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Ok. Hello everyone. I'm happy to make a start. Now. Um I'm gonna be taking your case for my co impairment. My name is Hannah. I'm second year medical student. Um Can we before we begin? Make sure you've all entered the mental code because I'd like to keep this as interactive as we can and it will make sure you're not just dozing off when I speak the code up in the corner and there'll be a few questions. Um There's some CSI style questions and there's also just some generic poll and other questions as well. So yeah, make sure you put in the ment code. I'll give you guys one minute um to get into mentee and put the code up on the screen. Can I just confirm that you can all hear me? You can let me know in the chat if you can hear me? Yeah, we can hear, you know, very cool. Ok. Um Also on that note, um on the mentee, I'll let you guys at the very end, there'll be a question um box, we can ask any question you'd like and if throughout you have any issues or questions, then the chat is free to use. So please use that as you wish. OK. Um I'm gonna type in a mentor code for anyone that joins them late. OK. Let's get started. So um oh right. Content of what we're doing today. So we're gonna start with mild cognitive impairment. Then look at the two tests that we used um for cognition, four types of dementia and then both mechanisms of Alzheimer's, the treatments and scans of dementia and then your multidisciplinary team, this will cover everything you've done in your CSI from part one, all the way to part three. So um we're gonna start with what is um my cognitive impairment. It's really important to look at the nice definitions. So let's quickly have a read. Um My cognitive impairment is a cognitive impairment that does not fulfill the diagnostic criteria for dime for dementia, for example, because only one cognitive domain is affected or deficits do not significantly affect daily activity. So I guess a really important thing to note here is you are not being affected in what you do um in your day to day life. And I think another key point which is not mentioned in this definition is that you still have your own independence. Um Some statistics to note is that there is a third. So if you have um MCI, then you have, you have a third chance to then develop dementia which is really high. Um And mild cognitive impairment is also reversible. Now, let's look at the nice definition for dementia. So, dementia is progressive, irreversible clinical syndrome that causes a decline in the person's ability to perform daily activities. So, already there you have your major difference um between MC and dementia is that one will severely affect your day to day life and one will just be a bit inconvenient rather than anything too severe. Ok. So um yes, um MTI can be reversible. So it's really important to make sure you understand that um my of impairment isn't just due to neurodegenerative causes as dementia is, it can be uh due to things like um issues with sleeping, uh very bad vitamin deficiencies, mental health issues or uh thyroid problems. And these are which you're kind of looking into a lot deeper as you progress through your BRS module. Um But today we want to focus on the irreversible MC, which is obviously due to your neurodegeneration um cannot be reversed, but obviously, we can slow it down um to prevent its progression to dementia. So um I'm not going to explain the graph just yet. I'd like you guys to kind of um practice your skills of being able to interpret the graph. So look at the heading and the axis and what you're being shown. And your first question of the mentee is what can you infer from the graph? Did I give you a minute to think of some answers for this? OK. OK. OK. Let's get some answers I mentioned to you because this is something that you are likely to get in your um exams. OK. So first answer, risk of progressing to dementia can be reduced in people with um MCI with reversion. OK. Good. Um irreversible MCI can lead to dementia after multiple years. Yes. Community incidence of dementia in the subjects increases from zero for everyone with time. Yes, that's a very good one to spot. Um because we'll get onto the risk factors, but essentially everyone with age is at increased risk of getting dementia and incidence of dementia increased with MCI that increases with lack of rev good. You all have the right idea. So let's have a look at what's going on in the car. Um So the black line, which is the highest line is MCI, no reversion. Um which is those that have um myo cognitive impairment due to neurodegeneration, something that can be reversed. The red line is people that have MC that can be reversed. And your um your blue line is just people that don't have um MC. And you can see obviously that those that have it due to neurodegenerative reasons are very much, very highly likely to um get dementia. So this just really reiterates how important it is that we identify MC at an early stage and do what we can to prevent it getting worse and preventing people getting dementia. So, symptom wise, um I think by now, we will, we will have understood that MCI is basically pre dementia, especially if it's the neurodegenerative one because um before you get dementia, you will have MC. So in terms of symptoms, they will all have these be within the same class of symptoms. Um but we'll have a look at what's different. So let's look at um memory problems. Our first the first box though with MCI, you have noticeable memory issues like forgetting recent events or conversations. So again, this is something that might not have a crazy effect on your life. But if you have dementia, you have severe memory loss that significantly impacts your daily life, for example, forgetting names and forgetting appointment. So um as you kind of read the difference in symptoms, you'll realize that like I said earlier on dementia is really what is something that is affecting your day to day life and something that gets rid of your independence and ability to do things um without the help of others. So I'm not gonna go through all of these. Um I guess what is the main thing to know? Yeah, so independence is very important bit. So if an individual can do their own independent