Qe Qi Bp © An 86-year-old gentleman comes to see you with his daughter for a medication review. His memory has been declining recently and he was referred to memory clinic three months ago, where he was diagnosed with Alzheimer's dementia His other medical history includes chronic back pain secondary to osteoporosis, ischaemic heart disease and atrial fibrillation. Which one of the following medications should you consider stopping? Amitriptyline Rivaroxaban Atorvastatin Alendronic acid Aspirin iubmit answer encaner ss pelAn 86-year-old gentleman comes to see you with his daughter for a medication review. His memory has been declining recently and he was referred to memory clinic three months ago, where he was diagnosed with Alzheimer's dementia. His other medical history includes chronic back pain secondary to osteoporosis, ischaemic heart disease and atrial fibrillation. Which one of the following medications should you consider stopping? Rivaroxaban Atorvastatin Alendronic acid Aspirin There are multiple causes of dementia as outlined below, the majority of which are progressive and irreversible. There are medications that can be used to slow progression, but as clinicians we also have a responsibility to ensure that our patients aren't taking medications which may make things worse. The STOPP-START Criteria (Gallagher et al., 2008) outlines medications that we should consider withdrawing in the elderly. One example of this is the use of tricyclic antidepressants in patients with dementia, due to the risk of worsening cognitive impairment. @ | "@ | @ Discuss (4) Improve | encaner ss pelDementia Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer's disease followed by vascular and Lewy body dementia. These conditions may coexist. Features « diagnosis can be difficult and is often delayed * assessment tools recommended by NICE for the non-specialist setting include: 10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT) * assessment tools not recommended by NICE for the non- specialist setting include the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia Management « in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’). * in secondary care, neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management *in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of dementia encaner ss pel8 a2 ip © A 78-year-old man is admitted from a nursing home with multi-infarct dementia, chronic obstructive pulmonary disease and biventricular failure. You are asked to assess his risk of pressure sores and need for referral to the tissue viability team during his inpatient stay. Which of the following is most useful in determining the risk of pressure sores? Glasgow criteria Rankin scale Ranson criteria Waterlow scale Townsend scale | Reference ranges v encaner ss pelRankin scale Ranson criteria Townsend scale The Waterlow scale was developed in 1985 to assess the risk of pressure sore development, helping to drive level of nursing intervention and use of special mattresses to reduce risk. Potential scores range from 1-64. A score greater than 10 indicates an increased risk of pressure sore development, with scores >15 indicating high risk and >20 indicating very high risk. A number of factors are taken into account when assessing patients using the scale including body habitus, continence status, malnutrition, mobility, neurological status and presence of major trauma. The Glasgow and Ranson criteria were drawn up to stratify risk in patients presenting with acute pancreatitis, with respect to identifying those at increased risk of mortality, and those who need to be treated in a high dependency area. The Rankin scale relates to the degree of disability in patients post stroke, and the Townsend scale is an indicator of deprivation. s@ | @ | @Discuss | Improve encaner ss pelPressure ulcers The following is based on a 2009 NHS Best Practice Statement. Please see the link for further details. Some selected points are listed below. NICE also published guidelines in 2014. Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel. The following factors predispose to the development of pressure ulcers: * malnourishment « incontinence * lack of mobility * pain (leads to a reduction in mobility) The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence. Grading of pressure ulcers - the following is taken from the European Pressure Ulcer Advisory Panel classification system.Grade Findings Grade —Non-blanchable erythema of intact skin. Discolouration of 1 the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin Grade Partial thickness skin loss involving epidermis or dermis, 2 or both. The ulcer is superficial and presents clinically as an abrasion or blister Grade Full thickness skin loss involving damage to or necrosis of 3 subcutaneous tissue that may extend down to, but not through, underlying fascia. Grade Extensive destruction, tissue necrosis, or damage to 4 muscle, bone or supporting structures with or without full thickness skin loss Management * a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound * wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g Evidence of surrounding cellulitis) * consider referral to the tissue viability nurse * surgical debridement may be beneficial for selected wounds caeanar ss ba°e Q3 p © A 64-year-old woman presents with her husband to the GP. Her husband describes how she has become more irritable and impulsive over the past year, buying expensive jewellery without telling him. He thinks she has developed more of a sweet tooth lately. During the consultation, the patient starts crying without warning. There is no previous psychiatric history. Her father developed a gambling addiction in later life. What is the most likely diagnosis? Bipolar affective disorder Schizophrenia Borderline personality disorder Frontotemporal dementia Lewy-body dementia Submit ansv | Reference ranges vunzupiicina Borderline personality disorder Lewy-body dementia Frontotemporal dementia presents with social disinhibition and often has a family history Importance: 50 In frontotemporal dementia, memory and visuospatial skills are usually not the main complaint, and the differential often includes psychiatric disorders. However, it develops later in life and often has a family history. Bipolar affective disorder, schizophrenia and borderline personality disorder would present earlier in life with different predominant symptoms: depression and mania in bipolar disorder, hallucinations and delusions in schizophrenia, and difficult emotions and behaviours in borderline personality disorder. Lewy-body dementia has more prominent memory features than frontotemporal dementia, and patients may experience visual hallucinations and