BASICS OF FAMILY MEDICINE | NOTES ZA WIZARA | CMT LEVEL 6

BASICS OF FAMILY MEDICINE | NOTES ZA WIZARA | CMT LEVEL 6

Below example of notes provided by wizara in each semister, directly download link of this module is below you can download and have it.

Definition

Dementia is a progressive and non-reversible clinical syndrome characterized by a global impairment of cognitive function with loss of previously acquired intellectual function in the absence of impairment of arousal

 

Senile Dementia:

Delirium, dementia and other organic disoders can be thought of as medical conditions rather than psychiatric disorders but are included in psychiatric classification and sometimes misdiagnosed because they manifest as disturbed behaviour

 DOWNLOAD HERE BASICS OF FAMILY MEDICINE 

NOTES ZA WIZARA | CMT LEVEL 6

Multiple neuropathologic processes may underlie dementia, including both neurodegenerative diseases and vascular disease.  Dementia is caused by the degeneration of the cerebral cortex.

Under the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), dementia is considered a major neurocognitive disorder, in which a deficit in cognitive functioning is acquired rather than developmental. 

 

All dementia share common molecular mechanisms responsible for disease etiology and progression, such as hypoxia and oxidative stress, neuroinflammation, mitochondrial bioenergetics, neurodegeneration, and blood–brain barrier permeability. 

 

Aetiologies/risk factors of Senile Dementia

The commonest cause of senile dementia is Alzheimer’s disease AND Diffuse Vascular Disease are the most common.

Rare causes of dementia should be actively sought in younger patients and those with short histories

NB: Please go read Davidson’s Principle and Practice of Medicine 21st Edition page 1197 table 26.74 causes of dementia.

1. Obesity.

2. Depression.

3. Hypertension.

4. Diabetes mellitus.

5. Sedentary lifestyle.

6. High caloric intake.

7. Hypercholesterolemia.

8. Excessive amounts of alcohol.

 

l Epidemiology

Prevalence: It affects 5% of those over 65 and 20% of those over 80.

About 47 million people live with dementia globally. by 2050, there will be an almost three-fold increase to an estimated 131 million people afflicted with dementia.

 

l Gender:

Dementia is more prevalent among women than men because of their longer life expectancy.

Lifetime risk for dementia in women is estimated to be 32%, whereas the lifetime risk in men is 18%.

However , the age-specific risk is equal in both sexes

 

l Age:

Dementia, particularly caused by Alzheimer’s disease, is seen predominantly in elderly persons.

However , certain types of dementia are seen in younger patients such as:

AIDS-related dementia.

Certain familial forms of Alzheimer disease.

Some cases of variant Creutzfeldt-Jakob disease i.e. bovine spongiform encephalopathy or mad cow disease.

 

l Race:

In the United States, dementia is more prevalent in African American, American Indian/Alaska Native, intermediate in Latinos , Pacific Islanders and Whites.

It is the lowest among Asian Americans

 

Clinical features

1. The usual presentation is with a disturbance of personality or memory dysfunction.

2. The first step is to exclude a focal  lesion by determining that there is cognitive disturbance in more than one area.

3. A careful history is essential and it is important to interview not just the patient but a close family member too.

4. Mini-Mental State Examination is useful in assessing cognitive deficit.

A history of chronic, steady decline in short and later long-term memory.

Difficulties in:

i. Work.

ii. Social relationships.

iii. Activities of daily life(ADL)

iv. Dressing

v. Eating

vi. Ambulation(walking).

vii. Toileting e.g. urinating and defecation.

viii. Hygiene e.g. bathing, combing, etc.

 

MINI-MENTAL STATE EXAMINATION

In Mini-Mental State Examination the following parameters are assessed:

l Orientation

Assess for time of the year, season, date, day and month: 5 points each 1

Where are we?  country, county/region, town/city, building, floor : 5 points each 1

 

l Registration

Name three common objects e.g. table, apple, house. Take 1 second to say each and then ask the patient to repeat all the three after you have said them

Give 1 point for each of the correct answer then repeat until he/she learns all three.

Count trials and record.