things and do them correctly, then they will like to have MCI than dementia. Um And the rest of them, I let you guys kind of read on your own time. OK. So um risk factors for um mild cognitive impairment, you have obesity high BP, high cholesterol, depression, drinking, smoking, heart problems, stroke and diabetes. Most of these are cardiovascular related and then you have depression, which is mental health related. So essentially, if you know your risk is cardiovascular or mental health related, then we know that any kind of prevention is going to have to tackle these areas as well. So these are your risk factors. Your next question is what are protective factors for MCI or dementia obviously bearing in mind they are almost the same thing. Um So have a think, what can you guys, what can you guys come up with? So what are protective factors? So protective factor is an opposite of a risk factor. So something that kind of um will prevent you getting something. So let's see what you guys can come up with. Yeah, let's get some answers again. Something that you like to come up in your exams. Mhm. So, I think the piece of this is, you know, your risk factors, protective factors essentially is going to be the opposite of your risk factors. So what are people said? Um, good diet? Yes. So why is good diet a protective factor? Because um bad diet. So diet that's high in salt or in cholesterol lipids, that's going to have a negative effect on your cardiovascular system and increase your risk of getting MCI because we said before that these kind of cardiovascular problems, increase your risk. So we want to tackle that. So we want exercise, healthy, diet, nutritional, diet, healthy amount of sleep. OK. So I like these, I have some interesting answers to someone's put, speaking multiple languages and someone's put, playing an instrument and they're both very correct. Do you guys want to elaborate why you put those answers? Why would, so I guess you kind of put very specific things. So speaking multiple languages and playing an instrument, what is the theme that you guys are trying to kind of say here? Yeah, let's see. Yes. So anything that kind of um works on your cognitive abilities, anything to do with learning things, playing an instrument, languages, like you guys mentioned are really good protective factors. And I think um very important to know there's been lots of studies done on this and they've even, they've even found that certain professions are um much less likely to get dementia compared to professions that don't require lots of cognitive um ability. Um And another very good. So other good answers is just socializing um being social and not being alone, taking care of your mental health good. Because we said previously that um depression is a risk factor. And if anything, I would say it's a very um underrated one, depression very, very largely contributes to progression of MC and that into dementia as well. OK, let me just double check with anyone if there's anything else stop drinking and smoking. So good. Again, just to remind you there's two things you want to tackle. One is the cardiovascular stuff. So anything that prevents you getting a stroke. So, low cholesterol, low salt, um no smoking or alcohol, that's your first thing you want to tackle. The second thing you want to tackle is the mental health aspect. So making sure you're not um you know, preventing the depression and the anxiety and the stress and stuff like that. Cool. So I think I put more information of that on the next slide. So, sorry guys. Um OK, so let's just summarize. So you have help mental stimulation, social engagement and control of card perspective. Lovely, cool. Ok, so um treatment of MCI is obviously going to be due to risk factors. So anytime you guys are asked about how to treat something, just think about what were the risk factors? Ok, we want to tackle each of those risk factors. So um like we mentioned, it's very much cardiac related. You want to um you want to prevent the kind of heart condition, diabetes and strokes. So, um treatment for MCI will often include any medication for heart disease tablets to reduce high BP, prevent clot or low cholesterol. Um Can people tell me on the chat, please? Um any names of any medications you've learned that will help with, that will help prevent getting cardiovascular problems. So I'm trying to kind of get the medical terminology out of you guys, but then to be fair I don't know if you guys have started. BR OK. Good. OK. Does anyone know what we call, um, things that lower your BP? What is the medic time for a, a drug that lowers your BP? You've learned this and to those statins. Yes, blood thinners. Anti hy. Ok. So blood thinner is the kind of, um, the public way of saying it antihypertensive. Yes. The medical way of saying it is the um statin. So I don't know if you guys have covered H MG co enzyme A in your P Yeah. Um but you'll get to do that. And yes, so statin um prevent the bad cholesterol and in return will prevent any damage to your cardiovascular system. So that is dealing with the whole cardiac stuff. We also want to deal with the mental health stuff. So again, we want to treat any depression if that's been diagnosed. Um We'll get onto that in a little bit as well. And so in the bright blue boxes, this is a NHS advice. So this is taking the NHS website. Um again, you're tackling both the cardiac stuff and the mental health stuff. So it's worth having a proper read of these. Maybe not now. Ok. So let's have a read of this case here. Um A patient is diagnosed with MCI. He presents with memory loss but he's still able to manage his daily activities, but he forgets why he leaves things around the house. His family says he always keeps alone and has stopped doing the things that he wants to like 5 kg weight loss, no history of health problems, no alcohol intake, good diet, no history of vascular problems. What do we want to give to this patient? So, don't forget he has been diagnosed with MCI. We want to slow the progression. So, um the reason I put this question is they like to ask questions like this in CSI where you're likely to just skim over and assume what the question is. So very important that you guys understand, you're being asked how to, how