DEMENTIA – An Easy Guide By Connie Smith
De- (away) Mentia (mind) • Dementia is a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.
QUESTION 1 • A 75 year old man has a poor memory on objective testing. His short term memory is particularly affected and he has problems remembering words. His symptoms came on slowly and have progressed over the past year. What is the most likely diagnosis? 1. Alzheimers disease 2. Vascular dementia 3. Dementia with lewy bodies 4. Creutzfeldt - Jakob Disease
QUESTION 2 • An 81 year old man who lives in a sheltered housing complex is admitted because he has a four day history of confusion. The GP referral letter stated that the man had been wandering at night and had been phoning the police claiming that aliens were trying to abduct him. He had fallen twice at home but had no apparent injuries. The GP referral went on to state that the man had some memory problems and was "more confused than normal." • On examination the man is inattentive and only intermittently appears to understand questions to which he gives inappropriate answers. His pulse rate is 80 and his blood pressure is 128/78 mm Hg. His temperature is 37.4° C. Further examination is unremarkable. • What is the most likely diagnosis? 1.Dementia 2. Depression 3. Delirium
QUESTION 3 • A 65 year old man comes to your clinic with episodes of confusion and deteriorating mobility. His daughter says he has been walking more slowly and has had recurrent falls. She also states that he sometimes seems to be talking to people in his room while alone and that he sometimes describes seeing childhood friends playing in his garden. His only past history is of mild osteoarthritis. He has never smoked and drinks 8 units of alcohol per week. • He scores 26/30 on the mini mental state examination. He has an expressionless face, increased tone in both arms, and walks with a shuffling gait. His pulse rate is 80 and regular and his blood pressure is 124/72 mm Hg with no postural drop • Which one of the following conditions are these features most in keeping with? • 1. Alzheimer's disease • 2. Korsakoff's psychosis • 3. Frontotemporal dementia • 4. Vascular dementia • 5. Dementia with Lewy bodies
QUESTION 4 A 70 year old man visits your clinic with progressive memory impairment. Following asssessment of the patient including a thorough background assessment, you diagnose mild Alzheimer's disease. His wife is concerned about the future and asks what his likely outlook is. What is the average survival after a diagnosis of Alzheimer's disease? 1. 3-6 years 2. 7-10 years 3. 11-14 years
WHAT QUESTIONS ? Amnesia - Gradual / sudden onset; Time of day worst; Variable Hallucinations, PD signs, low mood, GCS, behaviour PMH – vascular, cancer FH, Alcohol Function – global / specific Risks Mrs Bubbly brings her 75 year old husband to see you as she is concerned about his memory….
WHAT EXAMINATION? Cardiovascular Neurological MSE – depression MMSE / 6-CIT She states it has come on gradually, worse in evenings, same most days. She is taking over most tasks such as shopping , cooking and cleaning. He is repeating conversations and gets lost when out alone. He has had BPH and tinnitus. She seems to recall an uncle who had a memory illness.
WHAT INVESTIGATIONS ? FBC - TTP ESR – arteritis LFT – hepatic failure U+E – uraemia TFT – hypothyroid / hyper PTH Calcium – hypo/hypercalcaemia Glucose Vitamin B12 / folate - deficiency MSU / ECG / CXR – as necc Syphillis / HIV – as necc You cannot find any neurological deficit and cardiovascular exam in normal. He seems cheerful but aware of his memory problems. His MMSE is 19/30.
WHAT ARE YOUR DIFFERENTIAL DIAGNOSES? Alzheimers (6/10) Vascular (2/10) Lewy Body Fronto-temporal (Pick’s) Others – neoplasms, vasculitis, syphillis, AIDS, CJD, depression, alcohol, metabolic, NPH, SDH All his blood tests come back normal.
WHAT NEXT? REFER early to memory services. Halifax – call Single Point of Entry (01422 252215) Huddersfield – fax form You suspect Alzheimers Disease.
WHAT WILL THEY DO ? Consider MRI / CT head DRUGS - Cholinesterase Inhibitors; Antipyschotics Community Support You refer him to the local memory service and a specialist nurse goes out to further assess him. She informs you that she has asked the Consultant Psychiatrist to see him.
FOLLOW - UP 3/12 review by specialist team re: CI QOF – register (5pts) and yearly review (15pts) - physical - behaviour, mood - carers needs - social needs - local support groups A letter comes back 3 months later stating that your suspicions are confirmed and a diagnosis of Alzheimer’s is most likely. An MRI head has been done that shows cerebral atrophy. He has been commenced on Aricept.
KEY STAGES • Early stage(MMSE >21) Loss of memory, poor judgement, confusion, personality/behavioural changes • Middle stage(MMSE 20 or less) Memory worsens, difficulties with ADL, BPSD, communication problems, safety risks • Late stage Physical frailty, swallowing problems. malnutrition
and some Shakespeare……. • ‘Pray, do not mock me: I am a very foolish fond old man, Fourscore and upward, not an hour more or less; And, to deal plainly, I fear I am not in my perfect mind. Methinks I should know you and know this man; Yet I am doubtful: for I am mainly ignorant what this place is, and all the skill I have remembers not these garments; nor I know where I did lodge last night. Do not laugh at me; For as I am a man, I think this lady to be my child Cordelia.’ Shakespeare: King Lear: Act II Scene 7