Parkinsonian symptoms. @ | "@ | @Discuss | ImproveFrontotemporal lobar degeneration Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer's and Lewy body dementia. There are three recognised types of FTLD + Frontotemporal dementia (Pick's disease) + Progressive non fluent aphasia (chronic progressive aphasia, CPA) * Semantic dementia Common features of frontotemporal lobar dementias Onset before 65 Insidious onset Relatively preserved memory and visuospatial skills Personality change and social conduct problems Pick's disease This is the most common type and is characterised by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick's disease. Macroscopic changes seen in Pick's disease include: * Atrophy of the frontal and temporal lobes encaner ss pelMicroscopic changes include: * Pick bodies - spherical aggregations of tau protein (silver-staining) * Gliosis * Neurofibrillary tangles * Senile plaques Management * NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia CPA Here the chief factor is non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia Here the patient has a fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer's memory is better for recent rather than remote events. Save my notes Search Caaenh tavthnal ea encaner ss pel Search8 a6 Bp A 78-year-old female has been diagnosed with mild to moderate dementia. Which of the following is an effect of cholinesterase inhibitors? Improvement in physical function Improvement in activities of daily living Longer time before entering residential care Improved mortality Minimize the progression of dementia EIU odnali lai) >) | Reference ranges v| imoroverentin atte fey wing Longer time before entering residential care Improved mortality Minimize the progression of dementia Patients with Alzheimer disease have reduced production of choline acetyl transferase, leading to a decrease in acetylcholine synthesis and impaired cortical cholinergic functioning. The only role for cholinesterase inhibitors is to improve some cognitive function and improvement in activities of daily living. There is no role for cholinesterase inhibitors in advanced Alzheimer's disease. oy 1. @ Discuss (4) Improve |Alzheimer's disease Alzheimer's disease (AD) is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK. Genetics * most cases are sporadic * 5% of cases are inherited as an autosomal dominant trait * mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form * apoprotein E allele E4 - encodes a cholesterol transport protein * risk factors include Down's syndrome Pathological changes * macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus * microscopic: cortical plaques due to deposition of type A-Beta- amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein. Hyperphosphorylation of the tau protein has been linked to AD * biochemical: there is a deficit of acetylcholine from damage to an ascending forebrain projection Neurofibrillary tangles * paired helical filaments are partly made from a protein called tau * tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules « in AD are tau proteins are excessively phosphorylated, impairing the function Tr &y @ @ ] encaner ss pelo Q7 ra] © A elderly lady patient presents with arthritic pains. At the end of the consultation she tells you she has been to see a doctor at the memory clinic who diagnosed her with Alzheimer's dementia. She cannot remember why she was not given any tablets to help with this. Which of the following would represent a relative contraindication to donepezil prescription? Patient on warfarin Mild Alzheimer's dementia Stage II renal impairment Resting bradycardia Mini-mental state examination (MMSE) score of 18 | Reference ranges vMild Alzheimer's dementia Stage II renal impairment Mini-mental state examination (MMSE) score of 18 Donepezil is generally avoided (relative contraindication) in patients with bradycardia and is used with caution in other cardiac abnormalities Importance: 50 Donepezil is not renally excreted and is therefore safe to give in renal failure. There is no interaction between donepezil and warfarin according to the BNF. It is licenced for use in mild to moderate Alzheimer's dementia (as indicated by an MMSE score of 18 in this question). wh | @ | @Discuss | Improve encaner ss peleo ae p © You are a doctor on-call overnight. You are called by the nurse about an 82-year-old man on the orthopaedic geriatric ward has become increasingly confused following his total hip replacement 5 days ago. He was complaining of considerable post-operative pain and has been given regular morphine which is managing his pain. You go to see him and agree he is confused with an abbreviated mental test score (AMTS) of 4/10. He is unable to give you a history but consents to an examination. You assess his wound which is clean, chest is clear and abdomen soft, non-tender. Pupils are equal and reactive. The nurse reports he has been eating and drinking less. Observations are all within normal range. Urine dip negative. Bloods taken yesterday morning demonstrated a long-standing slight normocytic anaemia and his inflammatory markers are coming down since the operation. What is the most likely cause of his symptoms? Alcohol withdrawal Constipation Extradural haemorrhage Nosocomial infection Alzheimer's disease leant encaner ss pelExtradural haemorrhage Nosocomial infection Alzheimer's disease Constipation can cause delirium in the elderly Importance: 50 The patient has been on opioids and is likely not mobilising as well since the operation. Both of which can contribute to constipation which can be a cause of delirium. Alcohol withdrawal typically presents within the first 24 hours of cessation in patients who have abruptly stopped. Acute alcohol withdrawal may present with tremor, nausea, sweating, seizures, hallucination. Delirium tremens may occur typically 3 days in to cessation with global confusion and sympathetic overdrive (fever, tachycardia and hypertension). This is not the case in this patient. Dementia (e.g. Alzheimer's) is typically a chronic cognitive impairment, the stem describes an acute confusional state. There is no mention of a fall or sign of infection - both of which are potential reversible causes of delirium. &@ | @ | @ Discuss (1) Improve | encaner ss pelExtradural haemorrhage Nosocomial infection Alzheimer's disease Constipation can cause delirium in the elderly Importance: 50 The patient has been on opioids and is likely not mobilising as well since the operation. Both of which can contribute to constipation which can be a cause of delirium. Alcohol withdrawal typically presents within the first 24 hours of cessation in patients who have abruptly stopped. Acute alcohol withdrawal may present with