you can slow his progression, not prevent um or not treat anything. Essentially, you just want to slow down the progression of his um MCI. So have a read again. The options are n they're all correct, but we want to make sure you tailor your answer to the patient. So read the paragraph again and have a think interesting. So I've got some nice answers. Is anyone not aware of the meaning of any of these? Right? So you all know what antidepressants are? Um Statins I mentioned CBT is cognitive behavior, behavioral therapy, which is a way of kind of um someone that has really bad depression is kind of a way of, of talking to them about trying to get rid of the low mood that really affects someone's life. Um Social prescribing um might be a new, right? So social prescribing is. So as a GP, you can treat people both clinically with medication and referrals and stuff. You can also um refer them to places that help with their mental health. For example, like gardening places or art clubs, stuff like that. And these are used for people that most mostly used for people that experience loneliness, people that have depression due to loneliness. Um Social prescribing is a really effective way of helping those kind of people out. So let's look at your answers. So I've got basically every single answer. Um except actually two people for antidepressants don't like I mentioned, none of these answers are incorrect. And in day to day clinic, you will have these will all be prescribed kind of here and there. But you want to tailor your answer to the patient, you would not give antidepressants because that's kind of an extreme thing to do. So again, here, you're thinking of your first thing to do and um I'm gonna mention in your CSI exam, they're not giving you four correct answers. But your duty is to think which of these is most appropriate, which of these is first line. Um considering the patient you have in front of you. So you don't want to give antidepressants because they have lots of side effects. I think that's the main reason, right? We all know about the side effects of antidepressants. Um you have weight gain, they are very addictive when people stop using them. Um They get really bad side effects. Um why you use them and when you stop using them, so you kind of want to avoid that antidepressants, usually not prescribed when it gets very severe. Um So statins, why would you not prescribe statins? Well, because this patient, I mean, he doesn't have history of vascular problems, good diet and he's healthy, so she doesn't need them. Um Now we're left with B or D ST ST prescribing or cognitive behavior therapy. Now, this is a little bit of a trick question. So I made the options difficult like they would do in CSI because this patient. Um So, I mean, you guys should hopefully understand that the main issues are he has memory loss. Ok? Um But he can still do his daily activities. So that's fine. Um But he always keeps alone and has stopped doing the things he once liked and has lost weight. These are symptoms of depression. So wanting to stay alone and not doing the things you like anymore and weight loss are all symptoms of depression. So that is the key thing you want to look at treating. So we're thinking about either option B or option D. Um The reason you wouldn't want to do option B is because that kind of comes further down the line. Ok. The best thing to do here is social prescribing because he keeps alone. So the issue here is that you can kind of assume he's getting depressed due to kind of being alone. Ok. So you wanna give him some social prescribing, maybe um refer him to some um community activity stuff and then hopefully that will um help his depression. Ok. Remember that depression was a very, very big risk factor of um MCI progressing into dementia. So that's something you want to treat as early as you can. OK. Let me just quickly read what you guys are missing. Good. So she prescribing this. Um So if that hasn't worked, so if social prescribing doesn't work, then you could, yes, you would move on to CBT. And then in the worst case scenario, you would give antidepressant. So that's kind of the order of um treatment you'd like to give to the patient. OK? I think my main point here is remember um CSI lost to do this. Sometimes your options will not technically be wrong. It will just be that you need to prioritize what is the most appropriate thing to do right at the moment? OK. And really think about what is your patient presenting with? So yes, social prescribing and yes, depression, very factor for dementia. OK. So that's all for MTI we're gonna have a look at dimension out. Um This factors again, basically the same for MCI. It's just that the severity of how they present is gonna be really different um for the birth. So these are symptoms of dementia and I'm not gonna read to all of them because it's quite a long list. I just want you to understand the reason I've written them out is like kind of phases is because in primary care. So at your, in a GP consultation, um what will happen is with dementia, it will be um a patient family member or close friends talking about them and they will kind of tell you stuff like, oh my mother, she's forgetting things or she's being a bit confused lately or she's um you know, on the left, right. So she's having problems following conversations and then the bottom um the list of the bottom is mood and behavioral changes, which is also very important to note as we establish that depression, mental health is very closely linked to dementia. So I'm not going to go through all of these. You can look back at the the slides when they go up later on. Ok. This is not, well, not really part of your CSI stuff, but I thought it was very important and very useful to know. Um which is what is the journey from primary care to diagnosis? Obviously a very brief outline. So you're gonna start at your GP consultation, which I as I mentioned will be most often a family member close by talking about the patient and in the GP consultation. So in the UK NH 10 minute max Power consultation um in most clinics. So you'll do your six ci T test which we'll talk about later. Um If the results of this kind of imply that the patient has impairment of their cognition, then