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Geriatric Psychiatry (incomplete) (Dementia (Vascular (Lobe affected…
Geriatric Psychiatry (incomplete)
Dementia
Alzheimers
Pathophysiology
Decreased
ACh
leading to decreased neuronal stimulation and therefore neurone degeneration
Post-synaptic & long-term potentiation affected
Temporo-parietal lobe is the most commonly affected in alzhiemers disease
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Pharmaceutical Management
Acetylcholinesterase Inhibitors
Slows progression of the disease
Donepezil
Galantamine
Rivastigmine
Side effects
Feeling & being sick
Dizziness
Diarrhoea
Headache
Agitation
Insomnia
Muscle cramps
Bradycardia*
Memantine
NMDA receptor antagonist
Side effects
Consipation
Headache
Hypertension
Diagnosis
NINCDS/ADRDA Criteria
Dementia established by examination and objective testing
-Deficits in two or more cognitive areas
-Progressive worsening of memory and other cognitive functions
-No disturbance in consciousness
-Onset between ages 40 and 90
ICD-10
F00 = Dementia in Alzheimer's Disease
DSM-5
Symptoms
Early
Memory lapses
Signs of mood changes
Middle-stage
Worsened memory problems including struggling to recognise family & friends
Increasing confusion and disorientation
Obsessive, repetitive or impulsive behaviour
Delusions
Aphasia
Disturbed sleep
Late stage
Symptoms become increasingly severe and distressing for the person with the condition & carers, friends & family
Hallucinations
Delusions
dysphagia
Weight loss
Incontinence
Loss of speech (gradual)
Lewy Body
Diagnosis
International Consensus Criteria for DLB
Vascular
Lobe affected determines symptoms
Parietal Lobe
Agnosia
-
inability to understand sensory input
Apraxia
-
inability to do complex movements when peripheral motor function is preserved
Loss of pre-motor cortex
Temporal Lobe
Medial Temporal Lobe
Amnesia
-
loss of the hippocampus
Frontal Lobe
Personality changes
Pathophysiology
Progressive disease with many different aetiogies, all with the principle of the vasculature of the brain being affected.
e.g. Small vessell diseases -
binswanger disease & lacunar state
Diagnosis
NINDS-AIREN Criteria
BMJ Link
Dementia
Cerebrovascular disease
Onset of dementia within 3 months after a recognised stroke, abrupt deterioration in cognitive functions or fluctuating, stepwise progression of cognitive deficits
Clinical features consistent with the diagnosis of probable vascular dementia
Unlikely to be vascular dementia if:
Early onset of memory deficit & progressive worsening of memory/other cognitive functions
Absence of focal neurological signs & cerebrovascular lesions of CT or MRI
ICD-10
F01
F01.50 = without behavioural disturbance
F01.51 with behavioural disturbance
ICD10
DSM-IV
UpToDate article
Risk Factors
Vascular risk factors
Smoking
Excessive alcohol use
Obesity
Diabetes
Hypertension
Raised cholesterol levels
= secondary prevention of dementia
Pharmaceutical Management
No medication specifically for vascular dementia
Treat underlying cause
e.g. hypertension, hypercholesterolaemia, prevention of further strokes
Treatment of symptoms
e.g. antidepressants, anxiolytics
Management
Care Plans
Before treatment starts - address futher health & social care needs
Advance directives, power of attorney & Wills
Main aim of treatment = treat underlying cause to stop progression of disease
Genetics
Familial Autosomal Dominant Alzheimer's Disease
Frontotemporal dementia
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
Huntington's disease
Identification & Assessment
Primary Care
Referral considered with signs of
Mild Cognitive Impairment
6-Item Cognitive Impairment Test
= Screening for dementia in Primary Care
8/28 = abnormal
Takes <5 minutes
6CIT Online
People with learning disabilities -
included in their annual health check should be:
Mental health review
Physical health review
Review of current interventions
Agreed & shared care plan
Collateral history
Dementia Screen
Routine haematology
Biochemistry including
electrolytes, calcium, glucose, renal & liver function
Thyroid function tests
Serum vitamin B12 & folate levels
Mid-stream urine if delirium is a possibility
CXR or ECG if indicated by clinical presentation
Secondary Care
Memory Assessment Services & CMHT
History
Cognitive & mental state examination
Physical examination
Medication review
Clinical Cognitive Assessment
Attention and concentration
Orientation
Short & long-term memory
Praxis
Language
Executive function
Mini Mental State Examination
Cut off = 24/30
27/30 in highly educated
Sensitivity depends on care setting
Others include:
General Practitioner Assessment of Cognition
7-Minute Screen
ACE-III
Attenbrooks Cognitive Examination
.pdf)
Assessment for MCI & Dementia
Cut Off Cognitive Impairment = 88/100
Cut Off Dementia = 82/100
Diagnosis of subtype
International standardised criteria used
Mixed Dementia
Evidence of Alzheimer dementia and cerebrovascular disease
Clinically
Neuroimaging (
ischaemic lesions
)
Mild Cognitive Impairment
Syndrome defined as cognitive decline greater than expected for an individual's age and education level that does not interfere notably with activities of daily living
May lead to dementia in some cases -
not a diagnosis of dementia of any type
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Frontotemporal Dementia
Diagnosis
Lund-Manchester Criteria
NINDS criteria
Pathophysiology
Frontotemporal lobar degeneration - typical loss of over 70% of neurones
Symptoms
Tends to start at a younger age -
most diagnosed aged 45-65
Linked to the function of the lobes
Broca's area -
language problems
Wernicke's area -
understanding
Hippocampus -
memory
Frontal lobe -
personality and behaviour changes
Alcohol Associated Dementia
Organic causes of dementia
Parkinsons
Stroke
Depression
Assessment
Delirium
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