tremor, nausea, sweating, seizures, hallucination. Delirium tremens may occur typically 3 days in to cessation with global confusion and sympathetic overdrive (fever, tachycardia and hypertension). This is not the case in this patient. Dementia (e.g. Alzheimer's) is typically a chronic cognitive impairment, the stem describes an acute confusional state. There is no mention of a fall or sign of infection - both of which are potential reversible causes of delirium. sé | "@ | @ Discuss (1) Improve | encaner ss pelAcute confusional state Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital. Predisposing factors include: * age > 65 years * background of dementia ¢ significant injury e.g. hip fracture ¢ frailty or multimorbidity * polypharmacy The precipitating events are often multifactorial and may include: infection: particularly urinary tract infections metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration change of environment any significant cardiovascular, respiratory, neurological or endocrine condition severe pain alcohol withdrawal constipation* constipation Features - a wide variety of presentations * memory disturbances (loss of short term > long term) * may be very agitated or withdrawn * disorientation * mood change * visual hallucinations * disturbed sleep cycle * poor attention Management * treatment of the underlying cause * modification of the environment * the 2006 Royal College of Physicians publication ‘The prevention, diagnosis and management of delirium in older people: concise guidelines’ recommended haloperidol 0.5 mg as the first-line sedative * the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine Ble A. Save my notes Search encaner ss pel° a9 Bp © A 76-year-old woman is diagnosed with Alzheimer's disease. Which one of the following could be a contraindication to the prescription of donepezil? History of depression Sick sinus syndrome Concurrent simvastatin therapy Concurrent citalopram therapy Ischaemic heart disease Submit answ | Reference ranges v encaner ss pelConcurrent simvastatin therapy Concurrent citalopram therapy Ischaemic heart disease Donepezil is generally avoided (relative contraindication) in patients with bradycardia and is used with caution in other cardiac abnormalities Importance: 50 Donepezil may cause bradycardia and atrioventricular node block. Cd * @ Discuss (2) Improve |8 ato p © You are a GP reviewing letters for your patients. The next letter you come across is from an elderly gentleman you referred to the memory clinic for increasing forgetfulness. You note that he has been given a diagnosis of vascular dementia. Which of the following treatments is most likely to have been recommended? Tight control of vascular risk factors Donepezil Fluoxetine Cognitive behavioural therapy Memantine | Reference ranges v encaner ss pelDonepezil Fluoxetine Cognitive behavioural therapy Memantine Tight control of vascular risk factors, rather than antidementia medication, is recommended by NICE in vascular dementia Importance: 50 Cholinesterase inhibitors are licenced for use in Alzheimer's and mixed dementias. They are not recommended for the treatment of vascular dementia. NICE recommend tight control of vascular risk factors in order to slow progression of the disease. we | "@ | @Discuss (1) | Improve Vascular dementia Vascular dementia (VD) is the second most common form of dementia after Alzheimer disease. It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease. Vascular dementia has been increasingly recognised as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment (VCI). Early detection and an accurate diagnosis are important in the prevention of vascular dementia. encaner ss pelEpidemiology . VD is thought to account for around 17% of dementia in the UK Prevalence of dementia following a first stroke varies depending on location and size of the infarct, definition of dementia, interval after stroke and age among other variables. Overall, stroke doubles the risk of developing dementia. Incidence increases with age The main subtypes of VD: Stroke-related VD — multi-infarct or single-infarct dementia Subcortical VD - caused by small vessel disease Mixed dementia — the presence of both VD and Alzheimer's disease Risk factors . History of stroke or transient ischaemic attack (TIA) Atrial fibrillation Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease A family history of stroke or cardiovascular Rarely, VD can be inherited as in the case of CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Patients with VD typically presents with Several months or several years of a history of a sudden or stepwise deterioration of cognitive function. encaner ss pelSymptoms and the speed of progression vary but may include: « Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms The difficulty with attention and concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance . . Diagnosis is made based on: « Acomprehensive history and physical examination « Formal screen for cognitive impairment * Medical review to exclude medication cause of cognitive decline * MRI scan — may show infarcts and extensive white matter changes National Institute for health and care excellence (NICE) recommends that diagnosis be made using the NINDS-AIREN criteria for probable vascular dementia Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event * established using clinical examination and neuropsychological testing Cerebrovascular disease « defined by neurological signs and/or brain imaging Arelationship between the above two disorders inferred by: * the onset of dementia within three months following a recognised stroke * an abrupt deterioration in cognitive functions * fluctuating, stepwise progression of cognitive deficits encaner ss pelGeneral management * Treatment is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers « Important to detect and address cardiovascular risk factors — for slowing down the progression Non-pharmacological management * Tailored to the individual * Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy * Managing challenging behaviours e.g. address pain, avoid overcrowding, clear communication Pharmacological management * There is no specific pharmacological treatment approved for cognitive symptoms Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer's disease, Parkinson's disease dementia or dementia with Lewy bodies. * There is no evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia. * No randomized trials found evaluating statins for vascular dementia Bie &&- encaner ss pelOQ om Bp ° You are the doctor on-call overnight. You are called at 1am by the nursing staff to review an 88-year-old woman who is distressed and “acting out of character.” The patient underwent a hemiarthroplasty