Dementia Flashcards
What are the various types of dementia and frequencies?
- Alzheimer’s 60-80% (May be up to 85%)
- Lewy Body Dementia 5-10%
- Vascular Dementia 5-10%
- Frontotemporal Dementia 5-10%
- Others: Parkinson’s, Huntington’s
*May have mixed dementias
What are possible etiologies of memory loss?
- Neurodegenerative causes
- Secondary causes: depression, medications (anticholinergic side effects), multiple comorbidities
What is mild cognitive impairment?
Not part of normal aging
-Deficit in 1 of 4 areas of cognition (language, spacial ability, learning/memory, executive control)
- S/S: memory complaints, abnormal memory for age, no functional disability, normal general cognitive function
- Increases risk for developing AD
What are some examples of cognitive Impairment screening tools?
-Mini-Mental Status Exam (MMSE): Standardized, well-studied, tracks progress and decline, quantifies cognitive function 30 Components Scoring: 22-24: Mild 15-21: Moderate <15: Severe
Mini-Cog:
Uncued 3-item recall test with clock-drawing test (CDT)
What follow-up is required for positive screens for cognitive impairment?
Refer for neurological evaluation
Refer for neuropsychological evaluation
Diagnostic imaging and labs
What would signify a non-AD dementia diagnosis?
- Rapid onset
- Rapid progression
- Non-memory presentation
- Onset <50yo
Lewy Body Dementia
Characteristics
-Late-onset (75-80yo)
-Fluctuating cognitive impairment, recurrent visual hallucinations, parkinsonism, depression
Duration: 6 years
Dementia
Diagnostic Tests
Imaging and Labs
Structural neuroimaging: non-contrast CT or MRI
Screen for depression, B12 deficiency, hypothyroidism
Genetic markers not approvied
Alzheimer’s Disease
Characteristics
- Progressive, neurodegenerative disorder
- Average life span following diagnosis depends on age at dx, typically 7-10 years
- Amnesia, aphasia, apraxia, agnosia
- Difficulty with memory, recall, language, psychomotor function.
- Personality changes, irritability, hallucinations, agitation
- Incontinence, dysphagia
Alzheimer’s Disease
Etiology
Etiology unknown:
Amyloid Hypothesis: Abnormal processing of amyloid precursor protein (APP), increases in beta-amyloid creates plaques
Alzheimer’s Disease
Risk Factors
- Cardiovascular disease: heart disease
- Increased homocysteine levels
- APOE-e4 (cholesterol carrying protein) susceptibility gene for AD, affects age of onset of disease
- Aging
- Genetics
- Female gender
- Possibly depression
- Possible hypothyroidism
Screening for Depression in Older Adults with dementia considerations
Screen older adults using
- Single question
- Geriatric depression scale (GDS)
- Cornell Depression in Dementia Scale
What is the BEERS list?
- Meds to avoid in patients >65yo
- Anticholinergics
- Some may induce dementia like symptoms - decreased cognitive function
Vascular Dementia
Criteria/Characteristics
- Evidence of 2 or more strokes by history, neurologic signs, or imaging or single stroke with a clear temporal relationship to onset of dementia
- Evidence of at least 1 infarct outside the cerebellum by CT or T1-weighted MRI
Silent brain infarcts increase risk
Neuropsychological testing for dementia/cognitive impairment
- Aphasia: Ability to understand or express speech
- Agnosia: Ability to interpret sensations and recognize things. Spacial abilities, change in visual perception
- Learning and memory: MMSE, Recall
- Executive function: ability to organize, attention, concentration
Apraxia: Ability to act our intentions psychomotor speed, seen later
Alzheimer’s Disease
Diagnosis
Imaging and Labs
- Rule out other causes. CT (brain injury, tumor, stroke), MRI (cerebral atrophy)
- MRI without contrast typical for diagnosis
PET scans more detailed, hard to get approved by insurance (FDG or Amyloid)
Amyloid PET Scan
AD
- Measures beta-amyloid deposits.
- High levels of beta-amyloid are associated with beta-amyloid plaques.