you will refer them to a memory clinic in which you do the mm SE test. OK. If that also um shows that your patient um might have impairment, then you will do some blood tests. So you do blood tests to rule out other courses of impairment like you mentioned earlier. So, um really bad mental health or uh problem sleeping, very stressful um life recently and thyroid problem. So blood tests will kind of rule that out again. Nothing has been diagnosed yet. So you can't diagnose um up until this stage, you'll then do some brain imaging, which we'll have a look at in a bit and then you get diagnosed, um you get sorry, referred to psychiatry, which will have a look at the whole mental health stuff and then a specialist consultation um for the final diagnosis. So there's a lot of steps um just to arrive to the final diagnosis. And that's because um I guess as you progress to bi s um you kind of realize a lot of diseases present really um really similarly to each other and it's kind of hard to distinguish between others. So there are lots of stuff just to make sure people aren't getting incorrect diagnosis. And at the end, if someone is diagnosed, then you have to get a care plan for them which will involve the multidisciplinary team, which we'll talk about later as well. OK. Cognitive test. There's two main ones that we'd like to talk about today. Six ci T and mm se so this is your 630 test. It's very short. OK. 630 is your six question, cognitive impairment test has six questions. Um You don't need to remember the questions or the point system. You do need to remember the score ranges. So if you look at the bottom um between 0 to 7, that's normal and referral is not necessary at this point between 8 to 9, this suggests mild cognitive impairment and you would possibly refer between 10 to 28. This is significant cognitive impairment and you will refer um the reason why kind of the first two ranges are a bit wishy washy. So you're told referral is not necessary. So it's, they're not saying referral is not done, but they're told it's not necessary and that's because it will vary by patient. Ok. There's lots of factors you have to take into consideration. Um But please do remember the ranges and just appreciate the question. Not need. You don't need to re remember those. Um key point is this is not diagnostic, this is just a screening tool to assess general cognition. OK. And like we saw in the care plan, this is something you do at the beginning um at primary care. So in your GP consultation, because it's very short and it's easy and it gives you a brief kind of idea of this person's general cognition. So um OK, what also you do need to know is why these questions are being asked. So um people have cleverly put these questions for the six I see test because they examine different regions of the brain. Um So you have the dates and times. So between question 1 to 3, that's being assessed by your um posterior cingulate cortex, you have the actual stuff, which is your short term memory, which is all done by the hippocampus and the counting backwards or naming months backwards, assesses your attention which requires your anterior thalamus. And below, I've labeled those. So you have your singular GG as you can see in the sagittal section of the brain thalamus, all in the middle and hippocampus in the posterior view of the brain. OK. You need to know this. OK. Um These structures here all belong to something called your limbic system. I don't know if you've reached the stage um of be yet this slide you do not need to know, but I'm putting it up here anyways, um your limbic system. So you land for main parts, which is your Amygdala, hippocampus and mamillary body. Um And you have a diag labeled here. You do need to know how to label these structures here. Do the hippocampus, singular guys? Thalamus know how to label them and this entire system basically um looks like behavior and emotional responses. OK. So the mm se or mini mental state examination again, do not need to remember what questions are being asked, but it's nice to have a look and kind of appreciate what a patient will expect. Um When they're doing this, if you remember in the um the step that I laid out this would be done at the memory clinic. So at the memory clinic, you obviously have much more time and you're with, you're with kind of people that are specialized in this field. So you're not with the GP who is just general. Um you're with a specialist here and we can do the MM se in the memory clinic because we have time. This is a much longer test to do, it takes much longer to do again. This is not diagnostic, this is just screening. So this is just kind of getting more and more evidence um to the severity of um cognitive impairment of the patient again, no divens, no um severe impairment is between 0 to 9. Um moderate impairment is between I should say 10 to 9 to 2010 to 20. So um mind impairment 23 to 20 a normal range 30 to 24. So you'll notice that the scoring of the MM se and the scoring of the 60 I are in reverse. So with the MM se the higher the score, the better the patient with the 60. It the the higher the score, um the worse, the patient's cognition. OK. So that kind of opposite in terms of scoring. But please do remember the ranges don't need those for yours done. And the results of um these exam, these um examinations and tests that you do will tell you what you need to do next. So here's a little table comparing the two tasks that you do. The main thing you want to know here is that six ci T takes about 3 to 5 minutes and M MST takes a quarter of an hour. So just appreciate that you'll do the six it in primary care at the GP and mm se mm se in something that's more specialist. Um What else is nice to note. So, yeah, I think you can kind of um spot some limitations. So the M MSC is yeah, more susceptible to education level. Yes, because if you look at the questions, I mean, um I think in, I think last month we had to go in second year of, of doing this exa um this exam with our um with our peers and the questions were kind of hard for someone that doesn't have my impairment. So they're gonna be a lot harder for someone that does. And if you have a look at the very top, there's kind of a little disclaimer saying you need to