for a fractured neck of femur 12 days ago, and is now having physiotherapy until suitable discharge can be arranged. On arrival at the ward, the patient is trying to get out of bed, despite the reassurance of the nursing staff. She is shouting incomprehensible words and appears to be distressed. You are unable to gain a history from the patient or to examine her, but the nurses tell you that up until this evening she had been her usual self, quiet and well-mannered. Nursing staff manage to take observations: heart rate 85/min, blood pressure 140/85mmHg, oxygen saturations 98% on air, respiratory rate 22/min, temperature 36.5°C and blood glucose 6.3. From the medical notes, you note the patient has a past medical history of alzheimer's dementia, gout and type 2 diabetes. Her drug chart includes the following medications: codeine 30mg QDS (started on admission), paracetamol 1g QDS, donepezil, allopurinol, metformin, and ondansetron as needed for nausea. The fluid chart shows good oral intake and output. Her stool chart is not completed. Bloods taken earlier in the day: Male: (135-180) He Msg Female: (115 - 160) Platelets 250*10°/L (150-400) wec B5*10%L — (4.0-11.0) Na 143 mmol/L (135-145) K 37 mmol/L (3.55.0) encaner ss pelHer stool chart is not completed. Bloods taken earlier in the day: Male: (135-180) He nse Female: (115 - 160) Platelets 250*10°/L (150-400) wee 85*107L — (4.0-11.0) Na 143 mmol/L (135-145) K 37 mmol/L (3.5-5.0) Urea 5.0mmol/L. (2.0-7.0) Creatinine 95 pmol/L (55-120) ‘RP 6 mg/L «5) Of the options listed below, which is the most likely cause of the patient's presentation? Constipation Hypoglycaemia Pain Progression of Alzheimer's dementia Urinary tract infection Submit answer Reference anges v encaner ss pelHypoglycaemia Pain Progression of Alzheimer's dementia Urinary tract infection Constipation can cause delirium in the elderly Importance: 50 This patient has developed an acute confusional state, also known as delirium. This is characterised using the Confusion Assessment Method as an acute onset of a change in mental state from the patient's baseline with inattention, in addition to either disorganised thinking or altered consciousness. Sleep-wake cycle is often reversed. There are many causes of an acute delirium: + Pain * Infection * Constipation « Urinary retention * Metabolic: hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration * Medications: e.g. opioids * Hypoxia In this case, there is limited information available from the patient, however the medical charts available on the ward can often point to the most likely underlying cause of a delirium. encaner ss pelHer observations are stable including blood glucose, therefore hypoglycaemia is not the underlying cause. She is not febrile and her bloods are all within normal limits, which points away from an infectious cause. The patient is 2 weeks post-op, and her pain is likely to have stabilised, which makes this a less likely cause. The key to this question is spotting that the patient has been prescribed two highly constipating medications (codeine and ondansetron) without laxatives. Her stool chart does not demonstrate any bowel movements, therefore she is likely to be constipated. This is the most likely cause of the delirium in this case. @ | *@ | @ Discuss (1) Improve | Next question > awwOo a2 p © AGP receives a shared care document from the dementia specialist team, asking him to take over the prescribing of donepezil for a patient with Alzheimers disease. Which other medication if present on the patients repeat prescription may represent the strongest potential contraindication to donepezil? Tiotropium Verapamil Omeprazole Trimethoprim Glyceryltrinitrate spray jubmit an: r | Reference ranges v encaner ss pelOmeprazole Trimethoprim Glyceryltrinitrate spray One of the important possible side effects of the acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine) is bradycardia (or SA block or AV block). Hence these medications might be contraindicated or should be started with caution in patients with conduction abnormalities or those already taking negatively chronotropic medications such as beta blockers, rate-limiting calcium channel blockers or digoxin. Other possible side effects include gastrointestinal effects (nausea, vomiting, anorexia, diarrhoea), agitation, hallucinations, syncope; and less commonly gastrointestinal ulcers, seizures, conduction disorders, urinary retention and extrapyramidal symptoms. Neuroleptic malignant syndrome is also listed in the BNF as a very rare adverse reaction. Although currently only to be initiated by specialists with expertise in the area of prescribing these medications (eg. Psychiatrists, Elderly Care specialists, Neurologists), GPs may be asked to take over the prescribing and monitoring of these medications under Shared Care Agreements so it is important to be aware of prescribing issues. The AKT Summary report from the April 2015 exam noted that candidates struggled with questions on dementia, and advised they review the NICE guidance and the British National Formulary for information on prescribing for patients with dementia.Dementia Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer's disease followed by vascular and Lewy body dementia. These conditions may coexist. Features * diagnosis can be difficult and is often delayed * assessment tools recommended by NICE for the non-specialist setting include: 10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT) * assessment tools not recommended by NICE for the non- specialist setting include the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia Management ¢ in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’). « in secondary care, neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of dementia encaner ss pel@ Q13 Bp © A 87-year-old woman attends the GP with her son. She was diagnosed with Alzheimer's dementia three years ago and has recently moved into his home so that he can look after her. Since moving in, she has been significantly withdrawn and has reported seeing animals running around the house when there are none there. She does not report any other symptoms. Observations are all within normal limits and physical examination is unremarkable. What is the most likely explanation for her presentation? Pneumonia Delirium Depression Psychosis Urinary tract infection Reference ranges vDepression Psychosis Urinary tract infection New surroundings can cause delirium in cognitively impaired patients Importance: 50 This woman is experiencing delirium secondary to her new surroundings. People with dementia are more prone to becoming delirious, even with minor insults such as change of environment. Delirium can cause visual hallucinations. Community-acquired