45 - Neurocognitive Disorders: Dementia

Question 1

DSM-5: Neurocognitive disorders

NCD: describe disorders in which the primary deficit is in cognitive function and are ___ rather than developmental
- must repesent a ___ from previosuly attained level of functioning

Answer 1

acquired
decline

Question 2

mild neurocognitive disorders

• ___ cognitive decline from a previous level of performance in one or more cognitive domains
• does not interfere with ___
• not attributed to a ___ episode

Answer 2

• modest
• independence
• delirium

Question 3

major neurocognitive disorders

• ___ cognitive decline from a previous level of performance in one or more cognitive domains
• interferes with ___
• not attributed to ___ episode

Answer 3

• significant
• independence
• delirium

Question 4

donepezil (Aricept)
initiate

Question 5

neurocognitive domains

complex attention

Answer 5

sustained/divided attention, processing speed

Question 6

neurocognitive domains

learning and memory

Answer 6

immediate/recent memory, very long term memory

Question 7

neurocognitive domains

perceptual/motor

Answer 7

visual perception/praxis

Question 8

neurocognitive domains

executive function

Answer 8

planning, decision-mking, working memory, flexibility

Question 9

neurocognitive domains

language

Answer 9

expressive and receptive language (naming, word finding)

Question 10

neurocognitive domains

social cognition

Answer 10

recognition of emotions, range of behavior

Question 11

reversible cognitive decline

“reversible labs”

Answer 11

• B12 or folate
• hypothyroidism
• CBC
• electrolytes
• LFT
• infection (UTI)
• depression
• RPR/VDRL -syphilis

Question 12

Drug induced cognitive impairment

concerned with ACB score of ___ or ___

most frequent
- muscle ___
- ___ antidepressants
- bladder ___
- anti ___ (OTC allergy/cough cold)
- RX anti- ___

Answer 12

2, 3
- relaxants
- tricyclic
- antispasmodics
- histamines
- emetics

Question 13

dementia course by type

Which is which line? Alzheimer’s, vascular, Lewy Body

Answer 13

red = Alz
yellow = vascular
blue = Lewy Body

Question 14

rating scales

MMSE - used to assess cognitive function (out of 30)

change in ___ - ___ points over 1 year period indicated significant decline

Answer 14

3-4

perfect score = 3-
mild: 26-18
mod: 17-10
severe: 9-0

Question 15

rating scales

ADAS
- assess severity and dysfunction in cognitive and ___ behaviors over time
- used by FDA
- 0-70 (higher scores = worse cognitive performance)

Answer 15

non-cognitive

Question 16

rating scales

MoCA- ___ differentiates mild cognitive impairment
- visuospatial/exective attention, language, abstraction, orientation tests
- 30 point total score (higher scores better)

Answer 16

better

Question 17

cholinesterase inhibitors

• first line
• all approved for mild to moderate dementia
• ___ is FDA-approved for severe dementia (usually chosen first due to ease of dose titration/once daily dosing)

3 drugs: ___ (Aricept), ___ (Exelon), ___ (Razadyne)

Answer 17

donepezil
donepezil, rivastigmine, galantamine

Question 18

NMDA receptor antagonist

does not slow or prevent ___
- approved for moderate to severe dementia only
- not useful in ___ cognitive impairments
- marginal benefit usually realized in Alz disease

___ (Namenda)
___ / ___ (Namzaric)

Answer 18

neurodegeneration
mild
memantine
donepezil/memantine

Question 19

donepezil (Aricept)

IR: ___ mg, ___ mg, ___ mg
ODT: 5 mg, 10 mg

dosing: initiate 5 mg QHS, increase to 10 mg after 4-6 weeks, may increase to 23 mg after 3 months
- take with or without food

SE
- GI bleeding
- N/V/D
- bradycardia
- syncope
- insominia
- weight loss

CYP ___ and ___ substrate

Answer 19

5, 10, 23 mg
2D6, 3A4

Question 20

galantamine (Razadyne)