Tau PET Scan
AD
Identifies abnormal distribution of tau/Neurofibrillary Tangles (NFTs)
FDG PET Scan
AD
Visualization of glucose uptake in brain
Can be abnormal in certain areas with AD
Alzheimer’s Disease
Pharmacological Management
- Cholinesterase inhibitors (AChEIs)
- NMDA-receptor antagonists
- Disease modifying therapies (DMTs)
- Immunizations on the horizon
- Atypical antipsychotics
- SSRIs
Cholinesterase inhibitors (AChEIs) Indications/Considerations
- Tx of mild, mod, severe AD dementia
- Prevents AChE from breaking down into acetylcholine
- Slows progression
- May improve functional performance, slow rate of cog and behavioral decline
- Cannot stop med, patient will decline
- May d/c if side effects do not resolve, n/v/d, vivid dreams (try to take in AM), poor adherence to tx, hospice care
Cholinesterase inhibitors (AChEIs) Examples
- donepezil (Aricept)
- rivastigmine (Exelon)
- galantamine (Razadyne ER, Razadyne)
NMDA-receptor antagonist
Examples
-memantine (Namenda)
NMDA-receptor antagonist
Indications/Considerations
- Increased amount of glutamate available in the brain in AD
- Glutamate major neuroexcitatory neurotransmitter
- Blocks glutamate from accessing NMDA receptors, preventing excessive calcium from entering cells and causing damage.
- Slows progression
- Mod to severe dementia
- Continue for life
Dementia -
Primary care management
- Lifestyle changes: Nutrition, exercise, cognitive training, social activity
- Intensive monitoring and management of metabolic and vascular risk
- Regular assessment/reassessment of cognitive status, caregiver burden, stage-based approach, encourage structured environment, refer to community resources
Mild cognitive impairment -
Primary care management
- Fitness for driving: MMSE >24 fitness for driving, refer for handicap driving evaluation if borderline
- Depression screening
- Monitor functional and cognitive status
- Safety screen: firearms, caregiver, home setup
- Advance Care Planning
Early Stage Dementia -
Primary care management
- Depression screen
- Fitness for driving
- Safety screen
- Monitor functional and cognitive status
- Advance Care Planning
- Caregiver burden
Moderate to Severe Dementia
Primary Care Management
- Behavioral and psychological symptoms of dementia (BPSD): sleep-cycle, sun-downing, wandering, unsafe behaviors
- Dysphagia
- Caregiver burden
Dementia
Education/HP
- AD not normal part of aging
- Progressive brain disease
- Cannot predict prognosis, varies greatly
- Medications may slow progression or manage symptoms, no cure
Role of Ginkgo Biloba in dementia treatment?
Do not recommend. No measurable benefit.
Parkinson’s Disease
Characteristics
- Akinetic movement disorder
- Associated with basal ganglia dysfunction, Lewy bodies, and degeneration of the substantia nigral dopaminergic neurons
- S/S: Depression, anxiety, hallucinations, apathy
BEERs List
Anticholinergics
Anticholinergics:
- First Gen Antihistamines
- Antiparkinsonian Agents
- Antispasmodics
BEERS List
Antithrombotics
-dipyridamole
BEERS List
Anti-infective
-Nitrofurantoin
BEERS list
CV
-Peripheral alpha-1 blockers (doxazosin, prazosin, terasozin)
Central alpha-agonists (clonidine as first-line)
- Dysopyramidde
- Dronedarone
- Digoxin (as first-line)
- Nifedipine (hypotension)
- Amiodarone (as first-line)
BEERS List
CNS Agents
Antidepressants
-TCA, MAOIs (highly anticholinergic)
Antipsychotics
Barbiturates
Benzos
Meprobamate
Z-Drugs: Hypnotics
BEERS List
Endocrine Agents
- Androgens
- Desiccated thyroid
- Estrogens w/o progesterone
- Growth hormone
- Insulin, short or rapid
- Megestrol
- Sulfonylureas
BEERS List
GI Agents
- Metoclopramide (EPS SEs)
- Mineral oil
- PPIs (C. diff risk, bone loss, fractures)
BEERS List
Pain Meds
- Meperidine (delirium)
- Non-cyclooxygenase-selective NSAIDs (aspirin, ketoprofen, ibuprofen, naproxen - r/f ulcers, bleeding, CV risk)
- Indomethacin, ketorolac (bleeding, ulcer)
- Skeletal muscle relaxants
BEERS List
GU
Desmopressin (hyponatremia)
