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OK, thank you. Ok. What do you think? Ok. No. Yeah, I what was the what? Yeah. OK. More than one good. Oh, what is the? That's great. Shall we make a stop? Yeah. OK. So welcome everyone um to our first lecture in this two part series about cognitive disorders and psychotic disorders. So today we're cognitive disorders and I take great pleasure in welcoming doctor Loa Pre who's a general adult psychiatrist with a special interest in Lia on site. She's the trust lead for star event. Sorry starts well event which she organizes twice a year for the new consultants in the trust. Her team won London Clinical Team of the year award in 2022. And she came as a finalist in the London Psychiatrist of the year in 2023 organized by the Royal College of Psychiatrists. Her other roles um include sitting in recruitment interview panel, ACP panel examiner for the C ASC and medical students filing their exams and teaching trainees. So without further ado I'm gonna pass it over uh to doctor. Thank you. Thank you. Thank you for the warm welcome. Um I already did uh the introduction. So I'm not going to indulge further. I'm also international medical graduate. I did my medicine in South India and then I did my foundation training and uh the mostly training program here and I've been a consultant for three years. Uh I'm a gentle adult psychiatrist and as you know, like every speciality, um now it has become specialized. You have uh old age psychiatrist, you have a perinatal psychiatrist, eating disorder psychiatrist. And uh usually if someone has got uh cognitive problems or dementia, then we are dealt to the old age psychiatrist. Uh when asked me to do both cognitive and psychotic disorders. On the same day, I thought I couldn't do justice to both the topics. So, what we'll do is we'll um start with cognitive disorders today and then we can do psychotic disorders of part B on another day. Um I aim to finish on time because I'm doing my presentation uh at my office and the building closes by uh half six. So I don't want to get stuck here over the weekend and I know you all will be tired too. So let's start. Um So I just um put in two scenarios, common scenario. So either if you are uh in A&E or an outpatient clinic or you are a GP, um you could have these scenarios where you are asked either to perform a cognitive examination of a confused elderly gentleman who was wandering the streets and brought to the A&E department or it could be obtaining collateral history from family whose husband was referred to you by the GP. She's worried that her husband has had problems with memory for last nine months. Address the concerns. So these are the common, there are many scenarios which could happen, but these are the most common one that you will encounter. So if we talk about dementia, um as you have, it's a progressive degenerative syndrome and it's common 5% the prevalence is 5% over the age of 65 and 20% over eighties. Um most common as you know, is Alzheimer's dementia. And then you have the vascular dementia and then dementia with Lewy bodies, you could also mix dementia where the, where there's a picture of both Alzheimer's and vascular. And then 30 to 70 person with Parkinson's disease can also have uh dementia. Um if you tend to speak too fast and you're not able to understand anything about something, the chat function and they'll be able to address it, right. So, um and we'll look about Alzheimer's and the different types of dementia a little bit in detail and then we'll go to the history and the examination bit. So if you talk about Alzheimer's dementia, again, it's a global deterioration in intellectual capacity. So, um intellectual capacity is more about your way of thinking and um able to think and uh uh um what do you say deliver and do all those things and higher cortical functions are usually language awareness, um able to recognize and decline the personal activities of daily living. And the onset again is insidious onset in the sense that it develops. So gradually and slowly, sometimes the patients are not aware of it developing when it starts initially and they might lack the insight for it and then it, as you can see a slow deterioration. So you can diagnose only Alzheimer's dementia when there's absence of clinical evidence or any investigation, suggesting there's an organic uh cost to it. And there shouldn't be any uh sudden onset of physical or neurological signs, then it could be a different diagnosis. Then it comes as a differential against the communist and don't like, like you've already mentioned and you can start seeing short term memory loss initially, that is equally in males and females. And uh we already learned it's progressive. Next. If you go to vascular dementia, it's the second common. The age of onset is usually over 70 more in men than women. Again, you can see a very, there could be a very strong family history of vascular disease or risk factors. Even though the vascular disease or risk factors can run in families, the vast majority of vascular dementia are not genetic. So again, um it can be because of the ischemic damage to the brain, which is causing the cognitive impairment. And you can see a lot of behavioral disturbances occurring yearly in vascular