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444 final > Cognitive Impairment 3 > Flashcards

Cognitive Impairment 3 Flashcards

1
Q

lecanemab trial

A
  • N=1795, 235 sites
  • Intervention: Lecanemab 10 mg IV biweekly vs Placebo
  • Primary endpoint: Change in Clinical Dementia Rating Sum of Boxes
    (CDR-SB) at 18 months
  • Global cognitive and functional scale
  • Lecanemab = 1.21
  • Placebo = 1.66
  • Secondary endpoints:
  • Change in amyloid PET
  • Approximately 7.5 months slower decline
  • 27% decrease in clinical decline at 18 months
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2
Q

CDR-SB

A

ok

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3
Q

Mild Cognitive Impairment

A
  • DSM-V = mild neurocognitive disorder
  • “pre-dementia”, not necessarily progressing
  • Criteria: not normal, not demented
  • Evidence: AChE-I is harmful; no pharmacotherapy indicated
  • Focus on exercise, cog training, planning
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4
Q

Vascular Dementia

A
  • Most common type of non-Alzheimer Dementia
  • Associated with vascular risk factors
  • Presentation
  • Dependent on area of brain affected
  • Changes may occur suddenly
  • Prevention
  • Treat CV risk factors
  • Treatment
  • Focus on CV risks
  • CI or Memantine studied but not labelled
  • Questionable benefit if no AD component
  • Not covered by ABC
  • Evidence may have come from mixed dementia patients
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5
Q

Contrasting VaD with AD

A

Characteristic Vascular Dementia Alzheimer Disease
Onset
Sudden or gradual Gradual

Progression
Slow, stepwise Constant insidious decline

Neurological findings
Evidence of focal deficits Subtle or absent

Memory
Mildly affected Early and severe

Executive function
Early and severe Late

Dementia type
Subcortical Cortical

Neuroimaging
Infarcts, white matter lesions Atrophy (hippocampus)

Gait
Often disturbed early Usually normal

Cardiovascular history
TIA, stroke, vascular risk factors
Less common

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6
Q

Lewy Body Dementia
Parkinson Disease Dementia

A

Pathophysiology
* Lewy bodies deposited, leading to disruption in the substantia nigra and the cerebral cortex
* Neurotransmitter alterations
Differentiating
* Duration of parkinsonism in relation to dementia
Core features
* Fluctuations in cognition
* Visual hallucinations
* Parkinsonism
Treatment
* Evidence with rivastigmine
* Labelled for use
* Other CI?
Precaution
* Exquisite sensitivity to neuroleptics

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7
Q

Frontal Dementia
Etiology/Pathophysiology

A

Epidemiology
* 12% of dementias in subjects <65 years
* 5-20% of all dementias
Etiology/Pathophysiology
* Genetics (e.g. Chromosomes 15, 17)
* Mutation in tau proteins
* hyperphosphorylation leads to disruption in the frontal lobes
* Neurotransmitter abnormalities
* Deficit in serotonin

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8
Q

Frontal Dementia
Core diagnostic features

A

Core diagnostic features
* Insidious onset, gradual progression
* Early decline in social interpersonal conduct
* Early impairment of personal conduct
* Early emotional blunting
* Early loss of insight
* Many subtypes

Presentation
* Insidious
* Behavioural changes
* Personality change
* Social incompetence
* Stereotypic ritualistic behaviour
* Extrapyramidal features may
emerge
* Memory and visuo-spatial skills
preserved

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9
Q

Frontal Dementia
tx

A

Treatment
* Caregiver support
* SSRI
* Multiple studies, trends in benefit, small sample size
* AChE-I, memantine – no benefit

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10
Q

Monitoring

A
  • Serial measures
  • Cognition (e.g. MMSE, SLUMS)
  • Function (ADL)
  • Behaviour/mood
  • Caregiver reports
  • Specific goals
  • Safety
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11
Q

Ethical Issues in Dementia

A
  • Lying
  • Disclosure of diagnosis
  • Participation in research
  • Decision making
  • Quality of life
  • Behavioural control – restraints
  • Voting
  • Driving
  • Incarceration
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12
Q

Safety Concerns

A
  • Driving
  • Guns/weapons
  • Living/being left alone
  • Finances and risk of abuse
  • Use of MedicAlert, GPS monitoring, wandering registries
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13
Q

Drug Therapy Management

A
  • Challenges in
  • Assessment
  • E.g. pain – perception
  • Validation of tools
  • Risks of treatment
  • E.g. hypoglycemia with DM treatments
  • Adherence
  • Regimen complexity
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14
Q

Behavioural and Psychological Symptoms of
Dementia (BPSD)

A
  • Alternate terms
  • Neuropsychiatric symptoms (NPS)
  • Responsive behaviours
  • Epidemiology
  • Over the course of disease 98% of patients will have at least 1 form of BPSD
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15
Q

BPSD Classification

A
  • Aggression
  • aggressive resistance, physical aggression, and verbal aggression
  • Apathy
  • withdrawn, lack of interest, amotivation
  • Depression
  • sad, tearful, hopeless, low self-esteem, anxiety, guilt
  • Agitation
  • walking aimlessly, pacing, trailing, restlessness, repetitive actions,
    dressing/undressing, sleep disturbance
  • Psychosis
  • hallucinations, misidentifications, delusion
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16
Q

BPSD - Assessment

A
  • Antecedent
  • Behaviour
  • Consequence
17
Q

BPSD – Non-pharmacologic

A
  • Diverting attention:
  • music therapy, pet therapy, social events
  • Environment:
  • calendars, clocks, family objects, photographs, background noise, music, lighting,
    creating a safe wandering environment
  • Scheduling, routines
  • Sensory practices
  • aromatherapy, massage, multi-sensory stimulation
  • Psychosocial practices
  • validation therapy (vs confrontation), reminiscence therapy, music therapy, pet
    therapy, meaningful activities)
  • Structured care protocols
  • bathing, mouth care
    “Most practices are acceptable, have no harmful effects, and require minimal to
    moderate investment.” - Scales, et al, 2018
18
Q

BPSD - Interventions

A

bottom line: several nondrug and drug interven reduce aggression & agitation compared w usual care or modifcation of AODL

19
Q

BPSD – Prevention/Treatment
Non-pharmacologic

A

ok

20
Q

BPSD - Pharmacotherapy

A
  • Risperidone is the only medication labelled for BPSD in Canada
  • Treatment algorithm implementation in Canada
  • Green = high rating
  • Yellow = intermediate
  • Red = poor
21
Q

BPSD – Pharmacologic Treatment
continued

A
  • Labeled for BPSD in Canada
  • Risperidone 0.25 mg BID
  • Other medications with supportive evidence
  • Antipsychotics – Quetiapine 12.5 mg HS
  • Cholinesterase inhibitors
  • Memantine
  • Serotonergic agents (SSRI)
  • Anticonvulsant – Carbamazepine
  • Medications with evidence of no benefit
  • Divalproex
  • Benzodiazepines (?)
  • Safety Concerns with Antipsychotics
  • Antipsychotic trials found absolute mortality increase of 1.2% (2.3 vs 3.5%)
  • relative increase of 60% over 3 months
  • Warnings from FDA, Health Canada
  • Initiative in the US (2012) – target reduced antipsychotic use in LTCF

444 final (16 decks)

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