45 - Neurocognitive Disorders: Dementia Flashcards
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
acquired
decline
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
- modest
- independence
- delirium
major neurocognitive disorders
- ___ cognitive decline from a previous level of performance in one or more cognitive domains
- interferes with ___
- not attributed to ___ episode
- significant
- independence
- delirium
donepezil (Aricept)
initiate
neurocognitive domains
complex attention
sustained/divided attention, processing speed
neurocognitive domains
learning and memory
immediate/recent memory, very long term memory
neurocognitive domains
perceptual/motor
visual perception/praxis
neurocognitive domains
executive function
planning, decision-mking, working memory, flexibility
neurocognitive domains
language
expressive and receptive language (naming, word finding)
neurocognitive domains
social cognition
recognition of emotions, range of behavior
reversible cognitive decline
“reversible labs”
- B12 or folate
- hypothyroidism
- CBC
- electrolytes
- LFT
- infection (UTI)
- depression
- RPR/VDRL -syphilis
Drug induced cognitive impairment
concerned with ACB score of ___ or ___
most frequent
- muscle ___
- ___ antidepressants
- bladder ___
- anti ___ (OTC allergy/cough cold)
- RX anti- ___
2, 3
- relaxants
- tricyclic
- antispasmodics
- histamines
- emetics
dementia course by type
Which is which line? Alzheimer’s, vascular, Lewy Body
red = Alz
yellow = vascular
blue = Lewy Body
rating scales
MMSE - used to assess cognitive function (out of 30)
change in ___ - ___ points over 1 year period indicated significant decline
3-4
perfect score = 3-
mild: 26-18
mod: 17-10
severe: 9-0
rating scales
ADAS
- assess severity and dysfunction in cognitive and ___ behaviors over time
- used by FDA
- 0-70 (higher scores = worse cognitive performance)
non-cognitive
rating scales
MoCA- ___ differentiates mild cognitive impairment
- visuospatial/exective attention, language, abstraction, orientation tests
- 30 point total score (higher scores better)
better
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)
donepezil
donepezil, rivastigmine, galantamine
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)
neurodegeneration
mild
memantine
donepezil/memantine
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
5, 10, 23 mg
2D6, 3A4
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
twice, breakfast, dinner
16
2D6, 3A4
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
BID, meals
N/V/D
esophageal
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
IR
BID
seizure
carbonic anhydrase, bicarb
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
7 mg
meals
vagotonic
___ targets the N-terminus of AB
- different antibodies work at different parts of AB
aducanumab
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
aducanumab, lecanemab
amyloid beta
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
psychosis
repetitve
quetiapine, risperidone
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
SSRIs
paroxetine
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)
stroke
cholinesterase
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)
fluctuating
hallucinations
cholinesterase, memantine
quetiapine
