24. Dementia Flashcards
Definition of Major Neurocognitive Disorder (Dementia)
- Evidence of significant cognitive decline in one or more cognitive domains
- Learning/memory
- Language
- Executive function
- Complex attention
- Perceptual-motor
- Social cognition
- Impairs function (AVD, AVQ)
- Not better explained by other disorder
Name DDx Memory Loss (5)
- Major Neurocognitive Disorder (previously Dementia)
- Mild Neurocognitive Disorder
- Delirium
- Depression
- Neurological - Seizures, stroke/TIA
Name types of Major Neurocognitive Disorder (7)
- Alzheimer (most common 50%)
- Mixed Alzheimer and vascular (20%)
- Vascular (15%)
- Lewy Body (5%)
- Frontotemporal (1%)
- Parkinson disease with dementia
- Other: Progressive supranuclear palsy (vertical supranuclear gaze palsy and postural instability), Huntington disease
Describe : Alzheimer (3)
- Gradual onset
- Normal CNS
- Initial and most prominent deficit = amnestic (associated with impairment in learning and recall of recently learned information)
Describe : Vascular Dementia (5)
- Abrupt
- Stepwise
- Cardiovascular risks (HTN, DLP)
- Dysexecutive syndrome
- Focal neurological features
Name core features : Lewy Body Dementia (5)
- Fluctuating cognition
- Detailed visual hallucinations
- REM sleep behaviour disorder
- Parkinsonism (bradykinesia, rest tremor, rigidity)
- Other suggestive: Severe neuroleptic sensitivity (irreversible parkinsonism, impaired consciousness), postural instability, falls, syncope, autonomic dysfunction, hypersomnia, hyposmia, delusions, apathy, anxiety, depression
Describe : Frontotemporal Dementia (2)
- Behavioural problems (disinhibition, loss of social awareness)
- Language impairment
Describe : Parkinson disease with dementia
- Impaired executive dysfunction and visuospatial function
- Differentiate from Lewy Body as parkinsonism is present >1y prior to dementia (whereas in DLB dementia occurs before or at the same time as the parkinsonian signs)
Describe : Mild Neurocognitive Disorder (3)
- Decline reported by patient, informant or clinician with objective deficits in 1+ domains (typically memory)
- Preserved independence in function
- Follow q3-6 months, Alzheimer’s 15% per year (2/3 will eventually convert to Alzheimer’s)
Describe : Delirium
- Sudden onset
- Decreased concentration
- May have visual/tactile hallucinations)
- Caused by : Infection, Drugs/Toxins (polypharmacy, opioids, cholinergic, benzodiazepine, alcohol), Endocrine (Thyroid, B12), Electrolytes (glucose, sodium)
Describe Physical Exam of Dementia (4)
- Gait
- Neurological signs
- Extra pyramidal symptoms
- Parkinson (cogwheel rigidity, tremors)
Describe Investigations for dementia
- Labs (low yield <1%)
- Consider EKG prior to treatment. Avoid AchEI if LBBB, 2nd/3rd degree block, sick sinus, HR<50
- Consider CT head
- Depression screen
Name labs for dementia (6)
- CBC
- TSH
- Electrolytes (Glucose, Cr, Ca)
- B12
- Lipids
- Neurosyphilis screen only if high clinical suspicion
Consider CT head in dementia when ? (7)
- < 60yo
- Abrupt, rapid decline
- Focal neurological symptoms (headache, seizure, hemiparesis, babinski reflex)
- Urinary incontinence, gait disorder (r/o normal pressurehydrocephalus)
- Previous malignancy, trauma
- Anticoagulants/Bleeding disorder or history of bleeding disorder
- If presence of cerebrovascular disease would change management
Describe diagnosis : Dementia
- Investigate symptomatic
- Highly educated : Hopkins Verbal Learning test, Word List Acquisition test
- MMSE <24 suggests dementia/delirium (1 in 10 false positive)
- MoCA <26 (MCI 78%, AD 100%,1 in 4 false positive)
- Clinical Dementia Rating (Lengthy)
- Mini-Cog (Brief). Clock drawing task and uncued recall of three unrelated words
Describe LIFESTYLE tx of dementia
- Refer to Alzheimer society
- Discuss will, power of attorney, personal directives
- Safety issues (driving, stove, smoke detector, microwave)
- Occupational Therapy
- Hearing and vision screen
- Social work / Homecare services
- Healthy diet, smoking cessation
- Exercise program
- Eliminate medication (narcotics, anticholinergics, benzodiazepines);
- Alternative therapy : Aromatherapy, Multisensory stimulation, Music/dance therapy, Animal‑assisted therapy, Massage/touch therapy, Outdoor activities
What’s tx for mild cognitive disorder ?
