Demencia Flashcards
Quais as tres principais perguntas em doentes com demencia?
Three major issues should be kept at the forefront: (1) What is the most accurate diagnosis? (2) Is there a treatable or reversible component to the dementia? (3) Can the physician help to alleviate the burden on caregivers?
Qual deve ser a avaliação cognitiva da demencia?
(1) Brief screening tools such as the minimental status examination (MMSE) help to confirm the presence of cognitive impairment and to follow the progression of dementia. When the etiology for the dementia syndrome remains in doubt, a specially tailored evaluation should be performed that includes tasks of working and episodic memory executive function, language, and visuospatial and perceptual abilities.
(2) A functional assessment should also be performed. The physician should determine the day-to-day impact of the disorder on the patient’s memory, community affairs, hobbies, judgment, dressing, and eating. Knowledge of the patient’s day-to-day function will help the clinician and the family to organize a therapeutic approach.
(3) Psychiatric symptoms such as depression, anxiety, delusions, disinhibition, or apathy.
Quais exames complementares devemos solicitar em toda síndrome demencial?
The American Academy of Neurology recommends the routine measurement of thyroid function, a vitamin B12 level, and a neuroimaging study (CT or MRI).
Quais os padrões da RM de crânio nas principais demencias?
They also help to establish a regional pattern of atrophy. Support for the diagnosis of AD includes hippocampal atrophy in addition to posterior-predominant cortical atrophy. Focal frontal and/or anterior temporal atrophy suggests FTD. DLB often features less prominent atrophy, with greater involvement of amygdala than hippocampus. In CJD, MR diffusion-weighted imaging reveals abnormalities in the cortical ribbon and basal ganglia in the majority of patients. Extensive white matter abnormalities correlate with a vascular etiology for dementia.
Quais as medidas não farmacológicas para demencia de Alzheimer?
(1) In the early stages of AD, memory aids such as notebooks and posted daily reminders can be helpful. (2) Family members should emphasize activities that are pleasant and curtail those that are unpleasant. In other words, practicing skills that have become difficult, such as through memory games and puzzles, will often frustrate and depress the patient without proven benefits. Preparing lists, schedules, calendars, and labels can be helpful in the early stages. It is also useful to stress familiar routines, short-term tasks, walks, and simple physical exercises. For many demented patients, memory for events is worse than for routine activities, and they may still be able to take part in physical activities such as walking, bowling, dancing, and golf. Providing activities that are known to be enjoyable to the patient can be of considerable benefit
(3) Kitchens, bathrooms, stairways, and bedrooms need to be made safe, and eventually patients must stop driving. Demented patients usually object to losing control over familiar tasks such as driving, cooking, and handling finances
(4) Loss of independence and change of environment may worsen confusion, agitation, and anger. Communication and repeated calm reassurance are necessary. A move to a retirement home, assisted-living center, or nursing home can initially increase confusion and agitation.
(5) A proactive strategy has been shown to reduce the occurrence of delirium in hospitalized patients. This strategy includes frequent orientation, cognitive activities, sleep-enhancement measures, vision and hearing aids, and correction of dehydration
Como lidar com o estresse do cuidador na doença de Alzheimer?
Caregiver “burnout” is common, often resulting in (1)nursing home placement of the patient or new health problems for the caregiver, and respite breaks for the caregiver help to maintain a successful long-term therapeutic milieu. (2) Use of adult day care centers can be helpful. Caregivers should be encouraged to take advantage of day-care facilities and respite breaks. (3) Local and national support groups, such as the Alzheimer’s Association and the Family Caregiver Alliance, are valuable resources. Internet access to these resources has become available to clinicians and families in recent years. Education and counseling about dementia are important. Local and national support groups, such as the Alzheimer’s Association (www.alz.org), can provide considerable help
Quais as medidas farmacológicas na doença de Alzheimer?
The average patient on an anticholinesterase compound maintains his or her MMSE score for close to a year, whereas a placebo-treated patient declines 2–3 points over the same time period.
(1) Donepezil (target dose, 10 mg daily), rivastigmine (target dose, 6 mg twice daily or 9.5-mg patch daily), galantamine (target dose 24 mg daily, extended-release), memantine (target dose, 10 mg twice daily), and tacrine are the drugs presently approved by the Food and Drug Administration (FDA) for treatment of AD. Due to hepatotoxicity, tacrine is no longer used. Dose escalations for each of these medications must be carried out over 4–6 weeks to minimize side effects. Cholinesterase inhibitors are relatively easy to administer, and their major side effects are gastrointestinal symptoms (nausea, diarrhea, cramps), altered sleep with unpleasant or vivid dreams, bradycardia (usually benign), and muscle cramps.
(2) Memantine appears to act by blocking overexcited N-methyl-D-aspartate (NMDA) glutamate receptors. Double-blind, placebo-controlled, crossover studies with cholinesterase inhibitors and memantine have shown them to be associated with improved caregiver ratings of patients’ functioning and with an apparent decreased rate of decline in cognitive test scores over periods of up to 3 years
(3) Mild to moderate depression is common in the early stages of AD and may respond to antidepressants or cholinesterase inhibitors. Selective serotonin reuptake inhibitors (SSRIs) are commonly used due to their low anticholinergic side effects (escitalopram 5–10 mg daily). Agitation, insomnia, hallucinations, and belligerence are especially troublesome characteristics of some AD patients, and these behaviors can lead to nursing home placement. Before treating these behaviors with medications, the clinician should aggressively seek out modifiable environmental or metabolic factors. Hunger, lack of exercise, toothache, constipation, urinary tract infection, or drug toxicity all represent easily correctable causes that can be remedied without psychoactive drugs. Sometimes apathy, visual hallucinations, depression, and other psychiatric symptoms respond to the cholinesterase inhibitors, especially in DLB, obviating the need for other more toxic therapies. The newer generation of atypical antipsychotics, such as risperidone, quetiapine (starting dose, 12.5–25 mg daily), and olanzapine, are being used in low doses to treat these neuropsychiatric symptoms.
(4) Finally, medications with strong anticholinergic effects should be vigilantly avoided, including prescription and over-the-counter sleep aids (e.g., diphenhydramine) or incontinence therapies (e.g., oxybutynin).
Quais as principais causas de demencia reversíveis (10% dos casos)?
The major goals of dementia management are to treat correctable causes and to provide comfort and support to the patient and caregivers. Treatment of underlying causes might include thyroid replacement for hypothyroidism; vitamin therapy for thiamine or B12 deficiency or for elevated serum homocysteine; antimicrobials for opportunistic infections or antiretrovirals for HIV; ventricular shunting for NPH; or appropriate surgical, radiation, and/or chemotherapeutic treatment for CNS neoplasms. Removal of cognition-impairing drugs or medications is the most frequently useful approach employed in a dementia clinic