dementia when compared to Alzheimer's dementia, when uh you will start seeing the symptoms, when the dementia starts getting worse. Again, the main deficient factor in vascular dementia is the course a step twice the periods of intervening instability. So it's a stepwise progression and you can have periods where um the patient doesn't have any problems. And then there are periods when uh the problems are tend to get worse. So it's one of the diagnostic criteria and it usually follows a cerebrovascular event. Again, the the just the vascular dementia, they made it into a syndrome. So you could develop, it's also called a single infarct dementia when you develop after a single infarct, and then there's a multiple infarct dementia and then also there's a progressive small vessel disease which we call as bins ger disease. Again, the clinical features for vascular dementia um in the history. Um like with any other um um like for example, if you take psychosis or personality disorder or mood disorders in psychiatry, the main important um thing you need to remember is history taking. I think we come to a conclusion purely based on history taking. And the rest is only going to support your diagnosis or maybe give you a differential. But history taking is the most important in any aspect of psychiatry. So, and that's how you differentiate the different dementias and then only you go on to investigations and neuroimaging. Um So the clinical features for vascular dementia you have to, uh, you could be risk factors like smoking, diabetes, hypertension, high cholesterol could be a var heart disease atrial fibrillation again, full history and you have to do a thorough physical examination, ruling out. You have to check for hemiplegia dysplasia, poor mobility, bowel or bladder and do further investigations including blood test and imaging. And like I said, emotional and personal disorders, personality changes occur quite early and the cognitive fluctuate. You can also see um, depression, anxiety, affect your ability mo there and very strong emotions or it could be, uh, they, they'll be crying and then they'll be ok and then, um, they'll start crying. So you can see the strong uh emotions could, which are not appropriate and confusion is common and that is more at night. You could also see urinary incontinence and falls. Um However, you have to rule out the other causes of falls um, before uh pinpointing it to vascular dementia and being the reason for it. And you'll see other physical signs of O vs disease like af or peripheral vascular disease. Then we go on to uh Lewy body dementia. It's a third common. I think it's uh some, it can be a bit quite confusing because the dementia Lewy bodies and the Parkinson's dementia, they fall into the uh title Lewy body dementia again, uh to make a diagnosis of dementia, Lewy bodies, you need to have the motor symptoms of Parkinson's and the cognitive symptoms within the 12 months. Um, they should both have developed within 12 months of each other and you have all the symptoms of Parkinson's, which could, for example, you know, like the um slowing down um tremors, rigidity, um, et cetera and the onset is insidious, gradual. There could be no precipitating illness. You can have uh complex hallucinations, um neuroleptic sensitivity, which means the sense. Um If you start, uh for example, for hallucinations, examining psychosis, you'll be starting them on antipsychotics. For someone who's got dementia glowy bodies, you start them on antipsychotic, it'll be very sensitive and um it could be get, it could get worse for them. So uh you have to be really cautious in starting or sometimes you don't start at all if it's making it worse and you'll have wellformed dilutions um and presence of Lewy bodies in your imaging, certain parts of the brain. And again, the differentiating factor in Parkinson's disease dementia is you develop the motor symptoms first and they are per present for at least 12 months before you start getting the cognitive symptoms. And usually the motor symptoms are quite severe, right, the next, the frontotemporal dementia and you can see atrophy of the frontal temporal regions, um neuroimaging and it's a early onset between 35. It can even um you can develop as early as 35 to 75 gradual progression. There's a strong family history, men greater than women and in front of you can see, start seeing the behavioral problems quite common earlier on. Um typical symptoms of frontal lobe dysfunction, like this inhibition, repetitive behaviors, quite impulsive, repetitive. Um, they could be having uh sexually inappropriate behaviors, um, and loss of insight early on and memory goes on later. So these are the other uh types of dementia for you to be aware of. Again. Um, mixed dementia, like I said, you have a combination of uh vascular as same as dementia. Again, mild cognitive impairment. Um It's a preclinical stage of dementia. There's a chance they're going to develop, start developing uh dementia in the next few years. That's something that you need to be aware of is also depressive pseudodementia. And that is why you have to load other comorbidities like depression or anxiety before you make a dino of dementia. Um In this, the differentiating factor factor is the depressive symptoms