Dementia (Dr.

Murray supervision)

750,000 in UK have dementia – 6-7% of the elderly population.

Definition: PROGRESSIVE decline in global cognition

Dx of dementia needs: CONFUSION screen (rule out acute causes) + SCAN (CT head) + Hx
(including collateral)

Alzheimer’s disease
 MCC in UK (60%)
 Path:
o Tau NFTs, amyloid, global loss of volume = less ACh
 Classically,
o “Sinusoid” gradual progression
o Recent memory >>> long-term memory
o Speech – since temporal lobe affected
 Always behind in a conversation
 Hard to come up with words
o Mood changes esp. irritated – could be due to frustrations (e.g. family
members reminding them every 5 mins)
o End-stage: whole-body
 Incontinence, difficulty swallowing, agitation, clonus, etc.
 Tx
o AChEi – MODEST improvement (slows down progression)…
 Prolongs plateau phase but suddenly decline down the sinusoidal
pattern eventually. Some evidence that at the tail-end, significant but
small improvements in loss of cognition.
 3-month trial
 If S/E ++, then take it off – not worth the modest improvement
 Only for mild/moderate – no point in severe dementia

Vascular dementia
 2nd MCC (20%)
 Stepwise (sawtooth – some slightly improve) BUT NEVER get back to normal level
 Path:
o Blood vessels come in from outside to supply inner brain, thinning as it
reaches the inner brain
o Therefore, the capillaries supplying inner brain affected  so periventricular
atrophy
 Periventricular thinning normal for old age, but question is whether
significant for that age.
 Characteristics
o More insight than normal dementia
o Labile affect (could be due to the stroke – emotional)
 Optimise vascular risk factors – no silver bullet

Lewy body dementia

  3rd MCC (10-15%)
 Dx criteria:
o Hallucinations
o Fluctuating
o Parkinsonism
o + REM sleep disturbances
 Course: fluctuating – CAN get back to normal levels at times temporarily
 AChEi does help
 Biomarkers e.g. DAT – meh

Fronto-temporal dementia
 MCC = Alzheimer’s > tau/Pick > etc.
 Anatomical classification (vs previous 3: pathological)
 Since affects frontal lobe = 2 variants
 Behavioural variant
o +ve: social disinhibition
o -ve: lack of executive functioning (can explain procedure, can’t do)
 Speech variant (Broca)
o Primary progressive dementia/aphasia (PPD)
 Can’t use language
 E.g. repeat last syllable of word (logoclonia)
o Semantic dementia
 Snowman vs palm tree in desert background (pyramid) – can’t tell
which is wrong.
 AChEi some effect

MCI
 Non-progressive global cognition decline that is not functionally significant (MOCA:
20-25)
 AChEi not Rx !
o Can’t tell if early dementia or just MCI
o So just monitor first – MCI S/E on AChEi worse than AD.
o AChEi has NO benefits for MCI