15.4 (15.4) Dementia

Question 1

Diagnostic criteria for major neurocognitive disorder

Answer 1

1. Evidence of significant cognitive decline from previous level of performance by report of the patient or knowledgeable informant and support through objective cognitive assessment
2. Decline in cognitive abilities severe enough to interfere with independence in every activities (IADLs)
3. Cognitive deficits not accounted for by other psychiatric condition (e.g. delirium or depression)

Question 2

The diagnosis of dementia requires impairment in at least 1 cognitive domain. List the 6 domains that are considered

Answer 2

DSM 5
Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains*:

• Learning and Memory
• Complex Attention
• Perceptual-motor
• Language
• Executive function
• Social cognition

MAPLES

Question 3

List three screening tools for dementia. Which tool is both sensitive and specific?

Answer 3

MMSE - mini mental state exam
MOCA - Montreal Cognitive Assessment (high sensitivity and specificity)
Mini-Cog

Question 4

List four types of dementia. What is most common?

Answer 4

1. Alzheimer’s Dementia - most common (60-80% of all dementia)
2. Vascular dementia - 2nd most common
3. Dementia with Lewey bodies
4. frontotemporal dementia

Question 5

List three common features of dementia with Lewy Bodies.

Which meds are these patients sensitive to?

Answer 5

progressive cognitive decline*

vivid hallucinations*

motor features of Parkinson (TRAP)*

fluctuating cognition with pronounced variation in attention and alertness

(sensitive to neuroleptic medications)

Question 6

How to distinguish Dementia with Lewey Bodies from Parkinson’s disease with dementia?

Answer 6

Parkinson’s disease with dementia - motor features of parkinsonism present for longer than 12 months prior to onset of dementia

Question 7

How does mild cognitive impairment differ from dementia

Answer 7

cognitive impairment that does not meet criteria for dementia (e.g. can have some cognitive changes without interfering with IADLs)
-can be transitional stage from normal ageing to AD

Question 8

List 2 scales used to stage dementia

Answer 8

Functional Assessment Stage (FAST) scale

clinical dementia rating (CDR) scale

Global deterioration scale (GDS)

Question 9

List four domains on the clinical dementia rating scale (CDR)*

Answer 9

memory
orientation
Judgment
problem solving
community affairs
home and hobbies
personal care

Question 10

How long can patients older than 65 survive once diagnosed with Alzheimer’s?

Answer 10

4-8 years although a good degree of heterogeneity

Question 11

List four conditions which mark poor short term survival with dementia

Answer 11

aspiration

fever
sepsis
pressure ulcer
UTI

weight loss

Question 12

What is a common way in US to predict dementia with survival < 6 months

Answer 12

FAST stage 7 and at least 1 complication of dementia (below)

aspiration
fever
sepsis
pressure ulcer
UTI
weight loss

Question 13

Name 1 prognosis tool for dementia (in nursing home with < 6 months)

Answer 13

Mitchell’s ADEPT (advanced dementia prognostic tool)

Question 14

How to assess pain in a person with advanced dementia?

Answer 14

Combination of:
Patient report + Caregiver report + Direct observation

Question 15

List four behaviours that might be seen to suggest pain in someone with advanced dementia

Answer 15

changes in facial expressions
vocalizations
body movements
Interpersonal interactions
activity patterns
mental status
agitation
physical aggression
irritability

FS:
Facial
Vocal
Body movement
Behaviour/attitude

Question 16

List 1 pain scales for assessing pain in people with advanced dementia

Answer 16

Pain assessment in advanced dementia (PAIN-AD)
Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)
Doloplus-2 scale

Question 17

Name 4 neuropsychiatric symptoms of dementia (BPSD)

Answer 17

depression, apathy, delusions, hallucinations, agitation and sleep impairment

DADHAS

Question 18

Name three common triggers for behavioral issues

Answer 18

Unmet needs - hunger, thirst
Pain
Constipation
Medical issues - UTI, delirium
Environmental factors - changing caregivers

Question 19

3 Non-pharmacological ways to help manage neuropsychiatric symptoms?

When to offer pharmacological medications?

Answer 19

• Managing causes and triggers - document ABCs (antecedents of behaviour, behavioural disturbance and consequences of behaviour)
• Music*
• PT*
• Massage*
• Adjust environment (not to over and under stimulate, routine activity, separate patient from upsetting interaction/people)
• Effective communication (avoid arguing, complex instructions, more examples below:

Don’t disagree; respect the person’s thoughts even if incorrect
Physical interaction: maintain eye contact, get to their height level, and allow space
Speak slowly and calmly in a normal tone of voice.
Avoid finger-pointing, scolding or threatening
Redirect the person to participate in an enjoyable activity or offer comfort food he or she may recognize and like
Validate that the person seems to be upset over something. Reassure the person that you want to help and that you love him or her)

Pharmacological therapy only if non-pharm txs failed

Question 20

How to help manage apathy?

Answer 20

Non-pharm: activity program, music, art, support for caregiver/family

Methylphenidate may improve apathy

Question 21

Name 2 classes of meds to treat cognitive decline? How effective are they in very advanced dementia?

Answer 21

2 classes:

1. Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) to increase cholinergic transmission
2. N methyl D aspartate (NMDA) receptor antagonist (memantine)

Lack of evidence of efficacy in very advanced dementia (i.e. should be discontinued)

Question 22

List four side effects of acetylcholinesterase inhibitors

Answer 22

nausea*
vomiting*
diarrhea*

syncope
bradycardia*
permanent pacemaker insertion
hip fracture

Question 23

List three outcomes that are not improved with the use of a feeding tube in advanced dementia

Answer 23

survival
weight
aspiration pneumonia
pressure ulcers
comfort

Question 24

What 2 serious associations do anti-psychotics have?

What 2 neuropsychiatric symptoms can they improve?

Answer 24

Stroke and death

Psychosis and aggression

Question 25

How does Mirtazapine work?

Answer 25

Noradrenergic and specific serotonergic antidepressant (NaSSA) that acts by antagonizing the adrenergic alpha2-autoreceptors and alpha2-heteroreceptors as well as by blocking 5-HT2 and 5-HT3 receptors. It enhances, therefore, the release of norepinephrine and 5-HT1A-mediated serotonergic transmission (dual mode of action) .

Question 26

The most commonly identified cause of death in patients with Alzheimer’s

Answer 26

Pneumonia