pneumonia and urinary tract infections are common causes of delirium in the elderly but seem less likely with normal observations, examination and no other clues in the history. Depression is a common differential for dementia in the elderly. However, we know this woman has a diagnosis of dementia, and the history is much more acute- pointing towards delirium. Be aware, however, that symptoms of depression in the elderly are usually very non-specific. Psychosis would explain visual hallucinations, but you would expect other symptoms such as thought disturbance. The history is also too acute, again pointing towards delirium. | @ | @ Discuss Improve encaner ss pel8 aia p © A 78-year-old man is referred to neurology outpatients. For the past six months he has been troubled with memory impairment, hallucinations and a resting tremor. On walking into the clinic room he is noted to have a festinating gait and an expressionless face. He scores 12 / 30 on the mini-mental state examination (MMSE). Given the likely diagnosis, which one of the following tests is most likely to confirm the diagnosis? Serum copper levels Cerebral angiography MRI head SPECT scan PET scan | Reference ranges vPET scan This patient has Lewy body dementia. The findings on conventional imaging such as MRI are generally non-specific. w@ | *@ | @Discuss (1) | Improve Lewy body dementia Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas. The relationship between Parkinson's disease and Lewy body dementia is complicated, particularly as dementia is often seen in Parkinson's disease. Also, up to 40% of patients with Alzheimer's have Lewy bodies.Features * progressive cognitive impairment in contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss cognition may be fluctuating, in contrast to other forms of dementia usually develops before parkinsonism * parkinsonism + visual hallucinations (other features such as delusions and non- visual hallucinations may also be seen) ° Diagnosis * usually clinical * single-photon emission computed tomography (SPECT) is increasingly used. It is currently commercially known as a DaTscan. Dopaminergic iodine-123-radiolabelled 2-carbomethoxy- 3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-1 FP-CIT) is used as the radioisotope. The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of 100% Management * both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's. NICE have made detailed recommendations about what drugs to use at what stages. Please see the link for more details * neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent encaner ss pel°Q ais Bp © An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore? PSST-6 score PAST score MUST score Waterlow score Honeywell score cI edna e-1aS (oe | Reference ranges vPAST score MUST score Honeywell score Waterlow score - used to identify patients at risk of pressure sores Important forme Less important s@ | "@ | @ Discuss (1) Improve Next qu Pd°e Qi6 B © A 78-year-old man attends memory clinic with his daughter. He has a past medical history of hypertension and he is an ex-smoker. His daughter describes him being stable for many months, then noticing a sudden decline. This has occurred on multiple occasions. Montreal cognitive assessment (MoCA) score is 18/30 and physical examination is unremarkable. He denies visual or auditory hallucinations. What is the most likely underlying diagnosis? Alzheimer's dementia Frontotemporal dementia Lewy body dementia Parkinson's dementia Vascular dementia mit ansv | Reference ranges vParkinson's dementia Stepwise deterioration in cognitive function? - think vascular dementia Importance: 50 The stepwise deterioration in cognitive function along with risk factors for cerebrovascular disease (hypertension and smoking) point towards a diagnosis of vascular dementia. In this case, cognitive impairment is caused by ischaemia or haemorrhage secondary to cerebrovascular disease. Alzheimer's dementia is the most common form of dementia. It usually develops gradually and progresses slowly. Frontotemporal dementia affects the frontal and temporal lobes of the brain, leading to changes in personality, behaviour, language and attention. Like Alzheimer's, it tends to develop gradually, as those parts of the brain begin to atrophy. Lewy body dementia is typically associated with auditory, visual or even olfactory hallucinations. You may also notice Parkinsonian symptoms such as tremor and bradykinesia. Parkinson's dementia develops in patients with Parkinson's disease (PD) when their disease begins to impair thought processes, mental function, and memory. You would expect to find signs of PD on physical examination. w | "@ | @Discuss | Improve encaner ss pel°e Qi7 B © An 80-year-old male is referred to the memory clinic after presenting with progressive memory loss. This has been worsening for five months where the patient has been forgetting the names of his family and has been found on several occasions confused and disorientated. An assessment is made and treatment is given to limit the progression of the disease. What enzyme is blocked by the first-line drug for the likely condition? Catechol-O-methyl transferase Cholinesterase Monoamine oxidase A Monoamine oxidase B Tyrosine hydroxylase mit ansv | Reference ranges vMonoamine oxidase A Monoamine oxidase B Tyrosine hydroxylase Donepezil - acetylcholinesterase inhibitor Importance: 50 Patients with Alzheimer’s dementia (the most common type) have reduced amounts of cholinergic neurons. Medications such as acetylcholine inhibitors (AChE!) increase the amount of AChEI in the synaptic cleft leading to increased effects at the postsynaptic receptor. Examples of drugs that are AChEI inhibitors are donepezil, galantamine and rivastigmine. Donepezil is recommended first-line in Alzheimer's disease. Memantine, an NMDA receptor antagonist, is recommended second line. Tyrosine hydroxylase is an enzyme which breaks down catecholamines (dopamine, epinephrine and norepinephrine). Catechol-O-methyltransferase (COMT) are enzymes that also break down catecholamines. COMT inhibitors such as entacapone and tolcapone stop the peripheral breakdown of levodopa increasing the levels that cross the blood-brain barrier. Monoamine oxidase (MAO) breaks down monoamines which are neurotransmitters (examples include serotonin, dopamine and norepinephrine). MAO inhibitors are used in the treatment of many conditions including depression and panic disorder. w | "@ | @Discuss | Improve encaner ss pelQO as FB © A 78-year-old man is seen in the Memory clinic. His daughter reports that for the past 12 months he has become increasingly forgetful and has now started to wander around at night. A mini-mental test is performed and he