IR: 4, 8, 12 mg
ER: 8, 16, 24 mg
soution: 4 mg/mL

dosing
- IR: initiate ___ daily or 4 weeks with ___ and ___
- doses greater than ___ mg/day are not recommended for moderate renal/hepatic impairment

SE
- GI bleeding
- weight loss
- N/V/D
- bradycardia
- syncope
- insomnia

CYP ___ and ___ substrate

cannot provide efficacy at starting dose

Answer 20

twice, breakfast, dinner
16
2D6, 3A4

Question 21

rivastigmine (Exelon)

IR: 1.5, 3, 4.5, 6 mg caps
solution: 2 mg/mL
patch: 4.6, 9.5, 13.3 mg/24 hrs

dosing
- 1.5 mg ___ , take with ___ to minimize GI effects

SE
- GI bleeding
- weight loss
- toxicity due to not removing previous patch every day, ___ (SIGNIFICANT)
- ___ rupture (reason to restart at lower dose if therapy interrupted**
- bradycardia
- syncope
- EPS

no CYP interactions

Answer 21

BID, meals
N/V/D
esophageal

Question 22

memantine (Namenda)

IR: 5, 10 mg
solution: 2mg/mL
LA: 7, 14, 21, 28 mg
___ tablets only available as generic

dosing
- start low and titrate up

dose adjustments required in serveral renal impairment
- CrCl 5-29 mL/min, do 5mg once daily. If tolerated, can move up to ___

SE
- use in caution in patients with ___ disorder
- hallucinations
- insomnia
- confusion
- dizziness, headache, constipation

use with caution with ___ inhibitors and sodium ___
- clearance of memantine reduced by 80% is urine is alkalinized

no CYP interactions

Answer 22

IR
BID
seizure
carbonic anhydrase, bicarb

Question 23

memantine and donepezil (Namzaric)

M/D 28/10 mg, 21/10 mg, 14/10 mg, 7/10 mg

dosing:
- on donepezil 10 mg only, start Namzaric 7/10 daily and increase by __ mg increments as tolerated to 28/10
- if on memantine 10 mg BID or ER 28 mg, switch to Namzaric 28/10 with evening ___ once daily

SE
- warning for ___ effects like brady cardia and heart block
- increased risk for GI ulceration
- N/V/D
- bladder outflow obstruction

Answer 23

7 mg
meals
vagotonic

Question 24

___ targets the N-terminus of AB
- different antibodies work at different parts of AB

Answer 24

aducanumab

Question 25

antibodies

___ (Aduhelm) and ___ (Leqembi)
elegibility: required presence of ___ pathology prior to initiating treatment
- significantly reduce volume of plaques in the brain

not proved to be disease modifying yet

Answer 25

aducanumab, lecanemab
amyloid beta

Question 26

treatment of psychosis and behavioral disturbances

antipsychotics
- ___ or severe behavioral problems (psychomotor agitation, combativeness)
- not useful for ___ behaviors (yelling, wandering)
- atypical antipsychotics - ___ and ___
- boxed warning for increased risk of death or stroke in older adults with dementia

Answer 26

psychosis
repetitve
quetiapine, risperidone

Question 27

treatment of psychosis and behavioral disturbances

antidepressants
- depression common co-morbid condition in dementia
- efficacy controversial, but warranted
- ___ usually first line - avoid ___
- mirtazapine, venlafaxine, bupropion may also be considered

Answer 27

SSRIs
paroxetine

Question 28

vascular dementia

cognitive decline usually a result of vascular insult ( ___ )
- treat vacular condition, HTN, etc
- ___ inhibitors are recommended
- especially useful if mixed dementia (vascular + Alz common)

Answer 28

stroke
cholinesterase

Question 29

Lewy Bod dementia

___ cognition with variations in attention and alertness
- visual ___ common
- ___ inhibitors and ___ may be helpful
- VERY sensitive to SE of antipsychotics, may have to use at low doses ( ___ usual choice)

Answer 29

fluctuating
hallucinations
cholinesterase, memantine
quetiapine