1- OPMH: Dementia continued and Parkinsons Flashcards
who can do a risk assessment in patient presenting with cognitive impairment
✔ An occupational therapist. Can give advice on equipment, adaptions in the home,
such as hand rails, bath seats, raised toilets seats, adapted cutlery and kitchen tools,
etc. as well as assistive technology. To arrange a visit speak to your GP or local Social
Services department.
✔ A physiotherapist. Can give advice on mobility devices such as walking aids,
wheelchairs and safe ways to help individuals move round. You can ask your GP for a
referral to your local hospital physiotherapy department.
✔ A continence advisor. Can give advice on a range of aids to help with incontinence.
Ask your GP if one is available in your area.
✔ A district nurse. Will give advice on what equipment is available for nursing someone
at home safely. Can be contacted through your GP.
example of risk assessment modifications for those with cognitive impairment
ADL aids
Equipment can help with tasks such as:
• cutting food
• pouring kettles
• help turning taps
• getting out of the bath
• getting up stairs
• going to the toilet
• help remembering what pills to
take and when to take them
Assessing the ADLs of aptients presenting with cognitive impairment
assessed by OTs/PTs
• Functional mobility, which includes the ability to walk and transfer in and out of a
chair or bed. Essentially, it’s the ability to move from one place to another as a
person goes through their daily routines.
• Personal hygiene, oral care and grooming, including skin and hair care
• Showering and/or bathing
• Toileting, which includes getting on/off toilet and cleaning oneself
• Dressing, which includes selecting appropriate attire and putting it on
• Self-feeding
Occupational therapists t
medication used to treat dementia
Main medicines
- Acetylcholinesterase inhibitors
- Memantine
Medication to treat BPSD
- antidepressants
- antipsychotics
Medication to treat related conditions (e.g. vasc dementia)
- medication for AF e.g.apixiban
- glucose lowering
- antihypertensives
- lipid lowering drugs
acetylcholinesterase inhibitors MOA
prevent an acetylcholinesterase from breaking down a substance called acetylcholine in the brain, which helps nerve cells communicate with each other
examples:
- Donepezil
- rivastigamine
- galantamine
side effects (anticholingeric tests)
- nausea and loss of appetite
- insomnia
memantine
suitable for aptients who have mod to severe Alzheimers, dementia with lewy bodies
- suitable for those who cannot take anticholinesterases
MOA: blocks effect of glutamate
side effects
- headache
- dizziness
- constipation
The symptoms of BPSD can include:
increased agitation
anxiety
wandering
aggression
delusions
hallucinations
antipsychotic use in people with dementia
typical antipsychotics (haloperidols etc) are not licenced in people with alzheimers
atypical antipsychotics
- risperidone
- olanzapine
side effects of antipsychotics
- drowsy
- uncontrolled moveemnts
- stiffness
- dehydration
- water retention
The newer antipsychotics like risperidone and olanzapine tend to cause milder and less troublesome side effects, although these drugs carry an increased risk of stroke for older people.
patients with dementia are also at risk of
abuse
- emotional
- neglect
- financial
Parkinsons
Neurodegenerative disorder
Progressive clinical course
Motor symptoms improve with levodopa (symptomatic medication)
Non motor symptoms
Pathophysiology of IPD
- Degeneration of dopaminergic neurones present in substantia nigra
- If we remove dopamine provided by the SN, then we lose net excitation on the cortex (dopamine stimulates direct pathway (which increases movement)and inhibits indirect pathway (which decreases movement))
- Therefore cortical activity decreases- corticospinal pathways aren’t stimulating LMN adequately:
-> Tremor
-> Rigidity- reduction in proper coordination in flexors and extensors
->Bradykinesia- most easily explained by this pathway
->Psychiatric features- cognition circuit interlinked with the basal ganglia circuit
Non motor manifestations
Mood changes
Pain
Cognitive change
Urinary symptoms
Sleep disorder
Sweating
Low Blood Pressure
Restless legs
Fatigue
Hallucinations
Diagnosis of IPD (based on clinical opinion and not on tests)
- Clinical Features
- Exclude other causes of Parkinsonism
- Response to Treatment e.g. Levadopa
- Structural neuro imaging is normal
catecholamine synthesis
one way to target low dopamine is
to prevent its degradation
e.g. COMT or MAO inhibitors
outline neurotransmission starting at synthesis of NT e.g. dopamine
AP causes releases into synaptic cleft via action of calcium which causes vesicle docking
treatment of parkinsons disease
Symptomatic e.g. movement disorders and non motor features
- levodopa (LDOPA)
- dopamine receptor agonists
- MAOI type B inhibitors
- COMT inhibitors
- anticholinergics
- amatidine
- Neuroprotection
- surgery
Why use precursor Levodopa (L-dopa)and not dopamine?
- Dopamine cannot cross the BBB
- Also causes many peripheral side effects
* Irregular beart beat * Anxiety * Headache * SoB * Nausea
levodopa
is a drug used in combination with a peripheral DOPA decarboxylase inhibitor e.g. carbidopa or benserazide
- reduces dose required
- reduces side effects
- increase L-DOPA reaching the brain
MOA of levodopa
Once Levodopa has crossed the BBB it must be taken up by dopaminergic cells in the substantia nigra to be converted to dopamine
As disease progresses and cell degenerated- fewer remaining cells mean levodopa is less reliable- motor fluctuations
disadvantages of LDOPA
- freezing when drug wearing off
- requires some cells to be left to produce enzyme for conversion in the SN
Drug-drug interactions LDOPA
- Pyridoxine (vitamin B6) increases peripheral breakdown of L-DOPA
- MAOIs risk hypertensive crisis- (not MOABIs at normal dose-lose specificity at high dose)
- Many antipsychotic drugs block dopamine receptors and parkinsonism is a side effect (newer, ‘atypical’ antipsychotics less so)