scores 18 out of 30. Neurological examination is unremarkable. A full blood screen is also requested, all of which comes back as normal. What is the most appropriate next step? Arrange a MRI head Perform carotid Dopplers Give practical advice + advise family to contact Alzheimer's Society Prescribe aspirin + simvastatin Prescribe donepezil Wel | Reference ranges ¥ encaner ss pelA 78-year-old man is seen in the Memory clinic. His daughter reports that for the past 12 months he has become increasingly forgetful and has now started to wander around at night. A mini-mental test is performed and he scores 18 out of 30. Neurological examination is unremarkable. A full blood screen is also requested, all of which comes back as normal. What is the most appropriate next step? Perform carotid Dopplers Give practical advice + advise family to contact Alzheimer's Society Prescribe aspirin + simvastatin Prescribe donepezil Neuroimaging is required to diagnose dementia Importance: 50 o@ | @ | @ Discuss (3) Improve | Next question >Qo Qi9 Pe © You are on the night on-call team, and a 76-year-old woman on one of your wards has developed increasing confusion. She is wandering around the ward asking for her husband and is shouting at staff and other patients. She was admitted this morning with a high fever and a one-week history of a productive, purulent cough. She also has a history of Parkinson's disease. Nursing staff have been unable to calm her and she has now started to throw objects and hit staff members. The nurses have however been able to give you the following obs: Temperature 37.8°C Heart Rate 105 bpm. BP 138/78 mmHg $a0. 95% on room air Blood glucose 5 mmol/L Which of the following is the most appropriate treatment? Immediate release carbidopa-levodopa Olanzapine Lorazepam Amitriptyline Haloperidol encaner ss pelAmitriptyline Haloperidol Anti-psychotics should be avoided in delirious patients with a background of Parkinson's disease Importance: 50 This lady is currently suffering from delirium, a common issue in elderly patients in hospital. The combination of an underlying infection and the dark environment of the ward at night are likely contributing to her acute confusional state. Haloperidol and other antipsychotic medications are recommended first-line treatment options when nursing strategies have failed, however, these should not be used in patients with a background of Parkinson's disease. Anti-psychotics often have strong anti- dopaminergic action, and as such in a patient with Parkinson's, they will make their condition significantly worse. As such, lorazepam is the most suitable option. Immediate release levodopa would not be helpful in this situation as this ladies confusion is not due to her Parkinson's disease. While Parkinson's disease can cause behavioural changes, they tend to be more chronic, progressive and less labile in nature. w@ | "@ | @ Discuss (5) | Improve | Ne CP encaner ss peloO 20 p © A 64-year-old man who is under investigation for parkinsonian symptoms is brought to the GP by his wife. She is concerned her husband is becoming increasingly agitated. The GP prescribes haloperidol. One week later the GP is called out to see the patient as his parkinsonian symptoms have deteriorated markedly. What is the most likely underlying diagnosis? Lewy body dementia Normal pressure hydrocephalus Progressive supranuclear palsy Multiple system atrophy Dementia pugilistica | Reference ranges vA 64-year-old man who is under investigation for parkinsonian symptoms is brought to the GP by his wife. She is concerned her husband is becoming increasingly agitated. The GP prescribes haloperidol. One week later the GP is called out to see the patient as his parkinsonian symptoms have deteriorated markedly. What is the most likely underlying diagnosis? Normal pressure hydrocephalus Progressive supranuclear palsy Multiple system atrophy Dementia pugilistica Patients with Lewy body dementia are extremely sensitive to neuroleptic agents w& | "@ | @® Discuss (3) Improve | ion >eo Q21 fp © An 88-year-old woman visits her GP with a 4-week history of difficulty sleeping. She describes difficulty getting to sleep, as well as waking up early in the morning. This has led her to feel very fatigued. She has never had any problems sleeping before. She is accompanied by her daughter who mentions that her mother was seen in a care of the elderly (COTE) clinic 6 weeks ago for problems with her memory, and was started on a medication. Unfortunately she is unable to recall the name of the the medication. The patient has a past medical history of COPD, restless legs syndrome (for which she takes pramipexole), and ischaemic heart disease. You note from the GP record that she was also treated for an infective exacerbation of COPD 3 weeks ago with amoxicillin. Which medication of those listed below is the most likely cause of the patient's symptoms? Amoxicillin Clopidogrel Donepezil Pramipexole Rivastigmine bmit an: r encaner ss pelClopidogrel Pramipexole Rivastigmine Donepezil can cause insomnia Importance: 50 This question is testing your knowledge of the side effects of donepezil, an acetylcholinesterase inhibitor used commonly for mild to moderate Alzheimer's disease (AD). Sleep disorders are a common side effect of donepezil. Donepezil can also cause bradycardia, and is contraindicated in patients with pre- existing bradycardia. Rivastigmine is also an acetylcholinesterase inhibitor used to treat AD, but it does not cause sleep disorders. Pramipexole is a dopamine agonist used to treat Parkinson's disease and restless legs syndrome. It can cause sleep disorders, however it is not the most likely cause in this patient as the past medical history suggests she has been taking it for some time, and the donepezil was started recently. Amoxicillin and clopidogrel are not associated with sleep disorders. t& | "@ | @® Discuss (1) improve | le Cort encaner ss pelQe Q22 A © You are a junior doctor working in the Emergency Department. You have been asked to assess an 84-year-old gentleman who has come in with confusion. There is very little history from the patient but his wife reports that this has been worsening for a week. He has also been very irritable and ‘not himself’. He has not drank alcohol for many years. He is responsive to voice and has an AMT of 1. He looks dehydrated and smells strongly of urine. Neurological examination is difficult but he has normal tone and reflexes and his pupils are equal and reactive. What do you think is the most likely cause? Alzheimer's disease Frontotemporal dementia Delirium Korsakoff syndrome Acute psychotic episode Reference ranges v encaner ss pelKorsakoff syndrome Acute psychotic episode Delirium involves an impairment of conscious