usually proceed and you can pinpoint when it started and the patient will be complaining of memory problems, virus. If you see the uh other types of dementia, the usually the patients won't be the first approaching with memory problems. Usually the family members, they lack insight of that um for help uh in the first place. And then again, you also um need to know to differentiate it from delirium in a clinical setting, right? Again, like I said, um to come to a different diagnosis, you have to take a very detailed history. Uh spend enough time with the patient and cars and that and clinical evidence is the main diagnostic criteria in dementia. And uh you have to do a full mental state examination and a mini mental state examination. Good comorbidity like depression, anxiety and these are the bloods. Uh we normally do, you'll be aware of the full blood count, esr uh liver function, renal function, thyroid function, blood sugars, B12, folate urine, ECG and X ray and then comes the neuroimaging. So like with um any diagnosis in psychiatry or any specialty you go to, you'll always hear the uh term biopsychosocial model. And that is how um uh we get to know with any patient like the community mental health team, we work. It's always a biological, psychological and social model and that's how uh we help our patients. So, again, management of different dementia is there's no cure. All you do is you prevent further deterioration and you can just slow down the progress for a while. Um Again, um the treatment you treat the comorbid if they are depressed, try them antidepressant. And sometimes you'll be surprised if someone has got depresses. Pseudo dementia, treat the depression and uh the memory problems start getting better, treat the physical disorders um progress. And I think that that has come many times. Um MDT approach, like I said, any team, usually they have an occupational therapist um who will look at adaptations at home when the dementia get worse, how safe the home is and look at uh how the mobility is and whether they need um um later on stages when they develop motor symptoms, for example, Parkinson's where they need a wheelchair, et cetera and a psychologist very potent to every team. Again, one, I think any patient, you give them a diagnosis of dementia. Um it is not uh easy diagnosis to digest, so it's always good um uh to refer them to a psychologist to help them deal and also the car because it can be a big carer burden and for them to come to terms with the diagnosis. Again, we have got a lot of uh support groups, carers, groups. Alzheimer's Disease society can uh any type of different dementia, you can refer to them, right? Um I wanna touch base on vascular dementia management again, slightly different to Alzheimer's. You need to um establish the causative factors and what are risk factors you have. You start treating that aggressively and that is a way of um helping patients with vascular dementia. For example, daily aspirin is known to make a huge difference and statins ace inhibitors, antihypertensives and if they are uh diabetes, you need to bring it under control. So you give gentle health interventions and um if the obese reduce the weight, risk factor modifications, quitting, smoking, exercise, all self-explanatory. And there are no drugs that are formally like um licensed for vascular dementia. Um Yeah, I don't to touch pains of antidementia drugs. So, these are the common three the acetylcholine inhibitors, donor bay divas and Galantamine. Um they are licensed to treat mild to moderate. Um They work by reducing the inactivation of the neurotransmitter acetylcholine um producing improvement in memory and goal directed thought reverse treatment is licensed for uh Parkinson's dementia and memantine is the only drug which is diagnosed currently for moderate, which has been like um approved for um treating moderate to severe dementia. It's a N methyl D aspartate receptor undergone again. Um The current practice, even if um I see a patient, I'm worried about the memory. And the first instance, what I do is we'll be doing the MMC and then referring to the memory clinic and if the memory clinic sees a patient and they think this patient has got a diagnosis of dementia depending on the mm history and the investigation. Um The diagnosis is always made by a specialist, a old a psychiatrist and treatment is also started by them and monitored by them. For example, I um because I'm a psychiatrist, I wouldn't be starting treatment for a patient with dementia in my practice. And again, in the clinic, they ask us every six months and um they repeat the MC. So what they would expect is the MC, either it shouldn't have gotten really worse and or, or if it stays the same, um then they will, and there's some evidence of improvement, then they'll continue the treatment. But if this is starting to get, uh, if it's getting worse, then they might consider to stopping the treatment. So, again, um, to prescribe some of the antidementia drugs, first, I think they will also find out if the patient is able to take it, um, whether they will be concordant with the medications. Otherwise there's no point. And again, it doesn't cure the illness. I think that is something we make it clear to the carers and the patient. It helps to