medicnotes.org.uk :: Dementia

Dementia

Dementia is a syndrome, with many causes, of global impairment of cognition in clear consciousness

The patient:

The key to diagnosis is a good history (usually requiring the help of a spouse, relative or friend) of progressive impairment of memory and cognition together with objective evidence of such impairment
The impairment should go back at least several months, and usually several years
Typically, the patient has become increasingly forgetful, and has carried out the normal tasks of daily living (e.g. cooking, shopping) with increasing incompetence:

E.g. going to the butchers to buy sausages 6 times a day and then being baffled as to why there was a great mound of sausages in the kitchen

Sometimes the patient appears to have changed personality (e.g. by becoming uncharacteristically rude and aggressive)
For objective evidence, carry out the mini-mental state examination (MMS exam – see below)

Commonest causes:

Alzheimer’s disease
Vascular dementia (~25% of all cases):

Essentially multiple small strokes
Is usually evidence of vascular pathology (e.g. HT, previous CVAs)

Rarer causes:

Chronic alcohol/barbiturate abuse
Huntington’s disease
CJD
Parkinson’s disease
Pick’s disease
HIV

Ameliorable causes:

Hypothyroidism
B₁₂/Folate deficiency
Syphilis
Thiamine deficiency
Operable cerebral tumour
Subdural haematoma

Mini-mental state examination (MMS exam):

If dementia is suspected, test memory and other intellectual abilities formally. The MMS exam is one of many similar tests. It has been more fully studied than most.

What day of the week is it? [1 point]
What is the date today? Day, month, year [1 point each]
What is the season? [1 point]
What country are we in? [1 point]
What is the name of this town [1 point]
What are 2 main streets nearby [1 point]
What floor of the building are we on? [1 point]
What is the name of this place [1 point]
‘I am going to give you a piece of paper. When I do, take it in your right hand. Fold the paper in half with both hands and put the paper down on your lap’ [1 point for each of the 3 actions]
Show a pencil and ask what it is called [1 point]
Show a wristwatch and ask what it is called [1 point]
‘I am going to say something and I would like you to repeat it after me: No ifs, ands, or buts’ [1 point]
‘Please read what is written here and do what it says’ (show the patient a piece of card with CLOSE YOUR EYES written on it [1 point]
‘Write a complete sentence on this sheet of paper’ [1 point]
‘Here is a drawing. Please copy the drawing’. Show the picture of 2 pentagons intertwined [1 point]
‘I am going to name 3 objects. After I have finished saying all 3, I want you to repeat them. Remember what they are because I am going to ask you to name them again in a few minutes’ e.g. APPLE, TABLE, PENNY [1 point each]
‘Now I would like you to take 7 away from 100. Now take 7 away from the number you get. Now keep subtracting until I tell you to stop’. Score 1 point each time the difference is 7, even if the previous answer was incorrect. Go on for 5 subtractions [5 points]
‘What were the 3 objects I asked you to remember a little while ago?’ [1 point each object]

The maximum score is 30. 28-30 does not support the diagnosis of dementia. A score of 25-27 is borderline. <25 suggests dementia but consider also acute confusional state an depression

Investigations:

Urine dipstick
FBC/blood film
ESR
U&Es
LFTs
Ca²⁺
Syphilis serology
B₁₂/folate
TFTs
CXR
CT scan (atypical history, young patient, head injury)
EEG

Management:

There are specific treatments for Alzheimer’s, HIV, myxoedema and dementia associated with a low B₁₂ and folate

Treat concurrent illnesses (these may contribute significantly to confusion)
In most people the dementia remains and will progress
The approach to management is that of any chronic illness
Prepare the spouse for the day when the patient no longer recognises loved ones


