Topic: Dementia (usually collateral hx)

Ddx
- AD or other subtypes of dementia
- Delirum
- Pseudo-dementia (depressive disorder)
- Vitamin B12 deficiency
- Brain tumours
- Brain trauma
- Brain infections (HIV, Syphilis)
- Post-hypoxia syndrome

Presentation: memory loss

1. When did it start?

2. Were you well before?
3. Sudden or gradual?
4. What symptoms were noticed first? Longterm/short term memory?
5. Any progression? Any worse or staying the same? Can you give example?
6. Slowly progressive or stepwise progression?
7. Any fluctuation of symptoms?
8. Are symptoms worse at night? Do you wandering around at night?
9. Associated symptoms
- Confusion in familiar/unfamiliar surrounding?
- Word-finding difficulties?
- Any changes in behavior/personality? How were you before? Now? Do
you get agitated easily?
- Do you feel lack of motivation?
- Do you go out with friends/family?
- Mood? Sleep? Loss of appetite?
- Impaired swallowing?
- Incontinence
- Weight loss
- Fatigue
- High cortical function
- Anxiety?
- Delusion? Hallucination?
- Neurological Symptoms - Gait Disturbances
- Difficulties with ADLs cooking/cleaning/shower/getting dress/
Getting lost/unable to drive/difficulty planning task ie: managing
household bills

Risk Factors:
1. Smoking
2. Alcohol
3. Obesity
4. DM
 5. HTN
6. Cholesterol
7. Stroke/TIA
8. CVD/respi
9. Thyroid
10. Family hx/genetic factors
11. Head trauma
12. Change in medication
13. Malnutrition, malabsorption

Investigations
1. History, collateral history, physical exam
2. Review medication benzo, steroids, levodopa, TCA, anticonvulsant
3. Assess cognition
a. MMSE (Mini-Mental State Examination)
b. MOCA (Montreal Cognitive Assessment)
c. CAMCOG (Cambridge Cognition)
d. ACE-R (Addenbrookes Cognitive Score)
4. Bloods fbc, esr, u&e, b12, folate, tfts, lfts, glucose, lipid
5. Imaging CT brain, SPECT scan (differentiate btwn AD, VaD,FTD)

Management
1. Involves MDT approach and medication
2. Acetyl-cholinesterase (AChE) inhibitors
1. Donepezil
- Mild to moderate AD
- Prevents decline in cognitive function
- Can be used in VaD (not as effective)
- Side-effects:
o Nausea, Vomiting,
o Diarrhoea
o Dizziness, Insomnia
- Titration of dose gradually over two-four weeks to maximum
dose of 10mg OD
- Caution for patients with:
o History of Peptic Ulcer Disease; Heart block (any type)
or pre-existing bradycardia; C2H5OH abuse
2. Galantamine
- Mild-Moderate AD
- SE: Nausea, Hallucinations; Dizziness; Tremor; Bradycardia

3. Rivastigmine (Topical Preparation-Patch)

- Mild-Mod AD
- Mild-Mod AD in Parkinsons Disease
- SEs: Nausea, Diarrhoea; Anorexia; Insomnia; Worsening of
Parkinsons disease; Agitation; Confusion; Bradycardia

3. Memantine
Works by modulating effects of Glutamate via NMDA receptor
 Indicated in patients:
With moderate AD who are intolerant or have a contra-indication to AChE
inhibitors
Severe Alzheimers Disease
Improvements in cognition, global assessment and function
compared with placebo
SEs: Headache; constipation; Hypertension; Somnolence

4. Depression SSRI
5. Agitation - Lorazepam
6. Psychosis -Risperidone, Olanzapine, Quetiapine
Need close supervision due to SEs

Long term Mx:

Follow up 6 monthly at OPD
Monitor for cognitive decline
Repeat cognitive and functional assessments
If still driving ?needs driving assessment re: suitability to drive
Monitor drug side effects
Monitor for behavioural symptoms
Identify significant carer stress
Link with community social work/Alzheimers society/PHN
Discuss Enduring Power of Attorney (EPOA) early prior to significant
cognitive decline Only enacted once patient is deemed to no longer have capacity
to make their own decisions

Questions
1. Subtypes of dementia?
- Dementia of Alzheimers Disease
- Vascular dementia
- Mixed dementia
- Lewy body dementia
- Fronto-temporal dementia
- Dementia associated with PD
- CJD, Huntingtons, HIV related dementia
2. Staging of dementia according to MMSE
a. Mild Cognitive Impairment
Memory loss with no loss of function

b. Mild (MMSE > 20)

if a person still retains the ability to manage independently
(PADLs/DADLs/finances etc) but has functional loss(no
longer going shopping/driving).

c. Moderate (MMSE 10 -20)

if some help is needed in the ordinary tasks of living and
personal care, but not requiring 24 hour supervision

d. Severe(MMSE <10)
if continual help and support is required; requiring 24 hour
supervision