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Behavioral-Variant Frontotemporal Dementia Diagnosis

The document discusses various cases of dementia, focusing on diagnoses such as frontotemporal dementia, Lewy body dementia, and Alzheimer's disease. It highlights key symptoms, diagnostic criteria, and management options, including the caution needed when prescribing antipsychotics due to increased mortality risks in dementia patients. The document emphasizes the importance of recognizing specific clinical features to differentiate between types of dementia.

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0% found this document useful (0 votes)

40 views168 pages

Behavioral-Variant Frontotemporal Dementia Diagnosis

Uploaded by

Noor Ul Ain

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

3/29/24, 5:03 PM PassMedicine

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Question 1 of 38

A 60-year-old man is brought in by his daughter. He has recently been fired from his job due to
allegations of sexual harassment towards coworkers. His daughter states that he 'hasn't been
himself'. He is socially withdrawn and has increased his smoking to ten cigarettes a day. His house
is cluttered with newspapers and he has failed to pay his electricity bill on two recent occasions.

The patient states he feels fine. His daughter notes that her paternal grandfather developed
cognitive difficulty in his sixties. A 10-point cognitive screener test shows mild impairment.

What is the most likely diagnosis?

Alzheimer's dementia 5%

Dementia with Lewy bodies 4%

Frontotemporal dementia 81%

Major depressive disorder 6%

Vascular dementia 3%

Frontotemporal dementia presents with social disinhibition and often has a family history
Important for me Less important

This patient has a family history of early-onset dementia and displays deteriorating cognition,
disinhibition (socially inappropriate behaviour), apathy, hyperorality (increased cigarette use) and
executive dysfunction (unable to plan/pay bills). He likely has behavioural-variant
frontotemporal dementia (bvFTD) (previously known as Pick's disease). BvFTD is a common
early-onset dementia syndrome characterized by degeneration of the frontal and temporal lobes
and manifests clinically as progressive deterioration in behaviour/cognition associated with six
clinically discriminating features:
Disinhibition (loss of manners, decorum, socially inappropriate behaviour)
Apathy/inertia
Loss of sympathy/empathy
Perseverative/compulsive behaviours (eg. simple repetitive movements, ritualistic behaviours)
Hyperorolality (eg. oral exploration of objects, increased consumption of alcohol/cigarettes,
altered food preferences)

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Executive dysfunction with relative sparing of memory and visuospatial functions.

Memory difficulties tend to develop later in the disease course. A family history of dementia is
present in up to 40% of cases with an autosomal dominant component being present in 10%.

Alzheimer's dementia would likely present with more severe memory loss. This patient's
constellation of clinical features suggests bvFTD.

Dementia with Lewy bodies presents with at least 2 of 4 of the following: hallucinations,
fluctuating levels of consciousness/cognition ('good and bad days'), REM-sleep behaviour
disorder and parkinsonism. This patient's history fits more with FTD.

This patient does not meet the criteria for diagnosis of major depressive disorder. His
constellation of clinical features points towards bvFTD.

Vascular dementia does not present with disinhibition and hyperorality. These point more
towards a diagnosis of bvFTD.

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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

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Common features of frontotemporal lobar dementias

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

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.

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Textbooks

High-yield textbook

Extended textbook

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 4 0

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Score: 0%

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Question 2 of 38

A 72-year-old female is brought into the general practice by her worried husband.

She has been more forgetful over the past few months, on some days more than others, and
seems to struggle to keep her focus on simple daily activities and conversations. Her husband is
also worried as she occasionally states she is talking to their dog whilst apparently talking alone,
although they have never had any pets.

She is otherwise well, eating and drinking as usual. Examination and routine blood tests are all
unremarkable, and there is no reason to suspect delirium.

What is the most likely diagnosis?

Alzheimer's disease 15%

Depression 2%

Fronto-temporal dementia 10%

Lewy body dementia 70%

Vascular dementia 4%

Visual hallucinations with dementia = Lewy body dementia

Important for me Less important

Lewy body dementia (LBD) is the most likely diagnosis in a patient with early, fluctuating cognitive
impairment and visual hallucinations, particularly if the hallucinations are not unpleasant. Indeed,
hallucinations of friendly children and animals are often described, such as in this case. LBD
accounts for around 20% of dementia cases. Parkinsonism typically develops later and therefore
may not be mentioned on initial presentation. Treatment of LBD is similar to Alzheimer's
treatment; both acetylcholinesterase inhibitors and memantine can be used depending on the
stages. Antipsychotics should be avoided in LBD as they can precipitate parkinsonism.

Alzheimer's disease is a good differential but is less likely to fluctuate and cause visual
hallucinations (in this patient's case, talking to a dog). Early impairment in attention and executive
function (such as daily tasks and conversations in this case), rather than just memory loss, are

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characteristic of LBD and can help differentiate it from Alzheimer's.

Depression can cause patients to become more forgetful and even hallucinate their loved ones if
part of a grief reaction. However, this patient never had a dog, and no other symptoms of
depression (such as lack of appetite or poor sleep) are mentioned.

Fronto-temporal dementia, also known as Pick's disease, typically causes personality change and
impaired social conduct. Other common features include hyperorality, disinhibition, increased
appetite, and perseveration behaviours.

Vascular dementia typically causes a stepwise deterioration, rather than having a fluctuating
course, and is less likely to cause hallucinations.

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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
typically occurs before parkinsonism, but usually both features occur within a year of
each other. This is in contrast to Parkinson's disease, where the motor symptoms typically
present at least one year before cognitive symptoms
cognition may be fluctuating, in contrast to other forms of dementia
in contrast to Alzheimer's, early impairments in attention and executive function rather
than just memory loss
parkinsonism
visual hallucinations (other features such as delusions and non-visual hallucinations may also
be seen)

Diagnosis
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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-I 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

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 13 3

2018 Dementia guidelines

Report broken link

Media

[Link] 3/4
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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Lewy body dementia

Osmosis - YouTube 30 4

Parkinson's disease

MedFlix - YouTube 10 4

Report broken media

Score: 0%

1
2

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Question 3 of 38

A 75-year-old man presents to memory services. His daughter reports that he has had significant
cognitive decline over two years and is now unable to perform self-care.

The patient describes visual hallucinations, causing him significant distress. He is not currently
prescribed any medications.

On assessment, his heart rate is 70bpm and blood pressure is 180/90mmHg.

His MRI findings are consistent with Alzheimer's disease and small vessel disease.

What medication should be considered with caution in this patient, due to its association with a
significant increase in mortality in this condition?

Amlodipine 8%

Donepezil 30%

Memantine 13%

Olanzapine 42%

Rivastigmine 8%

Antipsychotics are associated with a significant increase in mortality in dementia patients

Important for me Less important

Olanzapine is an antipsychotic medication. Antipsychotics are associated with a significant

increase in mortality in dementia patients and should only be used with caution for patients at risk
of harming themselves or others, or when the agitation, hallucinations, or delusions are causing
them severe distress as in this case.

Amlodipine would be a sensible treatment to start given his raised blood pressure and known
small vessel disease. It does not cause increased mortality in dementia.

Donepezil is relatively contraindicated in patients with bradycardia which does not apply in this
case.