explain to the patient that the question um you asked that might be really difficult. That might be really easy. So yeah, a few limitations to this assessment. Ok. So another question for you guys have a read of this case. I, so hopefully it's easier to read. I'd like you guys to um try and diagnose whether this patient has dementia or mild cognitive impairment. So that should be the next slide on your meter. So can you guys vote? Is the patient presenting with MC or dementia? Ok. Ok. So I have mixed answers. Ok. Let's have a read 72 year old retired teacher worsening memory. The guests appointment loses, train of thought, repeats, question, disorganized, but she can still manage her usual activities. MRI reveals mind atrophy and no focal lesions. What is important here. So I think a lot of people um I think what's important to know is a 72 year old is going to have some sort of memory issue anyways because with age we just decline and so never think that if a patient walks in and they're really old and they have issues with their memory that they must have dementia. OK? Because that's just a natural kind of decline that we face as we age. The key phase here that I wanted you guys to pick out was she can still manage her usual activities such as cooking, paying bills and participating in the club that suggests. So that rules out dementia because as you remember, from the, the nice definition for dementia is um someone in which their cognitive impairment affects their day to day activities. And this patient here is not affecting their day to day activities. So for this patient, they just have MCI. OK, because they can manage their daily activity and they retain that independence. Um What might put people off. So again, I mentioned old age and memory, they come hand in hand. Um MRI reveals mild atrophy, consistent with her age. So, I mean, it's basically telling you that with age, your brain is going to kind of deteriorate anyways. But even with MCI, you will see um because like we mentioned earlier, there's kind of two types of MCI. There's one that's due to like um the reversible one which is like the emotional um mental health sleep issues, stuff like that. And then there's the neurodegenerative one. So don't think it's just dementia that presents with neurodegeneration. MCI has neurodegeneration. It's just to a lesser extent. OK. So you will have a little bit of atrophy um in a patient with MCI. OK? I hope you're all happy as to why that is um MCI, not dementia. OK. So what test do you want to do? Um I'll just put these really quickly because you don't really need to know this in too much detail. The blood test will rule out anything that's, that presents as dementia but isn't OK. Um So kind of really bad thyroid issues. Um Very bad mental health issues essentially, basically anything. OK. So that's what your blood tests are for. Again, blood tests are not diagnosing anything that's just kind of ruling out other causes. Um Your MRI is there to confirm any structural changes to the brain and then you'll do AP ET which stands for positron emission tomography. Um We'll get onto this later. What AP ET scan does? It lights up the brain in different colors according to how much glucose metabolism is occurring in that part of the brain. So, if the part of the brain is very well, then you can assume that there's lots of activity, lots of synapses, neuron. Um If it's not violet, then you can assume there's been some neuron and death. And that is exactly what we see in patients with dementia and patients with um MCI. We're gonna look at a picture of that later and that will show your amylo plaques or Tau Tangles again, which is um features of Alzheimer's we'll look at later. You can also do a CSF analysis. So um one thing I want you guys to think again, the CSI loss to be really sneaky CSF analysis requires sticking a needle that's like this long into your back just to take some fluid that's very invasive. So this is not something that you would do for every single patient. So if you get a question on your exam on Wednesday saying, well, um how do you want to diagnose this patient, it's very unlikely that you want to do CSF analysis because that's very invasive and you'd rather choose um things like MRI and P et over A C CSF analysis um the cerebrospinal fluid thing. So CSF is a fluid that surrounds your spinal cord. Um and that, so if you test that, that will kind of give you um very good indications of your brain hand. So any kind of um like I said on the slide, any kind of um Amylobeta or Tau proteins, you can, they will be present in the CSF with anyone that has Alzheimer's. So I guess this test would be used for someone. I mean, if we're trying to differentiate between the types of Alzheimer's and then the um genetic testing to differentiate between early onset and late onset Alzheimer's. OK. Um Another question on you, what is capacity? So four domains to capacity, there's understanding, retaining, weighing and communicating a decision. So all these four domains is going to help someone make a decision. Do patients with dementia have capacity? Can you all on the month? He um give me an answer for that. Do patients with dementia have capacity? Good. All three of you put it depends what a nice question. So um they love to throw this question. I even got asked placement the other day, whether um a patient has capacity, there's no definite answer. So it's going to change depending on the pattern. You can have patients with um dementia and capacity, the dementia and no capacity is is different. You can have patients with MC that don't have capacity. So um it depends on the patient. You can never give a definite answer for these questions. I think very important though. Do remember the domains um of the four things that um constitute capacity. OK. So the four types of dementia and the distinguishing symptoms before I look in these slides, I want to make it very clear that so many things will overlap. So if I say that memory is um a key symptom of Alzheimer's, that doesn't mean memory doesn't present in vascular dementia, they overlap. But the, the symptoms that we talk about now are going to be the distinguishing symptoms. Um Basically the ones that they will ask you in your exam. OK. So let's