level and often involves psychotic symptoms Importance: 50 The key point here is that this man has an acute confusion with impaired consciousness. Impaired consciousness is seen in delirium but not in dementia. The history is also not long enough to be suggestive of a dementing illness (1 and 2). The suggestion of a personality change is a red-herring here. The dehydration and smell of urine suggest a urinary tract infection which may precipitate an episode of delirium. Korsakoff syndrome (4) is unlikely. It is an amnestic disorder caused by thiamine deficiency associated with prolonged ingestion of alcohol. The main symptoms are amnesia, confabulation, minimal content in conversation, lack of insight and apathy. It is usually the result of untreated Wernicke's encephalopathy. In fact, the symptoms he has come in are more likely to be mistaken for Wernicke's than Korsakoff's. In Wernicke's encephalopathy the patient may be confused and have an altered conscious level. They also may be ataxic and have ophthalmoplegia (the ‘triad’), but these symptoms do not have to be present to make the diagnosis. Treatment is with thiamine to replace what is lost. There is not enough evidence in the question stem to suggest that this man is having an acute psychotic episode (5) as no psychotic features are mentioned w@ | "@ | @Discuss (2) | Improve encaner ss pelDelirium vs. dementia Factors favouring delirium over dementia * impairment of consciousness ¢ fluctuation of symptoms: worse at night, periods of normality * abnormal perception (e.g. illusions and hallucinations) * agitation, fear * delusions Next question > [Bie M- See Tr By &@ © Save my notes Search Q Google search on "Delirium vs. dementia" + Suggest link Media encaner ss pele Q23 Bp © An 80-year-old man with his wife presents to the emergency department. He states that he has been more forgetful over the past month by not being able to concentrate and continually leaving the fridge open. His wife expresses concerns at how he says that he has seen monkeys standing behind him on multiple occasions. Past medical history includes diagnosis of type 2 diabetes and hypertension over 15 years ago. What is the most likely diagnosis? Alzheimer's dementia Delirium Lewy body dementia Vascular dementia Creutzfeldt-Jakob disease (CJD) | Reference ranges vDelirium Vascular dementia Creutzfeldt-Jakob disease (CJD) Visual hallucinations with dementia = Lewy body dementia Importance: 50 The patient is showing signs of dementia which can be explained by all the answers, however, the only one which classically presents with visual hallucinations is Lewy body dementia. This dementia often has recurrent visual hallucinations that take the form of people or animals being in their presence. Delirium has more of an acute presentation. Alzheimer's does not typically present with hallucinations but if it does it tends to be in the latter stages of the disease. Vascular dementia and (CJD) do not present characteristically with hallucinations. w@ | @ | @Discuss | Improve Next question >8 a24 Bp A 69-year-old man who is known to have Alzheimer's disease is reviewed in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. What is the most appropriate management? Supportive care + memantine Supportive care + trial of citalopram Supportive care Supportive care + donepezil + low-dose aspirin Supportive care + donepezil Submit answ 9) | Reference ranges V encaner ss pelSupportive care + trial of citalopram Supportive care Supportive care + donepezil + low-dose aspirin | ie | ® Discuss (3) Improve | Next question > encaner ss pelQe Q25 A © A 78-year-old gentleman presents to the memory clinic accompanied by his wife. He is pleasantly confused. His wife reports he is still coping at home fairly independently, although she does have to remind him of things more frequently. He has a known diagnosis of Alzheimer's disease and was started on donepezil and successfully up-titrated to the maximum therapeutic dose. Cognitive testing reveals his mini mental test score to be 21/30. Six months previously his score was 24/30. What is the most appropriate management? Stop donepezil Add in memantine Switch to rivastigmine Continue donepezil Add in olanzapine Submit answ Reference ranges v encaner ss pelAdd in memantine Switch to rivastigmine Add in olanzapine NICE guidelines do not support the use of memantine in mild dementia Importance: 50 Despite evidence of a small cognitive decline, this gentleman still has ‘mild’ dementia as reflected by his MMSE and the fact he is coping at home. He has no evidence of significant behavioural or psychological symptoms. As such, continuing donepezil (which he is tolerating) would be the most appropriate answer. A cognitive decline despite initiation of donepezil would be expected due to the progressive nature of the disease. There is no evidence in this case to support switching to an alternative acetylcholinesterase inhibitor (e.g. rivastigmine) unless there is another reason to do so (e.g. rivastigmine comes in a patch form for those unable to swallow). NICE does not recommend stopping acetylcholinesterase inhibitors on the basis of disease severity alone. Memantine is only recommended in moderate and severe alzheimer's disease. There is no role for an anti-psychotic in this case. “ * @ Discuss (3) | Improve Ccaeaner ss8 026 p © You are called to see a 75-year-old man with a history of Parkinson's disease who has just come back from surgery. He has been complaining of nausea and appears to be suffering from post-operative delirium. Which of the following drugs would be contraindicated? Domperidone Haloperidol Lorazepam Olanzapine Ondansetron Tl eyaaliae-L oe | Reference ranges v encaner ss pelLorazepam Olanzapine Ondansetron Haloperidol is contraindicated in patients with Parkinson's disease Importance: 50 Haloperidol is a dopamine antagonist that can worsen symptoms in those with Parkinson's disease and should be avoided. Despite being a dopamine antagonist, domperidone does not easily cross the blood-brain barrier and is actually considered safe for treating gastrointestinal symptoms in patients with Parkinson's disease (PD) because the risk of developing extrapyramidal adverse effects is considered minimal. Lorazepam is safe to use in Parkinson's disease. Olanzapine is an antipsychotic that is often used to treat delirium. It is not contra-indicated in Parkinson's disease. Ondansetron is an antiemetic which is safe to use in Parkinson's disease. w@ | "@ | @ Discuss (2) improve | encaner ss pele Q27 Bp © A 90-year-old man presents with worsening confusion. He is a nursing home resident and is dependent on carers for most activities of daily living. He is usually able to have short interactions with