involve getting assessed for home help, seeing the OT for equipment and strategies to keep you safe and other support groups.