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Donepezil and rivastigmine are acetylcholinesterase inhibitors that are first-line options in
managing mild to moderate dementia. This patient has advanced dementia. Additionally, these
medications are not associated with increase mortality in dementia.

Memantine is an NMDA antagonist. It would be appropriate in this patient, either as a

monotherapy or in conjunction with an acetylcholinesterase inhibitor for severe Alzheimer's.

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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

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

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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

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

[Link] 3/4
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Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

Score: 33.3%

1
2
3

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Question 4 of 38

A 78-year-old woman with known Lewy body dementia presents to the clinician with her husband.
The husband is concerned as his wife is having increasingly more visual hallucinations and
paranoid delusions. She believes that her husband is an imposter and has been increasingly
aggressive.

At her last clinic review, 2 months previously, her dose of carbidopa-levodopa was increased to
target her resting tremor and overall bradykinesia.

Which of the following is the next best step in the management of this patient?

Decrease the dose of carbidopa-levodopa 52%

Discontinue carbidopa-levodopa 9%

Start clonazepam 17%

Start haloperidol 16%

Start tranylcypromine 6%

Typical antipsychotics should be avoided in delirious patients with a background of

Parkinson's disease
Important for me Less important

This patient's worsening hallucinations are likely to be driven by an increase in dopamine in the
mesolimbic pathway from her recent medication change. Decreasing the dose of carbidopa-
levodopa is likely to improve the patient's hallucinations and delusional thinking.

Abrupt discontinuation of carbidopa-levodopa has been reported to cause parkinsonism-

hyperpyrexia syndrome, which is similar to the neuroleptic malignant syndrome and therefore
should be avoided.

Clonazepam is a benzodiazepine used in the treatment of panic attacks and seizure disorders. It
facilitates GABA-A action by increasing the frequency of chloride channel opening resulting in
hyperpolarization of the neurons thereby producing a calming effect on the brain by reducing the
excitability of the neurons.

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Tranylcypromine is a monoamine oxidase inhibitor and haloperidol is an antipsychotic. Both are

used as antipsychotics and should be avoided when possible as many patients with Lewy body
dementia are known to have extreme sensitivity to neuroleptics. If antipsychotics are required,
low-dose second-generation antipsychotics such as clozapine, quetiapine, and aripiprazole are
preferred.

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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

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

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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
management can be challenging in patients with Parkinson's disease, as antipsychotics can
often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful
if symptoms require urgent treatment then the atypical antipsychotics quetiapine and
clozapine are preferred

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 8 0

2010 Delirium guidelines

Clinical Knowledge Summaries 11 6

Delirium

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Report broken link

Media

Delirium

Osmosis - YouTube 13 2

Parkinson's disease

MedFlix - YouTube 9 3

Report broken media

Score: 50%

1
2
3
4

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Question 5 of 38

A 78-year-old woman is seen in a memory clinic. She has longstanding cognitive impairment and
memory loss associated with her AD. Her husband who has accompanied her to clinic report that
she spends the whole night wandering around and hardly sleeps. He wonders if one of her drugs
may have caused her to have insomnia.

On examination, she looks lethargic and tired, otherwise, the examination is unremarkable.

Which one of the following drugs may be responsible for her insomnia?

Memantine 13%

Temazepam 2%

Zopiclone 2%

Donepezil 81%

Suvorexant 3%

Donepezil can cause insomnia

Important for me Less important

Memantine is an NMDA receptor antagonist used in the management of Alzheimer's disease (AD)
if anticholinesterases are ineffective or contraindicated. Its side effects include sleepiness. It is not
known to cause insomnia.

Temazepam, zopiclone and suvorexant are used to treat insomnia, therefore, are incorrect answers.

Donepezil, an acetylcholinesterase inhibitor, used as the first line drug in the management of AD is
associated with insomnia.

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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

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

Next question

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[Link] 2/4
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Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

[Link] 3/4
3/29/24, 5:05 PM PassMedicine

Score: 40%

1
2
3
4
5

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Question 6 of 38

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 2%

Rankin scale 6%

Ranson criteria 5%

Waterlow scale 84%

Townsend scale 3%

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.

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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: urinary and faecal
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 the skin, warmth, oedema,
1 induration or hardness may also be used as indicators, particularly on individuals with
darker skin

Grade Partial thickness skin loss involving epidermis or dermis, or both. The
2 ulcer is superficial and presents clinically as an abrasion or blister

Grade Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that
3 may extend down to, but not through, underlying fascia.

Grade Extensive destruction, tissue necrosis, or damage to muscle, bone or

4 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)
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consider referral to the tissue viability nurse

surgical debridement may be beneficial for selected wounds

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 5 1

2014 The prevention and treatment of pressure ulcers

NHS 1 1

Prevention and management of pressure ulcers

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Question 7 of 38

Mr. T is an 82-year-old man who is being been treated on the acute medical unit for a presumed
urinary tract infection. He has a history of ischaemic heart disease, hypertension, and Parkinson's
disease. The staff nurse has called you to prescribe some night sedation as he has become acutely
delusional and aggressive.

Which medication is best avoided in this case?

Diazepam 4%

Haloperidol 60%

Lorazepam 9%

Olanzapine 16%

Quetiapine 11%

Haloperidol is contraindicated in patients with Parkinson's disease

Important for me Less important

Diazepam and lorazepam are benzodiazepine agents, they may be used with caution for short-
term sedation in hospitalised patients if all other non-intervention methods have failed. They are
not contraindicated in Parkinson's disease.

Although the 2006 royal college of physicians guidelines recommended haloperidol 0.5 mg as the
first-line sedative, it is contra-indicated in Parkinson's disease, such as in this case, as the
dopamine blockade can worsen Parkinson's symptoms.

The 2010 NICE delirium guidelines advocate the use of olanzapine so this could be a suitable
choice in this situation.

If medication is required to manage delirium in Parkinson's disease then atypical antipsychotics

such as quetiapine can be helpful.

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Next question

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:

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

[Link] 2/4
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management can be challenging in patients with Parkinson's disease, as antipsychotics can

often worsen Parkinsonian symptoms
careful reduction of the Parkinson medication may be helpful
if symptoms require urgent treatment then the atypical antipsychotics quetiapine and
clozapine are preferred

Next question

              

Textbooks

High-yield textbook

Extended textbook

Links

NICE 8 0

2010 Delirium guidelines

Clinical Knowledge Summaries 11 6

Delirium

Report broken link

Media

Delirium
Osmosis - YouTube

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13 2

Parkinson's disease

MedFlix - YouTube 9 3

Report broken media

Score: 28.6%

1
2
3
4
5
6
7

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Question 8 of 38

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 62%

Perform carotid Dopplers 1%

Give practical advice + advise family to contact Alzheimer's Society 11%

Prescribe aspirin + simvastatin 1%

Prescribe donepezil 26%

Neuroimaging is required to diagnose dementia

Important for me Less important

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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

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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,
ESR/CRP, 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

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2018 Dementia guidelines

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Helping you to assess cognition - A practical toolkit for clinicians

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Question 9 of 38

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 69%

Donepezil 18%

Fluoxetine 2%

Cognitive behavioural therapy 7%

Memantine 4%

Tight control of vascular risk factors, rather than antidementia medication, is recommended
by NICE in vascular dementia
Important for me Less important

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.