start with Alzheimer's um most common type of dementia, gradual onset. So if you look at your uh graph here, the light blue curve line is showing Alzheimer's. So you have a very gradual decrease over time, it presents first with memory problems and then those um power tangles and um the problems there will spread to other regions of the brain. And then you'll get really um distinct cognitive decline, vascular dementia has a stepwise progression. So again, it's the same graph. If you look at the dark blue line, you kind of see the step. And the reason why that happens is you'll have a vascular event and then a very sharp decline in cognition and then stability, vascular event and sharp decline. So it's kind of like a little pattern. Um I hope you all know what we mean by vascular events or anything that kind of impairs the um vessels in such a way that it's going to affect what regions of the brain are getting oxygen and nutrients. Ok. Um Most likely it's going to be a stroke. And so, yes. So step five progression. Very key. What? And in vascular dementia, you get gait disturbance which may lead to falls. So that's because the areas um supplied by the vessels tend to primarily affect the motor regions, um which causes kind of the the gait disturbance stuff. And then this factor is obviously going to be vascular related. So anything like a atherosclerosis, hypertension, hypercholesterolemia and diabetes. Um in regards to that, if you ever get asked how you treat a patient with vascular dementia, you want to tackle the vascular stuff, don't you? So you want to tackle the the blood sugar, uh the lipid levels and high BP and everything like that. Ok. Ok. So Lewy body dementia, um most distinguishing symptom here is visual hallucination and fluctuating awareness, fluctuating awareness is when the patient kind of switches from being very alert to confused, to very alert to confused. And again, this is something that the a close family, close friends will spot. So what happens in Lewy body dementia, apologies. I don't have a diagram for this. I've just written like sequence of why she happened. So you have abnormal deposits of alpha protein, these are called Lewy bodies. These are deposited mainly in the primary motor cortex. Hence the movement issues. So tiny overlap with Alzheimer's but I guess for exam purposes um let just associate um motor issues to Lewy body dementia. And yeah, so that's basically what happened. Lewy bodies are also seen in Parkinson's um which gives the Parkin Parkinson's symptoms such as movement issues, memory becomes affected later. So in Alzheimer's memory was your first um presentation with Lewy body dementia. That is your kind of laser presentation. And how do we treat Lewy body dementia? So we give um acetylcholinesterase inhibitors. So, um this enzyme will break down acetylcholine in the synapse. Um The inhibitor will prevent the breakdown, obviously, which will then increase the availability of acetylcholine um between the new ones. OK? You don't need to know more than that. You don't need to know why ach um is good for body dementia. Just know it to the extent that I have written it on the slide and then fronto temporal dementia. Um Again, this region here, uh the most distinguishing symptom is this inhibition. So what is this inhibition about in a normal person? You can have thoughts that you shouldn't have or your brain telling you to do things you shouldn't do, but you can switch these off and that is inhibition. Someone with frontotemporal dementia does not have inhibition. So they have this inhibition, which means they tend to act on inappropriate behavior. And um when they present in clinic, it's, it's usually very obvious that they have frontotemporal dementia. Ok. Um So can you guys have a read of this and tell me what is the diagnosis? Um So essentially you're choosing from all four types of dementia, which type of dementia do we think the patient has in this case? So have a read and put your answer on the meter. Yeah. Yeah, good. So everyone for the correct answer. Um Yeah, this is the one that everyone loves because it's very easy. Um uh And the symptom is kind of really stands out compared to other ones, right? So let's have a look two years of, of progressive cognitive and behavioral changes. Yes. Um neglecting hobbies, um compulsive behaviors, inappropriate comments. So this is what really ticks the box, right? Um He has a tendency to make inappropriate comments which is unusual and yeah, so you have, so here's the important bit, right? If you have someone that's been really inappropriate their whole life, you can't really diagnose Fonto temporal dementia, right? In this case, you can because your wife is telling you that this behavior is unusual. So you can you're being told that he's changed and he's become different and he's become inappropriate and acting on things that he shouldn't be acting on um any other piece of information is irrelevant? Um Yes. So he has fonte and dementia this inhibition. So that's exactly what he's showing here, inappropriate and different behavior. Um OK. Question if you have vascular dementia that blocks vessels to the um cerebellum, does that affect balance? Ok. Yes. So essentially, um like I mentioned the way we're going through this now is is very like black and white for your exam in real life. That's not the case, right? Because even just having a stroke can give you gait issues and not give you dementia. So things are very wishy washy in your life and things really overlap. Um But for the purpose of this presentation and your exam, we're gonna make things very like definite, but yes, you're right. Um Anything could happen in your life. So yes, you could have definitely um vascular dementia can also present with um gait problems as well as Lewy body dementia. But just for your exam guys, remember that um vascular dementia is the um one with hallucinations and Lewy body is the one with the um gait issues. OK. So the two mechanisms of Alzheimer's um I these images and I hope they help rather than make things worse. So the kind of the order is written on the right. I'm not gonna read that out. I'm just gonna explain it from my diagram. So at the top, you have Alzheimer's and bottom, you have normal. So let's