stabilize or improve for a while. Efficacy is 40 to 50. It's low. Um, so you always start, um, slow, especially if it's a old adult population with any medication, we start slow and then, uh, we monitor and increase slowly after four weeks. Um, and it's not addictive and there's no withdrawal symptoms. And when do you stop treatment again, it's decided by the specialist and it's a patient centered and individual approach, it could be, the patient has deteriorated or they're not taking the medications and, um, they haven't seen any improvement at all, then they might decide to stop as a medical student. Um, I think when I used to work in the wards and liaison psychiatry, um there will be a lot of opportunities to do mini mental state examination if you really get familiarized with a mini mental state examination as a medical student, I think, um, that would really help you um, with diagno with dementia or learning about dementia or even in your clinical practice because even if you're a GP or in anywhere, um, I think you'd be expected to a mini mental state examination. Again, it's very simple. All you need to spend some time and get fe yourself after something. You didn't need um, the paperwork uh to do the emery, just do it by yourself. Uh Again, like I said, you look at the orientation to time, self-explanatory, you know the questions to ask the place person and the registration is a three item test. If you remember, I think it's Apple Table Penny and you ask them to repeat after yourself, you can give them a few times, they can, they can take the time to repeat it after yourself. And then, um you check the retention through that and then after some time you recall, um make sure check whether they're able to recall and um tell it back to you for the attention calculation. Either you use the world backwards or the C seven for my patients. I usually found world backwards is better than the C sevens, but each one is different again with the language of comprehension. Um It's like naming object. I think you may ask to name a pen or a watch. Um And uh three stage command where you ask them to, oh, repeating is no ifs ands or buts. Um So you might have to say that a few times for the patient to repeat after yourself. And the three stage command goes like, um, give them a piece of, so you need, you need to give them a uh instructions. I want you to take a piece of paper, hold it in your right hand and put it on your lap and you need to make sure you say it clearly to them and not, you say right one time and left turn because they'll get confused. Um, and then reading and writing, I think there's, uh, one section by your, it says close your eyes. So they need to read it and then, um, follow it through and you ask them to write something and then you'd, um, draw the clock face while you look at the vicious spatial orientation. So the interpretation of em, um, is very important, uh, again, um, to make a diagnosis and also refer for further investigations. Um, 25 to 30. Um, they wouldn't, um, go ahead with any consider that a normal 21 to 24 is mild. Uh, then, um, it could be classed as mild, cognitive impa and then, um, the worries is they're developing dementia. You start investigating and doing other tests. 10 to 20 is moderate and below 10 is severe. So, just for you to be aware of. So the, these are some of the memories usually you'll see in old age dementia working memory you test by the forward backward, uh, digit span like, um, you either plus seven or minus six and you keep going behind. That's your working memory, how much you can uh learn new things. Um So not learning you, this is working increase more about the digit sp and to me uh new learning and how much um you're able to uh do things learn and do and remember, retrograde memory is more about your personal events like um where did you go for schooling? And when did you get married? Et cetera? Semantic memory is a gentle knowledge that you develop throughout your life like um who is the current uh prime Minister of UK or are some of the gentle knowledge questions? Again, the five years to remember, amnesia is again, uh the memory in able to learn new things or retain the memory. Um Aphasia is again, uh more to do with uh language. Um agnosia is again, inability to recognize um people by having that difficulty APL has more to do with mo movements and associate symptoms. Again, it could be be behavior changes, hallucinations, dilutions. So when you take your history, if you remember these 55, and that will also help you again. If you go to the history taking, remember these things always um um sometimes it could be the patient you're asking or the history will come from the car. So that will be your collateral history. So when did it start? And was it sudden or gradual? And how has um how long the duration is, and how is this progressed? Is that a step wise or it has been just gradually dating and the other, the cognitive be here. And the other one we touch base a bit later. Um As usual, always as the past psychiatric history, it is very important. And you ask the relevant uh personal history and the family history, any family history of dementia or any vascular disease, past psychiatric history, you ask about any um psychiatric uh diagnosis. Um and um um personal