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PSYCHIATRY: DEMENTIA| S.M.

CHOK (Manchester Medical School)


DEMENTIA:

Alzheimer's

Vascular

Fronto-Temporal

Lewy Body

Pt Profile

>65yo
Caucasian
women>men

risk increases with age


African Carribean and South Asian

45-65yo

PC

early stage
memory lapses
amnesia: forgetful
agnosia: cannot recognise
people/places etc
aphasia

onset of dementia within 3/12 following


a recognised cerebrovascular event

behavioural variant FTD


disinhibition
inappropriate social behaviour
no motivation, empathy, sympathy
loss of control over eating or drinking
repetitive/compulsive
change in preferences
difficulty organising/ planning/
making decision
lack of insight
no awareness of personal hygiene,
incontinence

dementia
memory loss
decline in problem solving ability
spatial awareness difficulties
fluctuating levels of awareness and
attention

semantic dementia
aphasia
agnosia

sleep disorder
REM
restless legs syndrome
nocturnal cramps
fainting spells

disease progresses
difficulties with language
apraxia
prob planning and making decisions
confusion
later stage
wandering, disorientation
apathy
psych symptoms eg depression,
hallucination, delusions
behavioural probs eg disinhibition,
aggression, agitation
altered eating habits
incontinence

depending on the site of infarction


focal neurological abnormalities
difficulty with attention and
concentration
depression/anxiety accompanying
memory disturbances
early presence of disturbance in gait,
unsteadiness and frequent,
unprovoked falls
seizures
incontinence
emotional probs
pseudobulbar palsy

progressive non-fluent aphasia


slow, hesitant, difficult
grammatical errors
impaired understanding

parkinsonism
tremor
rigidity
lack of facial expression
festinating gait

recurrent well-formed visual


hallucination

HPC

progressive, worsening
no disturbances of consciousness

step-wise progression
fluctuating

insidious onset and progression


gradual
memory preserved in early stage

progressive

PMHx

hypercholestrolaemia
HPTN
DM
cardiovascular conditions
Trisomy 21 (amyloid)

parkinson?

cerebrovascular events
AF
HPTN
DM
hyperlipidemia
coronary heart disease

progressive supranuclear palsy


motor neurone disease
?Pick's disease
?parkinsonism

PSYCHIATRY: DEMENTIA| S.M.CHOK (Manchester Medical School)


DEMENTIA:

Alzheimer's

Vascular

DHx

benzodiazepines (drug-induced
cognitive impairment)
other medications that suggest CV
pathologies

medications that suggest CV pathologies

FHx

+ve (first degree relatives)


autosomal dominant with early onset
apoE3 and apoE4

FHx of stroke or CV diseases

SHx

smoking (CV risk)

smoking
obesity

MMSE (not diagnostic)

screen for cognitive impairment

Dementia Screen (bloods)


infection/inflammation
FBC (anaemia)
B12/folate
HIV/syphilis
TFTs (hypothyroidism)
LFTs (cirrhosis, carcinoma,
encephalopathy)
MSU (infection)
U&Es (dehydration)

exclude other organic causes


relevant blood tests and imaging
review medications

Exam / Ix

anticholinesterase (AChE)
eg donepezil, rivastigmine,
galantamine
acetylcholine

Lewy Body

meds that exacerbate memory


probs/confusion
anticholinergics
CNS drugs

Exam
neuro exam: primitive reflexes in later
stages
impaired orofacial movements eg
coughing, swallowing, gag reflex

Exam
cognition eg MMSE etc
Dementia Screen
to rule out other causes of memory
probs/confusion

MRI
infarcts, cortical lacunae, extensive
white matter changes
can show mixed AD and vascular
dementia

Dementia Screen

prevention of vascular risks


antiplatelets
anticoagulants
controlling BP and DM

SSRIs may be helpful in modifying


behavioural symptoms

AChE (only rivastigmine) might help


with cognitive fx

atypical antipsychotics for severe


behavioural probs eg agitation,

avoid neuroleptic meds for

MRI/CT
general/diffuse atrophy of
frontal/temporal lobes
amyloid plaques
atrophy of cholinergic fibres (
acetylcholine)
Mx

Fronto-Temporal

MRI
lobar atrophy of frontal and temporal
lobes
loss of neurons/gliosis but no plaque
formation
Histology
FTLD-TAU: corticobasal degeneration;
progressive supranuclear palsy (PSP)
FTLD-TDP: TDP-43
FTLD-FUS: rare, with ubiquinated
inclusions

SPECT and PET


dopamine transporter uptake

PSYCHIATRY: DEMENTIA| S.M.CHOK (Manchester Medical School)


DEMENTIA:

Alzheimer's
contra-i: bradycardia, conduction prob
in heart
SE: anorexia, abdo pain, nausea
vomiting, diarrhoea, insomnia,
confusion, agitation, headahce

Vascular
statin
AChE and NMDA antagonist
DO NOT help symptoms in vascular
dementia
given only if there is mixed dementia

Fronto-Temporal
psychosis (only if SSRI failed) - risks of
extrapyramidal SE
levadopa/carbidopa or dopamine
agonists if there are Parkinsonian
symptoms

Lewy Body
psychiatric/behavioural probs - can
induce severe sensitivity rxn
anti-parkinsonian Tx can worsen
psychosis

NMDA antagonist
eg memantine
for severe dementia, not widely used
inhibit glutamate NMDA-r, prevent
excitotoxicity
contra-i: seizure, leukopenia
can be given with AChE
SE: diarrhoea, insomnia, dizziness,
headache, hallucinations
Prognosis

7-10yrs

depending

8-10yrs (slow progression)


3-5yrs if associated w MND

3-4yrs

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