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CNSLF Med - Cognitive Impairment (Delirium & Dementia) (i) (Dementia…
CNSLF Med - Cognitive Impairment (Delirium & Dementia) (i)
Dementia definition
progressive neurodegenerative condition
DSM criteria
amnesia (memory imparirment)
AND 1 or more of...
apraxia (difficulty with learned purposeful fine motor movements)
agnosia (difficulty interpreting sensations + hence recognising things)
disturbance in executive function
@ least 2 domains of cognition involved
functional loss
causes significant impairment in social/occupational function - decline
gradual onset (if not gradual consider other things)
umbrella term for a range of forms of cognitive impairment
most common...
Alz (50-75%)
vasc dementia (a/w underlying cardiac risk factors) - 20-25%
lewy body dementia (4%)
frontotemporal dementia (2%)
can be mixed
Dementia prevalence
aged related: 4% over 65, 20% over 80, 50% over 90
v common + often unrecognised in earlier stages
Dementia dDx
SOL
tumour (primary or mets)
abscess
ischaemic - stroke
infective - abscess, meningitis - different hx
inflamm - AI encephalitis
toxic (alcohol most common)
prolonged delirium (transient unlike dementia but may persist)
depression
Dementia dx
Hx
collat/informant NB - e.g. son/daughter, good to get someone whose known the patient for a long time
instrumental activities become impaired (appointments, finances, travel, mobile phone etc)
repetitive/rapid forgetting
circumlocution (use of many words when fewer would do), word finding difficulties
safety issues (becoming lost, kitchen accidents e.g. leaving oven on)
withdrawal from social activity - stay @ home
apathy
weight loss, reduced dietary intake
driving difficulty
personality changes incl delusions, being more suspicious
exam
neuro-imaging + other investigations to outrule dDx
MRI brain, sometimes CT
B12/folate, TFTs, routine bloods - deficiencies can cause cognitive impairment - searching for table causes
12 lead ECG - look for a fib (stroke risk factor)
in selected patients 18 FDG PET scan (radiotracer as marker of metabolic activity - active = red, low/no activity = purple) + LP
acute/subacute/atypical presentation
<60y/o
rapid progression
considering AI encephalitis
will see reduced activity in an Alz brain
CSF findings non-specific
in mild cognitive impairment (MCI - abnormal psychometric tests but don't meet dementia criteria) + Alz will see reduced A-beta-42 (normal amyloid), increased T+P tau (neurofibrillary tangles), increased tau-A-beta42 (amyloid plaques)
bedside cognitive assessments
screening, measure cognition
MMSE
MOCA
RUDAS
Addenbrookes' Cognitive Exam (ACE III) - more detailed objective assessment, can be repeated in a few months if borderline score
excl dementia mimic
Dementia prognostic markers
weightloss
functional loss / personal care dependence
UTI/LRTI if dependent/nursing home resident
swallow impairment
Vasc dementia
caused by reduced blood flow to brain (cumulative effects of many small strokes i.e. micro infarcts
typically deteriorates in a step wise fashion as a results of repeated vasc insults (sudden drops unlike Alz which is a smoother decline)
risk factors
DM
HTN
high chol
obesity
smoking
a fib
symptoms depends on part of brain affected (no perceived change if in 'silent areas'), may overlap with other forms of dementia
Tx
risk factor management
cholinesterase + NMDA i's are not licensed, but may be used if overlaps with Alz
Frontotemporal dementia
progressive degeneration of temporal + frontal lobes of brain
these areas play a significant role in decision-making, behavioural control, emotion + language
1/3 of cases inherited
no specific tx available
medications can be prescribe to reduce agitation, irritability, depression
Lewy body dementia
3rd commonest
triad of visual hallucinations, fluctuating cognition + parkinsonism
histology characterised by Lewy bodies in brainstem + neocortex
no cure available
average survival time = 6-12 yrs