members of staff, though often struggles remembering names and naming objects. Carers are concerned as he appears less alert than usual. He needs significant prompting at mealtimes and remains incontinent of urine. On examination, he scores 12/15 on the Glasgow coma scale. Which factor would suggest a diagnosis of delirium rather than dementia? Difficulty with day-to-day tasks Impairment of conscious level Short term memory loss Urinary incontinence Word-finding difficultiesShort term memory loss Urinary incontinence Word-finding difficulties Delirium involves an impairment of conscious level and often involves psychotic symptoms Importance: 50 The differentiation between delirium and dementia can be difficult in the context of known cognitive impairment. One of the main factors favouring delirium is impairment of consciousness, demonstrated here by the reduced score on the Glasgow coma scale. Other factors which might suggest delirium include a fluctuation in symptoms and hallucinations. An acute confusional state can be caused by a number of physical health problems, such as dehydration, constipation or a urinary tract infection. It can also be precipitated by medication changes or being in an unfamiliar environment. Delirium is more common among elderly patients, especially those with poor hearing/eyesight or pre-existing memory problems. The other options listed, including difficulty with day-to-day tasks, short term memory loss, word-finding difficulties, and urinary incontinence are more typical of dementia and, in this scenario, they are premorbid signs. wa | "@ | @Discuss | Improve encaner ss pele Q28 Bp © A 88-year-old woman is referred to the memory clinic for assessment after her family report that she has become gradually more forgetful over the past few months. Her Mini Mental State Examination (MMSE) score is 15/30. The consultant asks you to start her on an acetylcholinesterase inhibitor. Which of the following medications would you start? Donepezil Memantine Oxybutynin Rotigotine TolterodineWhich of the following medications would you start? Memantine Oxybutynin Rotigotine Tolterodine Donepezil - acetylcholinesterase inhibitor Importance: 50 Donepezil is an acetylcholinesterase inhibitor, which along with with galantamine and rivastigmine, are first line for management of mild to moderate Alzheimer's dementia. Memantine is an NMDA receptor antagonist, used as a 2nd line or 'add on' treatment for mild-moderate Alzheimer's dementia. It may be used ‘1st line in severe Alzheimer's. Oxybutynin and tolterodine are anti-muscarinic medications used in the treatment of urge incontinence. Immediate release oxybutynin should, however, be avoided in ‘frail older women’ according to NICE. Rotigotine is a dopamine agonist used in the treatment of Parkinson's disease and restless legs syndrome. ho iscuss | Improve encaner ss pel8 a29 e © An 86-year-old man with Lewy body dementia is presents to memory clinic with his wife. His wife reports that his hallucinations have worsened, and he is becoming more confused. Despite the best efforts of his carers, he remains agitated. His wife feels threatened by him at times. Which medication must be avoided? Donepezil Lorazepam Memantine Olanzapine Clonazepam mit answer | Reference ranges vLorazepam Memantine Clonazepam Antipsychotics are associated with a significant increase in mortality in dementia patients Importance: 50 In all dementia patients, antipsychotics should be avoided if possible due to the increase in mortality, particularly from cardiovascular causes. Lewy body dementia is a special case however: these patients are particularly sensitive to neuroleptic medication. In addition to the increase in mortality, neuroleptic medication will worsen motor symptoms, and put the patient at an especially high risk of neuroleptic malignant syndrome. Acetylcholinesterase inhibitors such as donepezil are recommended by NICE in Lewy body dementia. Memantine is also recommended if acetylcholinesterase inhibitors are not tolerated. Benzodiazepines may be used with caution. w& | "@ | @® Discuss (1) Improve | Next question > Alzheimer's disease: management Alzheimer's disease is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK fweeer]Non-pharmacological management * NICE recommend offering ‘a range of activities to promote wellbeing that are tailored to the person's preference’ * NICE recommend offering group cognitive stimulation therapy for patients with mild and moderate dementia * other options to consider include group reminiscence therapy and cognitive rehabilitation Pharmacological management NICE updated it's dementia guidelines in 2018 the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer's disease memantine (an NMDA receptor antagonist) is in simple terms the ‘second-line’ treatment for Alzheimer's, NICE recommend it is used in the following situation reserved for patients with ~ moderate Alzheimer's who are intolerant of, or have a contraindication to, acetylcholinesterase inhibitors — as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer's * = monotherapy in severe Alzheimer's . . Managing non-cognitive symptoms « NICE does not recommend antidepressants for mild to moderate depression in patients with dementia * antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress Donepezil * is relatively contraindicated in patients with bradycardia * adverse effects include insomnia encaner ss pel°e Q30 Ip © A 79-year-old man with a known history of mixed type dementia (Alzheimer's and vascular) is assessed in memory clinic as his family have noticed a further deterioration in his memory and cognition. His mini-mental state score is 12 and as such he is commenced on memantine. Which of the following best describes the mechanism of action of memantine? Serotonin receptor agonist Dopamine receptor antagonist Acetylcholinesterase inhibitor Butyrylcholinesterase and acetylcholinesterase inhibitor NMDA antagonist Submit answer | Reference ranges v encaner ss pelDopamine receptor antagonist Acetylcholinesterase inhibitor Butyrylcholinesterase and acetylcholinesterase inhibitor Memantine - NMDA receptor antagonist Importance: In tackling this question it is possible to eliminate two answer easily by recognising that acetylcholinesterase and butyrylcholinesterase inhibition is characteristic of cholinesterase inhibitors, a class of drug that memantine is not part of and instead is occupied by donepezil and rivastigmine (amongst others). From here the other answers are quite tricky in that memantine does act at both the serotonin and dopamine receptors but as an antagonist and agonist respectively rather than the options given. This leaves on one answer left, an NMDA antagonist. wt 1. @ Discuss Improve