Dementia Flashcards
Background
Dementia: An umbrella term used for symptoms such as memory loss and difficulties with thinking, problem-solving or language, which occur when the brain is affected by specific diseases and conditions.
DE-Mentia - Decline - in mental function.
Clinical presentations:
- Memory issues short and long term
- Difficulties understanding others
- Cant self regulate emptions
- Often easily upset or frustrated
- Can become fearful
- May misrepresent actions of others
Agnosia - Failure to recognise or identify objects despite intact sensory function.
Aphasia: Deterioration of language function.
Apraxia: Impaired ability to execute motor activities despite intact motor abilities, sensory function, and comprehension of the required task.
Executive functioning: The ability to think abstractly and to plan, initiate, sequence, monitors, and stop complex behaviour.
- Pharmacological Treatments improve symptoms can slow down disease progression but don’t cure.
AD (Alzheimer)
Unknown cause.
Affects 3 thing that keeps neurones healthy:
Signal communication, metabolism, repair.
Disruption causes nerve cells in brain to stop working, lose connection with other nerves eventually die. Cholinergic neurons mainly affected. (there is a decrease in ACh and its transport)
- Characterised by widespread atrophy of cerebral cortex.
Deposited amyloid plaques hyper phosphorylated tau proteins in neurons helps degeneration of neurons.
Symptoms:
Memory failure, personality change, issue with daily activity, difficulty making decisions, dysphasia, aphasia, apraxia, agnosia
Over time: anxiety, depression, insomnia, agitation, paranoia. Eventually lose all bodily function ability to walk, swallow (feeding)
Causes:
- Modifiable - poor physical and CV heath (HTN, high cholesterol etc), head injury, reduced intellect activity, obesity, insulin resistance, increase in inflammatory markers, Parkinson’s
- Non modifiable - age, gender, genetics, down syndrome
Tests: MMSE (find deficit in orientation, attention, memory, language, vision) ADAS-Cog (for screening too)
Death -= 3 years if >80. 10+<80
Treatment:
1st line AChEi monotherapy for mild to moderate
- Donepezil, galantamine, or rivastigmine
ALT Memantine
Severe
Memantine
- If already taking AChEi ADD Memantine for moderate/severe AD.
VD (vascular D)
Preventable.
Caused by ischaemic injury to brain (stroke) = lead to neuronal death. Better to diagnose early.
Signs and symptoms:
- Gait
- Attention problems
- Personality changes
- Focal neurological signs (vision issues)
Higher risk:
T2DM, HTN, stroke, hyperlipidaemia
Treatment:
Treat underlying cause:
- Antiplatelet (low dose aspirin or Clopidogrel = reduce blood clot risk and future strokes)
- Anticoagulant (warfarin, apixaban, rivaroxaban, edoxaban, or dabigatran = reduce blood clot risk and future strokes)
- HTN meds
- High cholesterol meds (statins etc)
- Diabetes meds
- SSRi (sertraline, citalopram) (reduce agitation symptoms)
- Antipsychotics Haloperidol or risperidone = aggression or extreme distress symptoms -NEED TO BE LOWEST DOSE SHORTEST TIME AND REGULAR REVIEW EVERY 6 WEEKS MINIMUM.
- AChEi/memantine used if have VD + AD/DLB/or PD dementia.
DLB (D Lewy bodies)
Lewy bodies accumulation in the brain. travel around the brain causing impairment in function.
Progressive.
Symptoms:
- Disruption in info flow in the brain mainly frontal lobe.
DLB features difference to AD:
- Changes in varying attention and alertness,
- >2 hours day time sleep,
- Staring in to the air,
- Ep of disorganised speech.
- Can have parkinsons motor features and extrapyramidal ones in early DLB (bradykinesia, resting tremor, rigidity)
Other symptoms aid diagnosis:
- Hallucinations/delusions,
- REM sleep disorders,
- Unexplained loss of consciousness
- Neuroleptic sensitivity.
Treatment
Mild to severe:
1st line Donepezil/ Rivastigmine. ALT Galantamine (mild to moderate)
ALT memantine (severe) if AChEi intolerable
- SSRi for depression in DLB
FTD (Frontotemporal D)
TDP 43 and hyper phosphorylated TAU proteins in the front and temporal lobes = dementia,
Signs and symptoms:
- Early personality and behavioural changes and aphasia (worsening language).
- Personality changes (social/sexual disinhibition)
Most common >45 yrs
Treatment
NO AChEi
- Occupational therapy,
- Speech and language therapy,
- Physiotherapy,
- Relaxation,
- Social interaction,
- Ways to deal with challenging behaviour.
DRUGs used.
- SSRIs control over eating, compulsive behaviour
- Antipsychotics (rare use) - SSRI fail then used to control challenging behaviour especially if patient as risk of harming
Doses (EXAM Q) Donepezil/Memantine more common
AChEi
Common doses:
Donepezil - initially 5mg ON increased if tolerated & needed after 1 month to MAX 10 mg daily.
Galantamine - initially 8mg caps OD 4 weeks, then 16mg OD at least 4 weeks;
- maintenance dose: 16–24 mg OD (for older tablet forms and liquid preps half the total daily dose can be given BD).
- Hepatic impairment only 8mg
Rivastigmine - Initially, 1.5mg BD, increased in steps of 1.5 mg BD at intervals of at least 2 weeks, response dependent.
- MAX 6mg BD.
Memantine
Dose - initially 5mg OD, increased in steps of 5 mg at weekly intervals to a Max of 20 mg daily.
Differs in renal impairment
Stopping AChEi/Drugs worsening dementia
Shouldn’t stop AChEi as this can worsen cognitive function
Some drugs with Antimuscranicis effects can increase cognitive impairment so use them to a minimal amount. Drugs:
- Antidepressants, Antihistamines, Antipsychotics, Urinary antimuscarinics (tolterodine, Oxybutynin, mirabegron, Tropism, solifenacin)
MHRA warning - Antipsychotics & Dementia
Pts with dementia on Antipsychotics are more at risk of stroke.
- Use lowest effective doses for shortest possible time with regular review every 6 weeks.
Only offer antipsychotics if Pts at risk of self harm, harm to others, hallucinations or delusions.
DLB or PD dementia antipsychotics can worsen motor symptom’s.
Management of cognitive/non cognitive symptoms
Cognitive symptoms management
Drugs with Antimuscranicis effects use minimal.
Avoid AChei in cognitive impairment caused by MS
NON-Cognitive symptoms impairment
Agitation, aggression, distress and psychosis
- Psychosocial/environmental interventions
- Antipsychotics only used if they at risk (mention in previous flash card) BUT In DLB or PD Dementia antipsychotics can worsen motor function.
Depression and anxiety
- Psychological treatment
Sleep disturbances
- Non pharmacological treatments