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Vascular dementia

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.

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.

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

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Speech disturbance
Emotional disturbance

Diagnosis is made based on:

A comprehensive 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

A relationship 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

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
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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

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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

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Question 10 of 38

An 86-year-old man with no history of cognitive impairment is being treated on a geriatrics ward
for pneumonia and delirium. He is on intravenous antibiotics and fluids.

His delirium has become worse the last few nights, so he has been placed in a side room with a
member of staff he is familiar with and allowed open visiting from his wife.

These measures are insufficient and he has now become aggressive, posing an immediate physical
danger to staff on the ward. Security are already present.

What is the most appropriate immediate management?

Invite in the patient's wife to help calm him down 8%

Offer oral haloperidol, if refuses give intramuscularly 66%

Offer oral lorazepam, if refuses give intramuscularly 21%

Offer oral promethazine, if refuses give intramuscularly 1%

Refer the patient for psychiatry review 5%

Acute confusional state: if treating the underlying cause and environmental modification not
working then haloperidol sometimes used
Important for me Less important

Offer oral haloperidol, if refuses give intramuscularly is correct. Oral medication should always
be offered first as the intramuscular route is associated with more risks. If the patient refuses oral
medication, given that he poses an immediate physical danger to others, the intramuscular route
is justified in this instance.

Invite in the patient's wife to help calm him down is incorrect. Whilst inviting the wife to come
in may help settle the patient, it does not address the immediate risk the patient poses to staff at
that point in time.

Offer oral lorazepam, if refuses give intramuscularly is incorrect. Benzodiazepines may worsen
the patient's delirium so haloperidol would be the preferred option in this instance.

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Offer oral promethazine, if refuses give intramuscularly is incorrect. Elderly patients are more
sensitive to the anticholinergic effects of promethazine, so haloperidol would be the preferred
option in this instance.

Refer the patient for psychiatry review is incorrect. Although this patient will need referring for
a psychiatry review, this is unlikely to take place soon. The patient's risk to others needs
addressing immediately.

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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:

Features - a wide variety of presentations

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation
mood change

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visual hallucinations
disturbed sleep cycle
poor attention

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2010 Delirium guidelines

Clinical Knowledge Summaries 11 6

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Delirium

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Question 11 of 38

A 78-year-old woman with a background of mild Alzheimer's disease was admitted to the
orthopaedic ward 5 days ago after a fall at home resulted in a right neck of femur fracture. She
underwent a right hemiarthroplasty 4 days ago. Over the past 3 days she has become more
confused. Despite regular visits from family members and 1:1 nursing observation, she is
becoming physically aggressive towards staff and has nearly fallen on the ward.

What medication would you prescribe to manage her behaviour?

Diazepam 3%

Haloperidol 67%

Lorazepam 20%

Morphine 2%

Risperidone 8%

Acute confusional state: if treating the underlying cause and environmental modification not
working then haloperidol sometimes used
Important for me Less important

This patient presents with an acute deterioration in her cognitive function, consistent with delirium
or an 'acute confusional state'. The cause of her delirium is likely to be multifactorial, for example,
secondary to changes in the environment, surgical sedation, dehydration, pain, and constipation
due to opioid analgesics. She may have also contracted a hospital-acquired infection. Her pre-
existing cognitive impairment also increases her susceptibility to delirium. A delirium screen
should be conducted by the medical team.

Haloperidol is the recommended first-line sedative for delirium when treating the underlying
cause and environmental modifications are insufficient, especially when the patient poses a risk to
themselves as in this scenario, and/or others. Haloperidol has certain advantages over other
antipsychotics. It is available in different formulations (oral, intramuscular, and intravenous routes)
and is reported to be associated with a lower risk of sedation and hypotension.

Risperidone, another antipsychotic, could also be used but is not first-line for pharmacological

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management of delirium due to the advantages of haloperidol listed above.

As per NICE guidelines, lorazepam can be used for the management of challenging behaviour
associated with delirium but is not first-line and should only be prescribed on the advice of a
specialist.

Diazepam is used for acute anxiety or acute alcohol withdrawal rather than pharmacological
management of delirium.

Morphine may be considered if the patient were in severe post-operative pain despite simple
analgesia, but carries the risk of exacerbating delirium.

Discuss (1) Improve

Next question

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:

Features - a wide variety of presentations

memory disturbances (loss of short term > long term)

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may be very agitated or withdrawn

disorientation
mood change
visual hallucinations
disturbed sleep cycle
poor attention

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NICE 8 0

2010 Delirium guidelines

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Clinical Knowledge Summaries 11 6

Delirium

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Question 12 of 38

An 80-year-old man is investigated for progressive cognitive impairment. Which one of the
following features is most suggestive of Lewy body dementia?

Disinhibition 10%

Emotional lability 10%

Symptoms worsen with neuroleptics 62%

Urinary incontinence 5%

Paucity of extrapyramidal signs 14%

The correct answer is Symptoms worsen with neuroleptics. Lewy body dementia (LBD) is
characterised by fluctuating cognitive impairment, visual hallucinations, parkinsonism and a
pronounced sensitivity to neuroleptics. This sensitivity can manifest as a severe worsening of
motor symptoms or the development of Neuroleptic Malignant Syndrome (NMS), a potentially
fatal condition characterised by hyperthermia, altered mental state, autonomic dysregulation and
generalised muscle rigidity.

Disinhibition is not typically associated with LBD. Disinhibition, which refers to poor impulse
control resulting in inappropriate social behaviour, is more commonly seen in frontotemporal
dementia (FTD). FTD also presents with personality changes and language impairment but lacks
the characteristic features of LBD such as visual hallucinations and parkinsonism.

Emotional lability, defined as rapid, often exaggerated changes in mood, where strong emotions
or feelings (uncontrollable laughing or crying) occur. This symptom is not typical of LBD but it's
more commonly associated with pseudobulbar affect that may be seen in conditions like
amyotrophic lateral sclerosis or multiple sclerosis.

Urinary incontinence can be present in many types of dementia due to the general loss of brain
function affecting bladder control. However, it's not specific to LBD and tends to occur later in the
course of most dementias when significant brain damage has occurred.

Finally, Paucity of extrapyramidal signs, meaning few movement disorders relating to

Parkinson's disease such as tremors or rigidity are present. This would be unusual for LBD since
one of its key characteristics includes symptoms similar to Parkinson's disease such as slowed
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movement, rigid muscles and tremors.

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Lewy body dementia

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-I 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

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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

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NICE 13 3

2018 Dementia guidelines

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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

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Lewy body dementia

Osmosis - YouTube 30 4

Parkinson's disease

MedFlix - YouTube 10 4

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Question 13 of 38

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 3%

Frontotemporal dementia 13%

Delirium 75%

Korsakoff syndrome 6%

Acute psychotic episode 3%

Delirium involves an impairment of conscious level and often involves psychotic symptoms
Important for me Less important

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.

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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.

