15.4 (15.4) Dementia Flashcards
Diagnostic criteria for major neurocognitive disorder
- Evidence of significant cognitive decline from previous level of performance by report of the patient or knowledgeable informant and support through objective cognitive assessment
- Decline in cognitive abilities severe enough to interfere with independence in every activities (IADLs)
- Cognitive deficits not accounted for by other psychiatric condition (e.g. delirium or depression)
The diagnosis of dementia requires impairment in at least 1 cognitive domain. List the 6 domains that are considered
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
List three screening tools for dementia. Which tool is both sensitive and specific?
MMSE - mini mental state exam
MOCA - Montreal Cognitive Assessment (high sensitivity and specificity)
Mini-Cog
List four types of dementia. What is most common?
- Alzheimer’s Dementia - most common (60-80% of all dementia)
- Vascular dementia - 2nd most common
- Dementia with Lewey bodies
- frontotemporal dementia
List three common features of dementia with Lewy Bodies.
Which meds are these patients sensitive to?
progressive cognitive decline*
vivid hallucinations*
motor features of Parkinson (TRAP)*
fluctuating cognition with pronounced variation in attention and alertness
(sensitive to neuroleptic medications)
How to distinguish Dementia with Lewey Bodies from Parkinson’s disease with dementia?
Parkinson’s disease with dementia - motor features of parkinsonism present for longer than 12 months prior to onset of dementia
How does mild cognitive impairment differ from dementia
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
List 2 scales used to stage dementia
Functional Assessment Stage (FAST) scale
clinical dementia rating (CDR) scale
Global deterioration scale (GDS)
List four domains on the clinical dementia rating scale (CDR)*
memory
orientation
Judgment
problem solving
community affairs
home and hobbies
personal care
How long can patients older than 65 survive once diagnosed with Alzheimer’s?
4-8 years although a good degree of heterogeneity
List four conditions which mark poor short term survival with dementia
aspiration
fever
sepsis
pressure ulcer
UTI
weight loss
What is a common way in US to predict dementia with survival < 6 months
FAST stage 7 and at least 1 complication of dementia (below)
aspiration
fever
sepsis
pressure ulcer
UTI
weight loss
Name 1 prognosis tool for dementia (in nursing home with < 6 months)
Mitchell’s ADEPT (advanced dementia prognostic tool)
How to assess pain in a person with advanced dementia?
Combination of:
Patient report + Caregiver report + Direct observation
List four behaviours that might be seen to suggest pain in someone with advanced dementia
changes in facial expressions
vocalizations
body movements
Interpersonal interactions
activity patterns
mental status
agitation
physical aggression
irritability
FS:
Facial
Vocal
Body movement
Behaviour/attitude
List 1 pain scales for assessing pain in people with advanced dementia
Pain assessment in advanced dementia (PAIN-AD)
Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)
Doloplus-2 scale
Name 4 neuropsychiatric symptoms of dementia (BPSD)
depression, apathy, delusions, hallucinations, agitation and sleep impairment
DADHAS
Name three common triggers for behavioral issues
Unmet needs - hunger, thirst
Pain
Constipation
Medical issues - UTI, delirium
Environmental factors - changing caregivers
3 Non-pharmacological ways to help manage neuropsychiatric symptoms?
When to offer pharmacological medications?
- 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
How to help manage apathy?
Non-pharm: activity program, music, art, support for caregiver/family
Methylphenidate may improve apathy
Name 2 classes of meds to treat cognitive decline? How effective are they in very advanced dementia?
2 classes:
- Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) to increase cholinergic transmission
- N methyl D aspartate (NMDA) receptor antagonist (memantine)
Lack of evidence of efficacy in very advanced dementia (i.e. should be discontinued)
List four side effects of acetylcholinesterase inhibitors
nausea*
vomiting*
diarrhea*
syncope
bradycardia*
permanent pacemaker insertion
hip fracture
List three outcomes that are not improved with the use of a feeding tube in advanced dementia
survival
weight
aspiration pneumonia
pressure ulcers
comfort
What 2 serious associations do anti-psychotics have?
What 2 neuropsychiatric symptoms can they improve?
Stroke and death
Psychosis and aggression
How does Mirtazapine work?
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) .
The most commonly identified cause of death in patients with Alzheimer’s
Pneumonia
