Dementia

• What is dementia?

  Progressive, irreversible clinical syndrome with a range of cognitive and behavioural symptoms
• What is early-onset (young-onset) dementia?

  Dementia that develops before 65 years old
• What are the most common causes of dementia?

  Alzheimer's disease (50-75%)

  Vascular dementia (~20%)

  Dementia with Lewy Bodies (10-15%)

  Frontotemporal dementia (2%)
• Apart from the most common causes, what else can cause dementia?

  Parkinson's disease

  Progressive supranuclear palsy

  Huntington's disease

  Prion disease

  Normal pressure hydrocephalus

  Chronic subdural haematoma

  Benign tumours

  Metabolic & endocrine disorders

  Vitamin deficiencies (B12, B1)

  Infections (HIV, syphilis)

  Inflammatory & autoimmune disorders

  Transient epileptic amnesia
• What are the RFs for dementia?

  Age (older)

  Mild cognitive impairment

  Learning disability

  Genetics (FH)

  CVD (strong RF for vascular & mixed dementias)

  Cerebrovascular disease (strong RF for vascular dementia)

  Parkinson's disease

  Lower education

  HTN

  Hearing impairment

  Smoking

  Obesity

  Depression

  Low levels of activity

  Low social support

  Alcohol consumption

  Traumatic brain injury

  Air pollution
• What is mild cognitive impairment?

  Cognitive impairment that does not fulfil the diagnostic criteria for dementia
• What are the 3 stages of progressive deterioration of dementia?

  Early stage (mild) - years 1-2

  Middle stage (moderate) - years 2-5

  Late stage (severe) - years 5 and later
• What is early stage dementia?

  Often overlooked

  Gradual onset

  Features:

  • becoming forgetful
  • communication difficulty
  • losing track of time
  • difficulty making decisions
• What is moderate stage dementia?

  Limitations become clearer & more restricting

  Features:

  • becoming very forgetful
  • increasing communication difficulty
  • help needed with personal care
  • unable to prepare food
  • behaviour changes
• What is late stage dementia?

  Near-total dependence & inactivity

  Features:

  • very serious memory disturbances
  • more obvious physical features
  • unaware of time or place
  • difficulty understanding what is happening around them
  • unable to recognise relatives & friends
  • unable to eat w/o assistance
• What are the complications of dementia?

  Disability, dependency, & morbidity

  Behavioural & psychological symptoms of dementia (BPSD)

  Institutionalisation

  Carer morbidity

  Financial hardship
• What are the behavioural & psychological symptoms of dementia (BPSD)?

  Agitation

  Depression

  Apathy

  Repetitive questioning

  Psychosis

  Aggression

  Sleep problems

  Wandering
• What are the cognitive impairment symptoms of dementia?

  Memory loss

  Problems with reasoning & communication

  Difficulty in making decisions

  Dysphasia

  Difficulty carrying out coordinated movements (e.g. dressing)

  Disorientated & unawareness of the time & place

  Impairment of executive function (e.g. difficulties with planning, judgement, loss of initiative & problem solving)
• What are the DDx for dementia?

  Normal age related memory changes

  Mild cognitive impairment

  Depression

  Delirium

  Vitamin deficiency

  Hypothyroidism

  Adverse drug effects

  Normal pressure hydrocephalus

  Sensory deficits
• What should you look for in an examination for dementia?

  Focal neurological signs

  • coordination & gait abnormalities
  • sensory findings (peripheral neuropathy)
  • motor symptoms (hemiparesis, tremor, rigidity, bradykinesia)

  Visual or auditory problems

  Cardiovascular signs (HTN, arrhythmias, peripheral vascular disease)

  Head trauma

  Delirium
• What blood tests should be done in possible dementia to exclude reversible causes of cognitive decline?

  FBC

  ESR

  CRP

  Urea & electrolytes

  Calcium

  HbA1c

  LFTs

  TFTs

  Serum B12 & folate
• ADD COGNITIVE ASSESSMENT TOOLS
• What are the early symptoms of dementia?


  Forgetting events

  Forgetting names

  Difficultly remembering words

  Repeatedly asking the same Qs

  Impaired decision making

  Reduced flexibility
• What are the features of advanced dementia?

  Inability to speak or understand speech (aphasia)

  Dysphasia (can lead to aspiration & pneumonia)

  Appetite & weight loss

  Incontinence
• What is ACE-III?

  Addenbrooke's Cognitive Examination-III

  Detailed & comprehensive assessment tool for memory impairment

  Takes up to 90 mins

  5 domains

  • attention
  • memory
  • language
  • visuospatial function
  • verbal fluency

  Scored out of 100

  Score of 88 or less -> possible dementia
• Is there a cure for dementia?

  No

  Management inc. supporting pts & carers in coping with symptoms
• What can be done to plan ahead in the early stages of dementia?

  Nominating a lasting power of attorney

  Advanced decisions (around treatments they would or wouldn't want)

  Planning future care
• What medication can be used to manage behavioural & psychological symptoms of dementia?

  SSRIs (for depressive symptoms)

  Antipsychotics

  Benzodiazepines (only for crisis management)
• What specialist inx should be done for suspected dementia?

  MRI/CT

  CSF examination
• What non-pharmacological interventions should be done for mild to moderate dementia?

  Cognitive stimulation therapy

  Group reminiscence therapy

  Cognitive rehabilitation or OT