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Next question

Delirium vs. dementia

Factors favouring delirium over dementia

acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions

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Delirium

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Question 14 of 38

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 5%

Sick sinus syndrome 66%

Concurrent simvastatin therapy 2%

Concurrent citalopram therapy 8%

Ischaemic heart disease 19%

Donepezil is generally avoided (relative contraindication) in patients with bradycardia and is

used with caution in other cardiac abnormalities
Important for me Less important

The correct answer is Sick sinus syndrome. Donepezil, a cholinesterase inhibitor, is commonly
used in the management of Alzheimer's disease. However, it can increase vagal tone and cause
bradycardia. In patients with sick sinus syndrome - a group of heart rhythm disorders where the
sinus node doesn't work properly - this could lead to severe symptomatic bradycardia or even
sinus arrest. Therefore, donepezil should be used with caution in these patients.

History of depression is not a contraindication to the use of donepezil. Depression is common in

patients with Alzheimer's disease and there is no evidence that donepezil exacerbates depressive
symptoms. In fact, some studies suggest that it may improve neuropsychiatric symptoms in some
individuals.

Concurrent simvastatin therapy is also not a contraindication. While both drugs are metabolised
by cytochrome P450 enzymes, they do not share the same subtypes and therefore significant drug
interactions are unlikely.

Concurrent citalopram therapy does not contraindicate the use of donepezil either. Although
both drugs can cause QT prolongation, their combined use does not typically result in clinically
significant arrhythmias unless there are additional risk factors such as electrolyte abnormalities or
other QT-prolonging medications.

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Finally, Ischaemic heart disease, while requiring careful consideration when prescribing any new
medication due to potential cardiac side effects, is not a specific contraindication for donepezil.
The primary cardiac side effect of donepezil - bradycardia - may actually be beneficial in some
patients with ischaemic heart disease by reducing myocardial oxygen demand. However, each
patient's individual risk profile should be taken into account when prescribing this medication.

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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

Managing non-cognitive symptoms

NICE does not recommend antidepressants for mild to moderate depression in patients with
dementia

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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

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Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

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Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

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Question 15 of 38

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 2%

Clopidogrel 1%

Donepezil 71%

Pramipexole 15%

Rivastigmine 11%

Donepezil can cause insomnia

Important for me Less important

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

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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.

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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

Managing non-cognitive symptoms

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Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

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Helping you to assess cognition - A practical toolkit for clinicians

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Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

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Question 16 of 38

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 36.5ºC 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)
Hb 115 g/L
Female: (115 - 160)

Platelets 250 * 109/L (150 - 400)

WBC 8.5* 109/L (4.0 - 11.0)

Na 143 mmol/L (135 - 145)

K 3.7 mmol/L (3.5 - 5.0)

Urea 5.0 mmol/L (2.0 - 7.0)

Creatinine 95 µmol/L (55 - 120)

CRP 6 mg/L (< 5)

Of the options listed below, which is the most likely cause of the patient's presentation?

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Constipation 77%

Hypoglycaemia 2%

Pain 8%

Progression of Alzheimer's dementia 8%

Urinary tract infection 5%

Constipation can cause delirium in the elderly

Important for me Less important

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.

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.

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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.

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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:

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

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NICE 8 0

2010 Delirium guidelines

Clinical Knowledge Summaries 11 6

Delirium

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Delirium

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MedFlix - YouTube 9 3

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Question 17 of 38

A 75-year-old man presents with a 6-month history of worsening short-term memory, frequently
misplacing objects and difficulty finding his way home from the shops. He is diagnosed in clinic
with mild Alzheimer's disease.

What medication would you consider commencing?

Amitriptyline 1%

Galantamine 53%

Haloperidol 1%

Memantine 29%

Pyridostigmine 15%

NICE guidelines do not support the use of memantine in mild dementia

Important for me Less important

As per NICE guidelines, galantamine, as well as donepezil and rivastigmine, are all
acetylcholinesterase inhibitors used first-line as pharmacological treatment options for the
management of mild Alzheimer's disease.

Memantine, an NMDA receptor antagonist, is specifically licensed for:

Severe Alzheimer's disease as monotherapy, or
Patients with moderate Alzheimer's who are intolerant of, or have a contraindication to,
acetylcholinesterase inhibitors, or
As an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe
Alzheimer's disease.

NICE guidelines would not support the use of memantine in this patient who has mild dementia,
and he has no known contraindications to acetylcholinesterase inhibitors.

Pyridostigmine is an acetylcholinesterase inhibitor but is exclusively licensed for the treatment of

myasthenia gravis.

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Haloperidol is not licensed for the treatment of Alzheimer's dementia but is the first-line
pharmacological treatment option for delirium.

Amitriptyline is a tricyclic antidepressant that is not used in the management of Alzheimer's

disease. It also has anticholinergic side effects and so should be avoided for the treatment of
depression in patients with dementia as it may worsen cognitive impairment.

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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

Managing non-cognitive symptoms

NICE does not recommend antidepressants for mild to moderate depression in patients with
dementia

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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

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2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

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Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

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PassMedicine

Question 18 of 38

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 4%

Cholinesterase 88%

Monoamine oxidase A 5%

Monoamine oxidase B 3%

Tyrosine hydroxylase 1%

Donepezil - acetylcholinesterase inhibitor

Important for me Less important

Patients with Alzheimer's dementia (the most common type) have reduced amounts of cholinergic
neurons. Medications such as acetylcholine inhibitors (AChEI) 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

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include serotonin, dopamine and norepinephrine). MAO inhibitors are used in the treatment of
many conditions including depression and panic disorder.

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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

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
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adverse effects include insomnia

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2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

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Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

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PassMedicine

Question 19 of 38

A 78-year-old man is brought into the memory clinic by his wife, who is concerned that over the
past year he has become increasingly forgetful. He frequently stares off into space, and has
trouble with planning and organising himself. More recently, he has been talking to people who
aren't there, occasionally getting distressed by this.

She reports that his mental state will fluctuate from day to day, and sometimes from hour to hour,
with episodes of lucidity between.

Prior to this, he was well, suffering from mild cataracts and hypertension only.

What is the most likely cause of this presentation?

Alzheimer's disease 9%

Charles Bonnet syndrome 11%

Parkinson's disease 1%

Dementia with Lewy bodies 62%

Vascular dementia 17%

Visual hallucinations with dementia = Lewy body dementia

Important for me Less important

This man has progressive, fluctuant cognitive decline associated with visual hallucinations, which is
a classic presentation of Lewy body dementia. This condition, which is characterised by clumps of
proteins being deposited within neurons, can also feature rapid eye movement sleep disorders,
parkinsonism, and marked dysautonomia. The exact cause is not yet known. The early
development of higher-order functioning, such as planning and organisation, is also characteristic
of this condition.

Alzheimer's disease is the main distractor here, being more common than Lewy body dementia,
and presenting with cognitive decline. However, it is not generally fluctuant and does not
commonly cause hallucinations in its early stages. Further, loss of higher-order functions tends to
occur after memory loss has become established.

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Charles Bonnet syndrome (CBS) is a condition whereby people with poor sight develop visual
hallucinations. While this patient does have cataracts, CBS would not explain his cognitive decline.
Further, his cataracts are only mild, and CBS generally causes non-distressing hallucunations.