No pharmaco
Acetylcholinesterase inhibitors may be considered when ?
Acetylcholinesterase inhibitors may be considered only in mild to moderate Alzheimer’s Disease (lower quality evidence in Lewy bodies, vascular, Parkinson), where :
* Healthcare professional has expertise in diagnosing and treating Alzheimer’s Disease
* Adequate support and supervision
* Adequate adherence and monitoring of adverse effects, which generally requires the availability of a carer
* Baseline structured cognitive and functional assessment
* Follow up should be carried out on regular basis at least every 3 months : Taper slowly before stopping, May restart if decline shortly after stopping
* May reduce all-cause mortality in patient with dementia
Name examples AchEI (3)
- Galantamine
- Donepezil
- Rivastigmine
Describe pharmacotx in Alzheimer’s
- AchEI - Consider in mild to moderate (eg. MMSE 10-26)
- Titrate q4 weeks
- Discontinue when risks outweigh benefits (taper, and monitor 1-3 months, if declines can restart)
- NMDA receptor antagonists (Memantine) in severe AD
Name adverse effects : AchEI
- GI (nausea, diarrhea, vomiting)
- Bradycardia, hypotension, dizziness, syncope
- Insomnia / sleep disturbances
- QT prolongation and torsades de pointes (EKG prior to treatment as above)
Describe tx : Frontotemporal dementia (2)
- SSRI (paroxetine) or trazodone
- No evidence for AchEI
Describe tx : Vascular dementia
- Manage HTN, DM, smoking
- No evidence for AchEI
Describe tx : Lewy Bodies
- Can consider AchEI (eg. Rivastigmine (Exelon) 1.5-6mg BID)
- Avoid antipsychotics
- Risk of NMS
Describe tx : Parkinson’s/Cerebrovascular disease
Can consider AchEI
Describe investigation : Behavioral and psychological symptoms of dementia (BPSD)
r/o medication side effects or interactions, treatable medical conditions such as sepsis or depression
Describe tx : Severe agitation/Violent behaviour in Behavioral and psychological symptoms of dementia
Correct underlying
- Physical (pain, constipation, infection)
- Environmental (set routines, sound/lights, position, daytime activity)
- Psychiatric conditions (depression)
- Review medications
Intervention
- Relaxation, social contact, sensory (eg. music/aromatherapy)
- Increased services/care
Consider newer antipsychotics (less EPS), eg. Risperidone, Olanzapine, Seroquel
* Caution as increased risk of death, CVA, EPS, falls, somnolence, weight gain, diabetes
When to consider referral in dementia ?
- Rapid progression
- Young
- Frontotemporal, Lewy Body, Parkinson’s Dementia
Name risks of unsafe driving (4)
- Multiple motor vehicle accidents in past 5 years
- Self-restricted driving or Family/caregiver concerns
- Aggressive or impulsive behaviour
- MMSE 24 or less
Describe how to evaluate risk in driving assessment
- Clinical Dementia Rating scale of 1 or more suggests unsafe driver. The Clinical Dementia Rating score equals the memory score unless the patient scores more or less than the memory score in three of the secondary categories.
- On-road assessment by occupational therapy