history, you can always ask about whether it was smoking and um um taking medication. You could also ask about any illicit drugs past medical history. Again, you will cover all these um one we already spoke about. Um, again, um always uh check about alcohol and head injury. You'd be surprised to see um uh patients who have been uh taking alcohol for a long period of time. And we always, we have seen a quite a lot of these on psychiatry developing um alcoholic dementia later on. It's quite common. Um And you can also sometimes uh see uh dementia and head. So these are things for you to be aware of. Keep in mind keeping it, you know, um history taking and then education. I think the reason why they say education is um f for some who has had a very good education, I think they will ace the MC. Um And it's quite difficult. Maybe the family are reporting memory issues but they are quite good with the, mms. So, you need to have, that's why we always say history taking is more important than, uh, the M itself. It's only to help with your clinical, um, history. And again, somebody who has not had good education and is struggling, you give the, em, em, they might not be able to, uh, do all the parts of it because they'll, uh struggle with the task, um, occupation again. Um, it's useful to ask what, uh, whether, um, they've had a, they've been a professional for it. Same to do with the, em, em, I think, um, they'll do it better than the others or it could be any other risky, um, occupations they've been doing. But, um, what can I say? Like, um, very stressful if you want to go other affective disorders, stressful job or they've been sickly for a long time. So it would be good to know that they have been, not been able to do their job for a while and you explore that and the living situation, this is more to do about the safety and the risk, whether they are living on their own or living with a carer. And, um, how are they coping at home so gently these history, what I mentioned, uh, other than the second bit you'd be asking for any of the psychiatric disorders that makes you a complete history knowing everything about them in. I always tell my medicals be curious and give time to the patients. The more curious you are, you get more history from the patients, right? Again, comes to collect, like I said, again, with the car, you ask a very detailed history to them. They'll be the ones mostly um guiding you with the diagnosis in the memory short term things. For example, you can ask like, uh does he become forgetful? And uh he doesn't remember what has happened? Um um Few hours ago, he misplaces things um or he doesn't remember what he ate uh the previous night, long term. Um could be, he doesn't remember maybe uh the year of the marriage or with school, he went um again, um orientation. Does he get um confused and he forgets away uh back? Um Has he had uh trouble um returning um lost when he was trying to return home attention? Are they able to read books concerted on TV? Um language? Have they had any difficulties um in uh any word finding difficulties? Uh which special abilities again, um Are they able to navigate the way around? Are they able to um follow the signs if they're driving a car? Are they able to follow it through? Um They might have difficulty in naming objects. So it could be again, um forgetting the names of people um recognizing the faces of um people who they were familiar before. Um They'll have uh difficulty reading like they might have lost the interest and daily activities. Are they able to look after them? So it's always a self care. Um If they were um looking after their own money, uh financial stuff, are they able to still do it? Are they able to budget, are they able to shop or do other things? Um And um are they able to judge over there crossing the road or um uh leaving the to on when they are cooking? So these judgments. So these are some of the histories that you can ask in detail, the carrots and you would be surprised to see they'll be very forthcoming. Um, when you got the time to listen. Right. And then we go to the, uh, behavioral symptoms. So, like I said, um, I'll touch base on the second bit a bit more because I feel it's important when, um, you see patients with dementia, again, the bigger symptoms that you develop during dementia they could get very, they could start, uh, the, the more and more dementia progresses. You can see angry orur, very irritable, um, psychomotor agitation, verbal and physical aggression changes in the personality, um, socially inappropriate behavior, sexually inappropriate behavior, urinary, they might be urinating on the floor. So there's a lot of um, uh inappropriate behaviors and the other common is wandering behavior, putting the mattress hoarding behavior and very repetitive. So, again, with the psychological symptoms, these are things you keep in mind and to rule out. Um, they might have some crying spells, anxiety, apathy, paranoia, delusions, and hallucinations. Again, physical symptoms to be aware of all these um incontinence or they constipated and some of them might not be able to give you the history. Um So you just um check with the car, um weakness of limbs, gait disturbance. Um So spelling mistakes, side effect of medications, any abnormal movements. How