Parkinson's disease usually starts with motor symptoms (bradykinesia, rigidity, pill-rolling tremor)
before dementia begins.

Vascular dementia is generally seen in patients with vascular disease and results in a stepwise
progression following vascular events. Again, it would not normally fluctuate from day to day.

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Lewy body dementia

Diagnosis
usually clinical

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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-I FP-CIT) is used as the radioisotope.
The sensitivity of SPECT in diagnosing Lewy body dementia is around 90% with a specificity of
100%

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Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

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Parkinson's disease

MedFlix - YouTube 10 4

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Question 20 of 38

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 9%

Constipation 78%

Extradural haemorrhage 3%

Nosocomial infection 4%

Alzheimer's disease 7%

Constipation can cause delirium in the elderly

Important for me Less important

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,

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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.

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Next question

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:

Features - a wide variety of presentations

memory disturbances (loss of short term > long term)
may be very agitated or withdrawn
disorientation

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mood change
visual hallucinations
disturbed sleep cycle
poor attention

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NICE 8 0

2010 Delirium guidelines

Clinical Knowledge Summaries 11 6

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Delirium

Report broken link

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Delirium

Osmosis - YouTube 13 2

Parkinson's disease

MedFlix - YouTube 9 3

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Question 21 of 38

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 6%

Improvement in activities of daily living 33%

Longer time before entering residential care 4%

Improved mortality 3%

Minimize the progression of dementia 54%

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.

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Alzheimer's disease: pathophysiology

Alzheimer's disease (AD) is a progressive degenerative disease of the brain accounting for the
majority of dementia seen in the UK.

Risk factors
increasing age
family history of Alzheimer's disease
5% of cases are inherited as an autosomal dominant trait

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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
Caucasian ethnicity
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 its function

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3 0

2018 Dementia guidelines

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Helping you to assess cognition - A practical toolkit for clinicians

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PassMedicine

Question 22 of 38

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 2%

Impairment of conscious level 73%

Short term memory loss 10%

Urinary incontinence 13%

Word-finding difficulties 2%

Delirium involves an impairment of conscious level and often involves psychotic symptoms
Important for me Less important

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-

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finding difficulties, and urinary incontinence are more typical of dementia and, in this scenario,
they are premorbid signs.

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Delirium vs. dementia

Factors favouring delirium over dementia

acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions

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Delirium

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Question 23 of 38

A 64-year-old man is seen in the memory clinic with an 8-month history of cognitive decline. His
wife tells you that he has difficulty remembering basic tasks and is becoming more confused and
forgetful than usual. She has also noticed a change in his personality and has caught him swearing
more frequently and answering the door naked on multiple occasions. His mother had a similar
reputation for being 'too outspoken' in her twilight years. He reports smoking 20 cigarettes/day
and drinks 1 glass of wine each evening.

What is the most likely diagnosis?

Alzheimer's dementia 5%

Creutzfeldt-Jakob disease 2%

Frontotemporal dementia 82%

Lewy body dementia 5%

Vascular dementia 5%

Frontotemporal dementia presents with social disinhibition and often has a family history
Important for me Less important

This patient has frontotemporal lobar degeneration (FTLD). There are 3 subtypes of FTLD including
frontotemporal dementia (or Pick's disease), progressive non-fluent aphasia, and semantic
dementia. Of the 3 subtypes, this patient has Pick's disease which is characterised by an insidious
onset, commonly before 65 years, and a change in personality and social disinhibition. The
positive family history also makes frontotemporal dementia more likely.

Alzheimer's disease is the most common type of dementia. However, unlike this presentation,
Alzheimer's dementia presents as a progressive decline in episodic memory. Visuospatial
awareness may be impacted. Social disinhibition is not a common presenting feature and suggests
an alternative diagnosis.

Creutzfeldt-Jakob disease is a very rare condition. It is a type of prion disease that causes rapid
and progressive neurodegeneration. Cognitive decline and personality change are features.
However, typically additional symptoms such as abnormal jerking movements, loss of

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coordination, mobility, vision and slurred speech are also present.

Lewy body dementia is a type of dementia characterised by fluctuating confusion and

hallucinations. There is an overlap with Parkinson's disease and motor symptoms may also be seen
such as bradykinesia, tremor and a shuffling gait.

Vascular dementia is a type of dementia that follows a step-wise progression. Symptoms tend to
vary depending on the areas of the brain affected by vascular disease. However, the degree of
social disinhibition and positive family history in this case presentation makes vascular dementia
less likely.

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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

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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

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.

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Question 24 of 38

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 13%

Frontotemporal dementia 4%

Lewy body dementia 5%

Parkinson's dementia 1%

Vascular dementia 77%

Stepwise deterioration in cognitive function? - think vascular dementia

Important for me Less important

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

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to impair thought processes, mental function, and memory. You would expect to find signs of PD
on physical examination.

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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.

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

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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.

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:

National Institute for health and care excellence (NICE) recommends that diagnosis be made using
the NINDS-AIREN criteria for probable vascular dementia

Cerebrovascular disease
defined by neurological signs and/or brain imaging

A relationship 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

General management

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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

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

Next question

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Textbooks

High-yield textbook

Extended textbook

Media

[Link] 4/6
3/29/24, 5:13 PM PassMedicine

Parkinson's disease

MedFlix - YouTube 3 1

Vascular dementia

Osmosis - YouTube 11 4

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 2 1

Report broken media

Score: 41.7%

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PassMedicine

Question 25 of 38

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 73%

Normal pressure hydrocephalus 3%

Progressive supranuclear palsy 10%

Multiple system atrophy 6%

Dementia pugilistica 7%

The correct answer is Lewy body dementia. Lewy body dementia (LBD) is a type of progressive
dementia that leads to a decline in thinking, reasoning and independent function due to abnormal
microscopic deposits that damage brain cells over time. Parkinsonian symptoms such as
bradykinesia, rigidity and tremor are common in LBD. Additionally, patients with LBD can have
significant neuropsychiatric symptoms including agitation. Importantly, these patients are
extremely sensitive to neuroleptic drugs like haloperidol and can experience severe exacerbation
of their parkinsonian symptoms when exposed to these medications.

Normal pressure hydrocephalus presents with the triad of gait disturbance, urinary incontinence
and cognitive impairment. Although parkinsonian features may be seen, they are not as prominent
as in LBD. Also, this condition does not typically present with agitation or marked sensitivity to
neuroleptics.

Progressive supranuclear palsy is characterised by early onset of postural instability leading to

falls, vertical supranuclear gaze palsy and cognitive dysfunction. Agitation is not a typical feature
and there is no known sensitivity to neuroleptics.

Multiple system atrophy presents with autonomic failure (including urinary incontinence), poorly
levodopa-responsive parkinsonism and cerebellar ataxia. Again, agitation is not a typical feature
and there is no known marked sensitivity to neuroleptics.

Finally, dementia pugilistica, also known as chronic traumatic encephalopathy (CTE), results from
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repeated head injuries often seen in professional boxers. It presents with behavioural changes,
memory loss followed by parkinsonism but the history usually provides clues towards the
diagnosis and it does not show marked sensitivity to neuroleptics like haloperidol.