have a look at normal, you have um the amino precursor protein which is transmembranal goes through both sides of the cell surface membrane. And in a normal person's brain, this will be cleaved by Alpha Serita enzyme. OK. The results of this cleavage, you don't need to know to this extent. I'll tell you anyways. Um There's been studies to show that the um the products of the cleavage from alpha Serota um really helps brain function and maintains, like I wrote on the diagram, maintains normal neuronal growth and function. So that's good. That's what's happening in a normal person with someone that has Alzheimer's, they have more, much more activity of beta and gamma stse. And when these cleave the A PP protein, we get amyloid beta fibriles or just Amylobeta. OK? And this kind of settles on the um membranes and this forms um Amylobeta deposits which are insoluble plaques and you get an amyloid plaque. OK. Why is that going to affect brain function? Well, your, you have a plaque on a piece of tissue that's going to affect what's diffusing in and out. Um And then essentially, um I think even just the presence of these plaques in the brain cause neuronal death. OK. So that's what's happening. You have the, you have it in writing on the side. So if you wanna look at this diagram later, um let's have a look at now the tau protein mechanism. So we have normal at the top and Alzheimer's at the bottom. So let's look at the top normal in a normal person, you have TAU proteins, which is this green guy who's really happy. And this green guy is in charge of assembly of these microtubules, which are the um yellow guys walking in a straight line. They're all assembled and doing their job as they should do microtubules very important to know. Um These are so these are in the brain and they allow transport of nutrients. Ok. So that basically the tissue can survive and do a stop and obviously allow for growth and development of the neuron. That's what happens in a normal person. In someone with Alzheimer's, this th protein gets hyperphosphorylated. OK? And this causes oligomerization which is polymerization, but a really small oligomers which is th protein and then this massive clump, this massive um oligomerization of P protein, which is hyperphosphorylated because it's all um bunched together. It can't keep the microtubules in order. Ok. So now the microtubules are also messed up and you have impaired neuronal growth. Um You can't get the nutrients transported to the neurons and then you have death of the neuronal tissue. Um obviously, both these mechanisms are going to result in neuron or that which will come on to x rays and MRI s um not x-rays, sorry, MRI S and PT scans where you can kind of see this stuff happening and this neuron or that is giving you your symptoms. So two types of Alzheimer's early on that familial before the age of 65. This is genetic and it progresses a lot faster than late onset. Late onset is above age of 65. This is your common, your, your um standard dementia, 95% of people have this, this type and it's not genetic. Ok? You need to know these two and the difference between them both. OK. Five keywords, just remember the definition. Um Don't wanna run out of time. So I'm gonna skip those for now. Um I've written that these are symptoms of Alzheimer's to be fair, these present in any type of dementia. OK? Like I mentioned in real life, everything is very wishy washy and everything overlaps, but it's important to know the definition of these. What? OK. So what are the treatments for dementia? Um We cannot cure dementia because it's neurodegenerative. Once the neurons has died, they cannot become alive again. Ok. Um Especially at old age. Your kind of your degeneration of neurons is basically not that. Ok. Um So we don't have cures, but we have treatments to slow its progression. Um So this was taken from your uh part three of your CSI stuff, which is a massive chunk of reading. Um Most important bit is I think let's have a look at these bullet points. So the first two, I don't think you need to know, but nice to read and appreciate you have cholinesterase inhibitors. Um Yeah. So these were for Alzheimer's um increases ach in the synapse, which um is proven to be very good medicine to control BP. So good. Remember, we want to prevent the whole vascular stuff. Ok. Vas for vascular dementia, anything that controls BP and cholesterol and SSRI s. So these are selective serotonin reuptake inhibitors. These are very um good drugs to give to someone that has depression. Again, if this is an option in your multiple choice, it's usually not gonna be first line option unless your patient has very bad depression. Like I mentioned, you would want to do social prescribing or CBT before you give anything like um SSRI S to the patient embryo. That's basically it for treatment of dementia. Um OK. So we have um this is a real image of the brain with Alzheimer's and a normal brain. Um You'll notice the one with Alzheimer's is very shrunk, it's atrophied. OK. That's what we call when um the cells kind of lose their content and they shrink because they're not getting that. Um There's so many mechanisms going on, right? But I think the main thing is they're not getting their nutrients because of all the tau proteins and um all the blockages to the blood vessels. So they tend to shrink compared to a normal brain. Um Why do we get atrophy? Oh I think this was a question but we'll skip it anyways. Um due to loss of neurons and their connection, which is a hallmark of neurodegenerative disease that leads to reduction in brain volume. So your bone is getting smaller. So this is the um pet scan I was talking about position one emission tomography which highlights glucose metabolism in your brain. Um So let's have a look in the normal brain. You have lots of activity, very bright red, bright yellow um areas in the brain with MC less activity. But you can see quite a lot of it is still there, right? In the brain with Alzheimer's, the middle section is completely gone. So very, very um you can see that there is no glucose metabolism happening, which um is because your new ones have died, ok? The microtubules aren't transporting blood vessels have been blocked and therefore glucose cannot get through to the