is the sleep appetite and um and have they started becoming suspicious of everyone? Very confused again? This form, this will form a very important um aspect of your history taking, assessing the risk. Um not only dementia and every other psychiatric disorder. So risk of self neglect, um if they are unable to look after themselves and that is a problem. Um, risk of falls, uh risk of wanting will be surprised to see how many of the patients when they more than the moderate trans dementia risk of wanting. And that's when it's important because um end of the day is about the safety, whether the carers can manage them at home or whether we need to start looking at placements. I think we try your best um to help them uh by having adaptations at home, giving them alarm, um finding a cat package, giving them blister pack. But there sometimes will come a point when the cats can no longer cope with them, it might not be safe to look after them. At that point, you might consider whether they need to go into a residential placement. Um, again, there could be risk of cell form when they're finding it difficult to cope with the diagnosis. Um, or they are depressed along with the, uh, dementia risk of noncom. So they're really taking, it's not only the anti dementia medication they might have risk of, uh, stop, uh, when they can't take the other medications, they are a diabetic hypertensive. Then that might go out of control Again. Fire risk is quite common when they can, uh, cook and leave the, um, on or the smoking. Again, there's a risk of, uh, fire risk and risk of financial abuse could be common as well. That's when we, what we normally do is we assess the capacity and, uh, if they lack the capacity to, of the finances, then they go on an appointee ship. Uh, uh, someone looks after, uh, the money, um, and then, um, they get, um, they, they, the carriers help them with a card but they can take money when they need all the, all the, whether the, um, payments for the, where they are staying or everything else is, um, paid off automatically through the bank account. Um, and you had to be, uh, that is the reason you look at all these risks because they all have implications. Um, risk of aggression. Again, this could be towards the carers and you might, they might not engage in the carers. That's when it becomes difficult. You have to either they get admitted or they get, um, um, they go into more 24 hour supported placement, um, risk to others again, verbal and physical abuse and risk of driving again. When someone you see who's got, uh diagnosed with dementia, you with any psychic disorder, you always ask them, um, to refer them since the DVLA. But, uh, if they are reluctant, then you have a duty responsibility to refer them to the DVLA. So these are some of the tips of your history of medical students start with open questioning, let them talk and then uh you can go to close questions, take the time to listen, be empathic and have a nonjudgmental approach. You can get a lot from not only speaking to the patient, uh but also observing the surroundings. Um And you'd be surprised to see how much uh information we get from home visits. Um Use simple 10 and avoid jargons and uh be curious unless your c is very difficult um to get more information and have a structure in your mind. Um I think each have their own structure. Um You can develop a structure which suits you. Um And then uh follow it through, right? So, um that's all I had for today because the reason I don't put, well, i it's 30 slides, too many slides, but I don't want to overburden you with information. Um So this is a gentle overview as a medical student. What I would expect you to do. Uh I don't know um cause I can't really hear you guys, I don't know how you found it. Um I also wanted to um tell you guys give feedback uh because uh this is the first time I do the presentation for uh the medical insurance live. So unless you give feedback, it's quite difficult to know whether it's been useful for you or whether you would like to um have a different type of presentation or more information included. So, Karen, that's it from me. Perfect. Thank you so much for the presentation so far. And like like like you said, if everyone could fill in the feedback, it really helps with all this presenters knowing what they can do and what not. And it also helps you get access to the slides and generates the certificate uh of attendance. If anyone has any questions, feel free to pop it in the chat box. Um and we can give it a couple of minutes to see if there are any questions. Mhm. And if anyone has any issues with the QR code, please also drop a message in the chat box and I can send a link if that would be easier and keep uh I uh oh OK. Someone said, could you send a link? I can do that, just bear with me and I will do that. Any other questions regarding the content? If not? Thank thank you uh for our presentation and hopefully we'll have a second part next week which will keep everyone updated on, on the posts. I will send the link by, by the way. Um But yeah, thank you. Thank you and good luck to everyone. Thank you, darling. Thank you. II will just send the link now. Bear with me everyone. Uh Got it. Thank you. Bye. Thank you, everyone. I will now close the light. Cheers.