Discuss (6) Improve

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Lewy body dementia

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Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 13 3

2018 Dementia guidelines

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

[Link] 3/5
3/29/24, 5:13 PM PassMedicine

Lewy body dementia

Osmosis - YouTube 30 4

Parkinson's disease

MedFlix - YouTube 10 4

Report broken media

Score: 44%

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PassMedicine

Question 26 of 38

The GP is asked to see a 95-year-old man in residential care.

Over the last week, his behaviour has changed.

He has no previous mental health history.

The staff say he now sleeps most of the day, and in the evening he awakens and becomes agitated
and aggressive easily. Some days he is much more agitated than others.

On examination, he is unkempt. His speech is repetitive and he is disorientated, believing it is 1945

and he is at his son's house. He doesn't respond appropriately to questions and does not
recognise the staff around him, despite repeated reminders of their identities.

What is the most likely diagnosis?

Catatonia 2%

Delirium 76%

Dementia 17%

Depression 3%

Schizophrenia 2%

Fluctuation of symptoms helps to differentiate delirium and dementia

Important for me Less important

Delirium is correct. This patient is experiencing an acute confusional state. He is displaying

evidence of disordered thinking, labile mood, reversal of the sleep-wake cycle, inattention,
disorientation and memory impairment. These symptoms fluctuate throughout the day and from
day to day. Symptoms have manifested over a short period, making delirium the more likely
diagnosis.

Catatonia is incorrect. Catatonia characteristically presents with mutism, posturing, staring,

rigidity and echopraxia/echolalia.

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Dementia is incorrect. The set of symptoms this patient is experiencing would fit with a diagnosis
of dementia, however, the fluctuation of symptoms and the onset over a short period makes
delirium the more likely diagnosis.

Depression is incorrect. Depression in elderly patients may present with confusion and a decline
in functioning (pseudodementia), however, the fluctuation in symptoms and acute onset favours a
diagnosis of delirium rather than depression.

Schizophrenia is incorrect. It would be highly unlikely for a first presentation of a primary mental
illness at age 95, and again the daily fluctuation of symptoms makes this diagnosis less likely.

Discuss Improve

Next question

Delirium vs. dementia

Factors favouring delirium over dementia

acute onset
impairment of consciousness
fluctuation of symptoms: worse at night, periods of normality
abnormal perception (e.g. illusions and hallucinations)
agitation, fear
delusions

Next question

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Textbooks

High-yield textbook

[Link] 2/4
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Extended textbook

Media

Delirium

Osmosis - YouTube 12 1

Parkinson's disease

MedFlix - YouTube 2 3

Report broken media

Score: 42.3%

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PassMedicine

Question 27 of 38

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 3%

Add in memantine 56%

Switch to rivastigmine 7%

Continue donepezil 32%

Add in olanzapine 2%

NICE guidelines do not support the use of memantine in mild dementia

Important for me Less important

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

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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

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

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[Link] 2/4
3/29/24, 5:14 PM PassMedicine

Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

[Link] 3/4
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Score: 40.7%

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PassMedicine

Question 28 of 38

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 2%

Cerebral angiography 1%

MRI head 43%

SPECT scan 50%

PET scan 3%

This patient has Lewy body dementia. The findings on conventional imaging such as MRI are
generally non-specific.

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Next question

Lewy body dementia

Features

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progressive cognitive impairment

typically occurs before parkinsonism, but usually both features occur within a year of
each other. This is in contrast to Parkinson's disease, where the motor symptoms typically
present at least one year before cognitive symptoms
cognition may be fluctuating, in contrast to other forms of dementia
in contrast to Alzheimer's, early impairments in attention and executive function rather
than just memory loss
parkinsonism
visual hallucinations (other features such as delusions and non-visual hallucinations may also
be seen)

Next question

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Textbooks

High-yield textbook

[Link] 2/4
3/29/24, 5:14 PM PassMedicine

Extended textbook

Links

NICE 13 3

2018 Dementia guidelines

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Lewy body dementia

Osmosis - YouTube 30 4

Parkinson's disease

MedFlix - YouTube 10 4

Report broken media

Score: 39.3%

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PassMedicine

Question 29 of 38

A GP 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 13%

Verapamil 67%

Omeprazole 3%

Trimethoprim 6%

Glyceryltrinitrate spray 11%

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.

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Dementia

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

*in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of
dementia

Next question

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Textbooks

[Link] 2/4
3/29/24, 5:14 PM PassMedicine

High-yield textbook

Extended textbook

Links

NICE 3 0

2018 Dementia guidelines

Alzheimer's Society 4 6

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 2 3

Report broken media

Score: 37.9%

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PassMedicine

Question 30 of 38

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 14%

Supportive care + trial of citalopram 1%

Supportive care 4%

Supportive care + donepezil + low-dose aspirin 4%

Supportive care + donepezil 78%

The correct answer is Supportive care + donepezil. Donepezil is a cholinesterase inhibitor which
is recommended by the National Institute for Health and Care Excellence (NICE) guidelines in the
UK for the treatment of mild to moderate Alzheimer's disease, which this patient has based on his
MMSE score. The goal of treatment with donepezil is to improve cognitive function and slow
down the progression of symptoms. Supportive care, including psychosocial support, should be
provided alongside pharmacological therapy.

Supportive care + memantine is incorrect because memantine is not first-line treatment for mild
to moderate Alzheimer's disease. Memantine, an NMDA receptor antagonist, is recommended for
severe Alzheimer's disease or for patients with moderate disease who cannot tolerate or have not
responded to cholinesterase inhibitors like donepezil.

The option Supportive care + trial of citalopram is also incorrect. Citalopram, a selective
serotonin reuptake inhibitor (SSRI), may be used in patients with Alzheimer's disease to manage
neuropsychiatric symptoms such as depression and anxiety but it does not have a direct effect on
the progression or symptoms of Alzheimer's itself.

The choice Supportive care, without any pharmacological intervention, would be inappropriate
given that this patient has symptomatic Alzheimer's disease that could potentially benefit from
medications like donepezil.

Finally, Supportive care + donepezil + low-dose aspirin would also be incorrect. While low-
dose aspirin may be indicated in certain patients for cardiovascular protection, there's no evidence
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that it offers any benefit in slowing down cognitive decline or improving symptoms in Alzheimer's
disease. Therefore, its addition here would not represent optimal management according to
current guidelines.

Discuss (5) 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

Managing non-cognitive symptoms

[Link] 2/5
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Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

[Link] 3/5
3/29/24, 5:15 PM PassMedicine

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

Score: 36.7%

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PassMedicine

Question 31 of 38

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 2%

Dopamine receptor antagonist 4%

Acetylcholinesterase inhibitor 12%

Butyrylcholinesterase and acetylcholinesterase inhibitor 3%

NMDA antagonist 78%

Memantine - NMDA receptor antagonist

Important for me Less important

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.