new ones and they've died. Ok? Um The MDT, I'm not gonna spend too long talking about this because I know you guys have done this so many times. Um, they're very important to dementia because the last steps, the very last step of your um you kind of your route to diagnosing dementia is um a care plan. Ok. So here's just a nice table of um people that might be involved. Uh We all know what most of these do. Let's just go over occupational therapists. Um I think is the most important one, right? If you have dementia, you're going to struggle as we said in the, we still on the definition, you're gonna struggle maintaining daily activities. So you will most likely need an occupational therapist who will come to your house and kind of assess things and see, is there any changes we can make? So that um being at home doesn't get in the way or becomes easier for you if you have dementia? Ok. That's what an occupational therapist does. They recommend strategies, modification and devices to help the person at the um in their home life, physical therapist um will help with uh their physical health again, being physically healthy is going to slow your progression into uh a severe dementia and um is also going to reduce the risk of you falling, which is very, becomes very severe, very quickly in older patients. And then um yes, we have dieticians and speech language therapists for those that have um impaired eating abilities or swallowing difficulties. I think it's a very important one to know, right? Because if you have issues with swallowing, then you're likely to aspirate and get food down into your lungs, which becomes very dangerous very quickly. Um And yeah, you can read the rest of them in your own time and I think that is it, we have about three minutes until we do your next case. So if you want to just really quickly drop me any question um on the meter and I can answer those for you. What ID later is Um So I hope this was very informative for you guys and basically, this has covered everything you need to know from part one to part two to part three of your CSI cases. Um After your next CSI case, I'm gonna post a link to a little um um a little like a questionnaire if you, if you guys can just wait, how much you like today. This is my first time doing a lecture and that would be very, I'd really, really appreciate that. And in the meantime, I'm just gonna wait for people to ask me questions if you have any questions. I think um if I give you any um really serious side tailored tips, it will be really um look at the c uh because it's multiple choice, right? Look at the options you've been given. They love to trick people think. Why are they giving me these four options that all look that they could be correct? Ok. They're trying to trick you. So there will be a trick in almost everything that they um that they put you. Um Another thing is, oh, you haven't covered MSC. Ok. Interesting. Um You can ignore it then um Yeah, but for the 60 I test, please do know the know the ranges for the scoring. Um One thing which I haven't done today is looking at stats test. So CSI lost to give you graphs. And what tends to be the case is that the trick with the graph questions tends to be statistics related. Um So looking at significance level and P values and all of that stuff, um I'm not gonna go through that today. Um But I do recommend you do that in your own time. Just a little bit of preparation with Manchester. What's the P value? What's the significance level and stuff like that? And don't ignore those if you're given ap value in significant level, do not ignore it in your exam because it's there for a reason. OK, so, oh, do you know where we can find? Um Yeah, I don't think you need to. I mean, you can look at Note Bank, have a look at Noeb Bank for um I'm sure someone's done loads of questions that you don't really need to do uh graph practice because I can give you like a list of 100 graph and you'll still get something completely different in your exam on Wednesday. Just practice. Make sure, you know, um make sure you know the whole um P value statistic that that's it. It'll take you five minutes to learn, watch a youtube video or something. Um You don't get given paper in the exam now you can't bring paper sorry into the exam. I think you can ask for paper if that helps, do ask for paper. Any other questions you have one minute left? Um I don't find this ci t question brain matching. Convincing. Mm I don't know what you mean by. I don't. Is this a Acsi question from Acsi case? Can you just elaborate on what you've written? Um Also in the chat, um Ayash has a feedback form for me. So please please give me some feedback because this is my first time. And obviously the more feedback you can give me the better I can be for your next sessions. And today is also a really um interesting day because me and Aish are both your um we're both your head for phase one Acsi and you're both, you're all getting a lecture from us. So good for you guys. Oh OK. So someone very quickly, someone asked, how did they figure out the ci T questions can be related to brain regions? Um This is, so that's a good question. Let me just go back to this. So they're talking about um mapping the different questions to the different regions. Um How do I put this into simple terms in neurology and in BRS and in C SA, you'll learn that this vision of the brain does this and this vision does this. That is not the case in your life because there's so many overlaps. Um The reason why um we're looking at the mapping here is we just, I think they just want you to kind of appreciate that um to say, right? They want you to appreciate that the questions are not just random questions, they kind of have a bit of thought for that. Testing your short term memory, they're testing your long term memory, uh your ability of reading something backwards. Um They're just assessing everything, right? Um So yeah, obviously the hippocampus does more than just short term memory. And I think, yeah, again, this is very black and white. It's not going to, that's not going to be the case in your life. It's very much like that. Ok. Ok, so um I'm happy to leave it there if you have any questions, uh you can email me. I'm going to write my short code in here.