Welcome Anaesthetics Breast Surgery Cancer Medicine Cardio Medicine Cardio Surgery Endo Gastro Medicine Gastro Surgery General Medicine Acute confusional state Acute lumbar disc prolapse Acute renal failure Alcohol abuse Anaemia Anaemia of chronic disease Anxiety disorder Causes of spinal pain Cerebral infarction Cerebrovascular disease and stroke Chronic renal failure Clinical patterns of UMN disorders Cluster headache Dementia Depression Folate deficiency Giant cell arteritis Guillain-Barre syndrome Haemodialysis Haemofiltration Hypertension Intracerebral haemorrhage Iron deficiency anaemia Mechanisms of damage to peripheral nerves Meningitis Metabolic neuropathies Migraine Mononeuritis multiplex Mononeuropathies Osteoarthritis Peripheral oedema Peritoneal dialysis Polyneuropathies Renal transplantation Rheumatoid arthritis Septic arthritis Subarachnoid haemorrhage Tension headache Thiamin deficiency Transient ischaemic attacks Venous thromboembolic disease Vitamin B12 deficiency and pernicious anaemia General Surgery Respiratory
	Dementia Dementia is a syndrome, with many causes, of global impairment of cognition in clear consciousness The patient: The key to diagnosis is a good history (usually requiring the help of a spouse, relative or friend) of progressive impairment of memory and cognition together with objective evidence of such impairment The impairment should go back at least several months, and usually several years Typically, the patient has become increasingly forgetful, and has carried out the normal tasks of daily living (e.g. cooking, shopping) with increasing incompetence: E.g. going to the butchers to buy sausages 6 times a day and then being baffled as to why there was a great mound of sausages in the kitchen Sometimes the patient appears to have changed personality (e.g. by becoming uncharacteristically rude and aggressive) For objective evidence, carry out the mini-mental state examination (MMS exam – see below) Commonest causes: Alzheimer’s disease Vascular dementia (~25% of all cases): Essentially multiple small strokes Is usually evidence of vascular pathology (e.g. HT, previous CVAs) Rarer causes: Chronic alcohol/barbiturate abuse Huntington’s disease CJD Parkinson’s disease Pick’s disease HIV Ameliorable causes: Hypothyroidism B₁₂/Folate deficiency Syphilis Thiamine deficiency Operable cerebral tumour Subdural haematoma Mini-mental state examination (MMS exam): If dementia is suspected, test memory and other intellectual abilities formally. The MMS exam is one of many similar tests. It has been more fully studied than most. What day of the week is it? [1 point] What is the date today? Day, month, year [1 point each] What is the season? [1 point] What country are we in? [1 point] What is the name of this town [1 point] What are 2 main streets nearby [1 point] What floor of the building are we on? [1 point] What is the name of this place [1 point] ‘I am going to give you a piece of paper. When I do, take it in your right hand. Fold the paper in half with both hands and put the paper down on your lap’ [1 point for each of the 3 actions] Show a pencil and ask what it is called [1 point] Show a wristwatch and ask what it is called [1 point] ‘I am going to say something and I would like you to repeat it after me: No ifs, ands, or buts’ [1 point] ‘Please read what is written here and do what it says’ (show the patient a piece of card with CLOSE YOUR EYES written on it [1 point] ‘Write a complete sentence on this sheet of paper’ [1 point] ‘Here is a drawing. Please copy the drawing’. Show the picture of 2 pentagons intertwined [1 point] ‘I am going to name 3 objects. After I have finished saying all 3, I want you to repeat them. Remember what they are because I am going to ask you to name them again in a few minutes’ e.g. APPLE, TABLE, PENNY [1 point each] ‘Now I would like you to take 7 away from 100. Now take 7 away from the number you get. Now keep subtracting until I tell you to stop’. Score 1 point each time the difference is 7, even if the previous answer was incorrect. Go on for 5 subtractions [5 points] ‘What were the 3 objects I asked you to remember a little while ago?’ [1 point each object] The maximum score is 30. 28-30 does not support the diagnosis of dementia. A score of 25-27 is borderline. <25 suggests dementia but consider also acute confusional state an depression Investigations: Urine dipstick FBC/blood film ESR U&Es LFTs Ca²⁺ Syphilis serology B₁₂/folate TFTs CXR CT scan (atypical history, young patient, head injury) EEG Management: There are specific treatments for Alzheimer’s, HIV, myxoedema and dementia associated with a low B₁₂ and folate Treat concurrent illnesses (these may contribute significantly to confusion) In most people the dementia remains and will progress The approach to management is that of any chronic illness Prepare the spouse for the day when the patient no longer recognises loved ones
	disclaimer & copyright These notes are provided on an 'as is' basis with no guarantee on content and you agree to not hold anyone liable for them. However they should be of sufficient quality to be helpful. The copyright is from the authors of the notes but also may belong to lecturers, textbooks and other sources from which they were compiled. They are for educational purposes only. These notes and suggestions have been reproduced and combined with express permission from various sources, including Nem's, Phil's & Christian's notes. You can add yours too!
	© 2012	accessibility \| legal \| privacy \| sitemap