Discuss (4) Improve

Next question

Alzheimer's disease: management

[Link] 1/4
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Alzheimer's disease is a progressive degenerative disease of the brain accounting for the majority
of dementia seen in the UK

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

              

[Link] 2/4
3/29/24, 5:15 PM PassMedicine

Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

Score: 35.5%

[Link] 3/4
3/29/24, 5:15 PM PassMedicine

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PassMedicine

Question 32 of 38

An 84-year-old-woman is found wandering in the street by her neighbours and brought to the
emergency department by ambulance. Her past medical history includes osteoarthritis. She takes
paracetamol regularly. She does not smoke and lives alone. A collateral history is obtained from
her daughter who reports that her mother has had progressive memory loss over the preceding
year. She is having difficulty carrying out normal activities of daily living such as cooking, cleaning,
washing and is unable to manage her finances. Furthermore, she occasionally doesn't recognise
her daughter's face and has become apathetic.

Her observations are heart rate 81 beats per minute, respiratory rate 17/minute, oxygen
saturations 96% on room air, blood pressure 151/84 mmHg and temperature 36.8ºC.

The patient was alert. Cardiovascular, respiratory and abdominal examinations were unremarkable.
The six-item cognitive impairment test demonstrated a score of 18/28. Neurological examination
was otherwise normal and there was no evidence of bradykinesia, tremor or rigidity.

Urinalysis was normal. An ECG demonstrated sinus rhythm with no ischaemic changes.

Plain radiography of the chest was normal.

Blood tests:

Male: (135-180)
Hb 137 g/L
Female: (115 - 160)

Platelets 190 * 109/L (150 - 400)

WBC 4.8 * 109/L (4.0 - 11.0)

Na+ 136 mmol/L (135 - 145)

K+ 4.1 mmol/L (3.5 - 5.0)

Urea 5.3 mmol/L (2.0 - 7.0)

Creatinine 100 µmol/L (55 - 120)

CRP 4 mg/L (< 5)

Adjusted calcium 2.42mmol/L (2.2-2.63)

TSH 4.1 miU/L (0.2 - 5.5)

Free T4 14.2pmol/L (10 - 24.5)

What further investigation is required to formalise the likely diagnosis?

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Electroencephalogram (EEG) 1%

FDG-PET (fluorodeoxyglucose-positron emission tomography-CT) imaging 8%

Lumbar puncture 1%

Magnetic resonance imaging (MRI) of the head 76%

Dopamine transporter (DaT) scan 14%

Neuroimaging is required to diagnose dementia

Important for me Less important

MRI head is correct. The diagnosis is dementia. The lack of fluctuation and the chronic history
make a delirium unlikely. The probable subtype is Alzheimer's disease dementia as evidenced by
the insidious onset of memory problems in association with other cognitive deficits such as
impaired reasoning and handling of complex tasks, impaired visuospatial abilities and change in
personality. There are no specific features to suggest vascular dementia, frontotemporal dementia,
dementia with Lewy Bodies or Creutzfeldt-Jakob disease. Structural imaging in the form of CT or
MRI head is recommended in the investigation of dementia, both to exclude reversible causes of
cognitive decline (i.e. subdural haemorrhage) and assist with subtype diagnosis. MRI features
suggestive of a diagnosis of Alzheimer's disease, for example, include mesial temporal lobe
atrophy and temporoparietal cortical atrophy.

EEG is incorrect. An electroencephalogram (EEG) is primarily used in the diagnosis of seizure based
disorders and is not required in the diagnosis of dementia. However, if there is suspicion of
Creutzfeldt-Jakob disease (CJD), then it can be used to support a diagnosis. CJD is a long latent-
latency infection caused by a prion. It is associated with rapid cognitive decline, which is absent in
this case. The stereotypical EEG in established disease demonstrates disease-typical periodic sharp
wave complexes.

FDG-PET (fluorodeoxyglucose-positron emission tomography-CT) is incorrect. This imaging

investigation can be used to support a diagnosis of either Alzheimer's disease or frontotemporal
dementia if there is diagnostic uncertainly and if classifying a subtype of dementia would change
management. It is not a required investigation in the general diagnosis of dementia and should be
preceded by structural imaging in the form of MRI or CT head. Features of frontotemporal
dementia include predominant behaviour and personality changes, executive function difficulties
and a younger age of onset (45-65) with memory loss occurring later in the disease course.

Lumbar puncture is incorrect. This is not an obligatory investigation in the diagnosis of dementia.

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It is an investigation that can be used to exclude causes of delirium if a diagnosis such as

encephalitis is suspected or it can be used to support a diagnosis of Alzheimer's dementia if there
is diagnostic uncertainly and if classifying the cause of dementia would affect management.
Findings in the cerebrospinal fluid that would support a diagnosis of Alzheimer's include total tau,
phosphorylated-tau 181, amyloid-beta 1-42 and amyloid-beta 1-40.

Dopamine transporter (DaT) scan is incorrect. This investigation can be used to support a
diagnosis of Lewy Body dementia if it is suspected and there is diagnostic uncertainly. Features
suggestive of Lewy Body dementia include visual hallucinations, sleep cycle abnormalities and
features of Parkinson's disease. There is nothing in this scenario that suggests a diagnosis of Lewy
Body dementia and therefore this investigation is not required.

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Next question

Dementia

[Link] 3/6
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*in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of
dementia

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 3 0

2018 Dementia guidelines

Alzheimer's Society 4 6

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 2 3

[Link] 4/6
3/29/24, 5:16 PM PassMedicine

Report broken media

Score: 34.4%

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PassMedicine

Question 33 of 38

A 70-year-old woman is seen in the clinic as her family reports increasing episodes of restlessness,
agitation, and memory issues. The patient is otherwise well and previously independent but she is
now considering moving in with her family due to concerns over her deteriorating condition.

Several investigations are carried out, including a mini-mental state examination, which is
indicative of mild dementia. Several treatment options, as well as the likely progression and
prognosis of the condition, are discussed.

What treatment is not supported by NICE guidelines for this patient's condition?

Donepezil 8%

Galantamine 15%

Group cognitive stimulation therapy 9%

Group reminiscence therapy 20%

Memantine 48%

NICE guidelines do not support the use of memantine in mild dementia

Important for me Less important

Mild dementia is an early stage of cognitive decline marked by subtle memory lapses and
cognitive functional issues that typically do not significantly interfere with daily functioning.
Second-line treatment for dementia often involves medications like memantine, which regulates
glutamate activity in the brain. While effective in moderate to severe cases, NICE doesn't
recommend memantine for mild dementia due to insufficient evidence supporting its efficacy at
this stage.

Donepezil is a cholinesterase inhibitor prescribed for mild dementia, particularly in Alzheimer's

disease. It enhances acetylcholine levels, supporting cognitive function and is supported by NICE
for use in mild-moderate dementia. Though not a cure, it may temporarily alleviate symptoms and
improve the quality of life for individuals with early-stage cognitive impairment.

Galantamine is a cholinesterase inhibitor as well as a nicotinic receptor modulator, potentially

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providing a different therapeutic profile compared to other dementia medications. Its use is
supported in mild to moderate dementia, particularly in patients with Alzheimer's disease.

Group cognitive stimulation therapy (CST) entails structured activities and discussions employed
in dementia management. NICE endorses group CST as a non-pharmacological approach,
accentuating its role in enhancing the well-being and quality of life of individuals with early-stage
dementia.