 

l Attention

Ask the client to spell the word backwards(DLROW)

The score is the number of letters in the correct order

Each correct letter score 1 point

Recall

Ask for the three objects named during registration be repeated

Give 1 point for each correct answer

NB: Recall cannot be tested if all three objects were not remembered during registration

 

l Language

Name a ‘pencil’ and a ‘watch’ (2 points)

Repeat the following: ‘No ifs, ands or buts’(1 point)

Follow the three stage command: ‘Take this paper in your right hand, fold it in half, and put it on the floor’ (3 points)

Read and obey the following: (1 point)

(CLOSE YOUR EYES)

Depending on their clinical features dementias are often divided into

Cortical

Subcortical

 

Loss of visuospatial function, language ability, concentration and attention occur later and gradually.

Many of the primary degenerative diseases that cause dementia have characteristic features that may allow a specific diagnosis during life. The more slowly progressive dementias are more difficult to distinguish during life

 

Frontotemporal dementia:(FTD)

Patients may present with personality change due to frontal lobe involvement (presents with abnormal reasoning ability, disinhibition and poor insight) or with language disturbance due to temporal lobe involvement.

These diseases are much rarer than Alzheimer’s disease.

 Memory is relatively preserved in the early stages. There is no specific treatment

 

Lewy body dementia

This is a neurodegenerative disorder clinically characterized by dementia and signs of Parkinson’s disease.

The cognitive state often fluctuates and there is a high incidence of visual hallucinations.

The condition is associated with accumulation of abnormal protein aggregates in the neurons.

 

Complications

Delayed recognition of dementia can result in trauma secondary to cognitively impaired driving or the use of other hazardous equipment, including cooking stoves.

Patients with dementia are at increased risk of victimization by predatory business practices ,Internet scams and other fraudulent or criminal attacks.

 

Investigations

Aims:

i. To discover a treatable cause, if present

ii. To estimate prognosis using a standard set of investigations

1. Blood test:

2. Blood glucose,

3. Urea and  Creatinine

4. Serum calcium,

5. Liver function tests

6. Full blood count,ESR

7. Thyroid function tests

8. Vitamin B12

9. VDRL to exclude syphilis

10. Radiological imaging: CT scan and/or MRI

This is important to exclude potentially treatable structural lesions such as hydrocephalus, cerebral tumour or chronic subdural haematoma.

11. Chest X-ray

12. EEG

 

IN SELECTED PATIENTS

i. Lumbar puncture

ii. HIV serology

iii. Brain biopsy

 

Treatment

 This is directed at addressing treatable causes and providing support for patient and careers if no specific treatment exists

 Anticholinesterase inhibitors are the drugs of choice for patients with dementia.

Examples:Donepezil,Galantamine,Rivastigmine.

 These medications are useful early in the disease course, but they lose their effectiveness or may worsen mental status in advanced stages of the disease.

 N-methyl D-aspartate (NMDA) receptor antagonists: Example:Memantine(Namenda) appear to improve cognitive functions to some extent.

 Antidepressants :Example ; selective serotonin reuptake inhibitors (SSRIs)-Sertraline,-Fluoxetine,-Paroxetine,-Citalopram,-Fluvoxamine,-Escitalopram.

Benzodiazepines: Example: Diazepam. They are useful for sedation or sleep. However, these drugs may worsen cognitive deficits, increase the risk of falls and are best avoided if possible

 

 Antipsychotics

 Example : Risperidone , a newer atypical antipsychotic

 Psychotropic drugs may help where there is associated disturbance of sleep, perception or mood or aggressive behaviour.

However, a long-term use of atypical antipsychotics as a group has been associated with a slightly higher death rate in patients with dementia (3.5% vs. 2.3% for placebo).

 

Prognosis

Dementia is usually insidious and persistently progressive.

However, about 20-30% of cases are due to  reversible causes.

Patients with primary dementia have a significantly reduced life expectancy, depending on the cause of the dementia and it’s severity and rapidity of progression

On average, patients with Alzheimer disease die within 8 years of onset, with a range of 2-15 years.

Younger patients usually have a more fulminant course. Pick’s disease has a similar course.