Group reminiscence therapy involves collective recall of past experiences to stimulate memory
and enhance well-being in individuals with mild dementia. NICE recommends it as a non-
pharmacological intervention, given its evidence to positively impact cognition and patient quality
of life.

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

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

              

Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

[Link] 3/5
3/29/24, 5:16 PM PassMedicine

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

Score: 33.3%

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PassMedicine

Question 34 of 38

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 8%

PAST score 3%

MUST score 6%

Waterlow score 80%

Honeywell score 2%

Waterlow score - used to identify patients at risk of pressure sores

Important for me Less important

The correct answer is the Waterlow score. Developed by Judy Waterlow, this scoring system is
widely used in the UK to assess a patient's risk of developing pressure ulcers. It takes into account
several factors including build/weight for height, skin type, sex/age, malnutrition score, mobility,
continence and other special risks such as tissue malnutrition and neurological deficits. A higher
score indicates a greater risk of developing pressure sores.

The PSST-6 score, or Patient Skin Scrutiny Tool-6, is not a recognized tool for assessing the risk of
pressure ulcers. This option might have been confused with other tools such as the Braden or
Norton scales which are also used for pressure ulcer risk assessment but are not as commonly
used in the UK.

The PAST score is not an established tool in medical practice. It does not exist and thus cannot be
used to assess the risk of pressure sores.

The MUST score, or Malnutrition Universal Screening Tool, while important in assessing
nutritional status and identifying those at risk of malnutrition, it does not consider other key
factors relevant to pressure sore development like mobility or continence. Therefore, it would not
be sufficient on its own to assess pressure ulcer risk.

Lastly, there is no known tool named the Honeywell score within this context. This could

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potentially be mistaken with Honey's Wound Assessment Tool (HWAT), but this tool is designed
for wound assessment rather than specifically predicting the risk of pressure sores.

Discuss (3) Improve

Next question

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.

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 the skin, warmth, oedema,
1 induration or hardness may also be used as indicators, particularly on individuals with
darker skin

Grade Partial thickness skin loss involving epidermis or dermis, or both. The
2 ulcer is superficial and presents clinically as an abrasion or blister

Grade Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that
3 may extend down to, but not through, underlying fascia.

Grade Extensive destruction, tissue necrosis, or damage to muscle, bone or

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Grade Findings

4 supporting structures with or without full thickness skin loss

Next question

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Textbooks

High-yield textbook

Extended textbook

Links

NICE 5 1

2014 The prevention and treatment of pressure ulcers

NHS 1 1

Prevention and management of pressure ulcers

Report broken link

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Score: 32.4%

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PassMedicine

Question 35 of 38

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 87%

Memantine 9%

Oxybutynin 1%

Rotigotine 2%

Tolterodine 1%

Donepezil - acetylcholinesterase inhibitor

Important for me Less important

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.

Discuss Improve

[Link] 1/5
3/29/24, 5:16 PM PassMedicine

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

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

[Link] 2/5
3/29/24, 5:16 PM PassMedicine

              

Textbooks

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

[Link] 3/5
3/29/24, 5:16 PM PassMedicine

Report broken media

Score: 31.4%

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PassMedicine

Question 36 of 38

A 74-year-old man has been referred to the memory clinic with a 1-year history of progressive
memory loss, word-finding difficulties and problems with organising his thoughts. His wife
mentions that he has been unsteady on his feet in the past year, which they attributed to a fall at
home where he did not sustain any significant injuries. He has a history of hypertension and pre-
diabetes.

On examination, his gait is slightly ataxic but there is no other focal neurological deficit. His blood
results are normal and his Montreal Cognitive Assessment (MOCA) score is 22/30.

What is the next most appropriate investigation?

CT head 26%

Dopamine active transporter (DAT) scan 12%

Lumbar puncture 2%

MRI head 55%

No further investigations required 5%

Neuroimaging is required to diagnose dementia

Important for me Less important

The latest NICE guidance recommends that neuroimaging should be offered to either rule out
reversible causes of cognitive decline (e.g. normal pressure hydrocephalus) or to assist with
dementia subtype diagnosis.

There are some situations where imaging may not be required, such as when dementia is well-
established and the subtype is clear. However, where there are neurological symptoms or signs
with no imaging done during the lifetime of the presenting cognitive symptoms, imaging is
usually required.

In this patient, the presence of ataxia which occurred around the time of a fall, together with his
cardiovascular risk factors, suggests that there may be a diagnosis of vascular dementia.
Neuroimaging would therefore be appropriate to support this diagnosis.

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Vascular dementia is the only dementia subtype where MRI is superior to CT, as cortical and
subcortical ischaemic lesions are better demonstrated, and some vascular pathologies such as
micro-bleeds may be otherwise missed. Therefore, if the dementia subtype is uncertain and
vascular dementia is suspected, MRI is the preferred modality.

A dopamine active transporter (DAT) scan is used as a tool to help diagnose Parkinson's disease.

A lumbar puncture is seldom necessary for the diagnosis of dementia.

Discuss (2) Improve

Next question

Dementia

*in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of

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dementia

Next question

              

Textbooks

High-yield textbook

Extended textbook

Links

NICE 3 0

2018 Dementia guidelines

Alzheimer's Society 4 6

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 2 3

Report broken media

[Link] 3/5
3/29/24, 5:17 PM PassMedicine

Score: 30.6%

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PassMedicine

Question 37 of 38

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 3%

Mild Alzheimer's dementia 5%

Stage II renal impairment 4%

Resting bradycardia 85%

Mini-mental state examination (MMSE) score of 18 4%

Donepezil is generally avoided (relative contraindication) in patients with bradycardia and is

used with caution in other cardiac abnormalities
Important for me Less important

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).

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

Non-pharmacological management
[Link] 1/5
3/29/24, 5:17 PM PassMedicine

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

Managing non-cognitive symptoms

Donepezil
is relatively contraindicated in patients with bradycardia
adverse effects include insomnia

Next question

              

Textbooks

[Link] 2/5
3/29/24, 5:17 PM PassMedicine

High-yield textbook

Extended textbook

Links

NICE 12 1

2018 Dementia guidelines

Alzheimer's Society 5 1

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Pharmacology - DRUGS FOR ALZHEIMER'S DISEASE

Speed Pharmacology - YouTube 45 2

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 7 1

Report broken media

Score: 29.7%

1
[Link] 3/5
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PassMedicine

Question 38 of 38

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 73%

Rivaroxaban 6%

Atorvastatin 9%

Alendronic acid 8%

Aspirin 5%

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 (7) Improve

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

[Link] 1/4
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disease followed by vascular and Lewy body dementia. These conditions may coexist.

*in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of
dementia

              

Textbooks

High-yield textbook

Extended textbook

Links

NICE 3 0

[Link] 2/4
3/29/24, 5:18 PM PassMedicine

2018 Dementia guidelines

Alzheimer's Society 4 6

Helping you to assess cognition - A practical toolkit for clinicians

Report broken link

Media

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia)

Rhesus Medicine - YouTube 2 3

Report broken media

Score: 28.9%

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[Link] 4/4

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