Dementia Flashcards
According to DSM-5, what is major neurocognitive disorder?
A) Evidence of significant cognitive decline from prior level (comparison to baseline:
- Concern of the individual, a knowledgeable informant or the clinician there has been significant decline in cognitive function (no awareness)
- A substantial impairment in cognitive performance preferably documented by standardized neuropsychological testing or in its absence other quantified clinical assessment
B) The cognitive deficits interfere with independence in everyday activities
C) The cognitive deficits do not occur exclusively in context of delirium -> exclude out delirium/ mental disorder (transient episodes of disoriented)
D) The cognitive deficits are not better explained by another mental disorder -> exclude out delirium/ mental disordder (transient episodes of disoriented)
According to DSM-5, what is minor neurocognitive disorder?
A) Evidence of modest cognitive decline from prior level of performance in one or more cognitive domains (complex attention, executive function, learning & memory, language, perceptual-motor or social cognition:
- Concern of the individual, a knowledgeable informant or the clinician there has been mild decline in cognitive function
- A modest impairment in cognitive performance preferably documented by standardized neuropsychological testing or in its absence other quantified clinical assessment
B) The cognitive deficits interfere with independence in everyday activities
C) The cognitive deficits do not occur exclusively in the context of delirium
D) The cognitive deficits are not better explained by another mental disorder
Which areas are manifestations of dementia?
Cognitive, psychological, behavioural, sleep, physical
What is the earliest manifestation of dementia?
Cognitive - ST memory loss
What are the stages of AD according to MMSE scores?
Mild: 20-24
Moderate: 10-19
Severe: <10
What are the different types of dementia?
Alzheimer’s Disease
Vascular dementa
Lew body dementia
Frontotemporal Dementia
Mixed type
What are hallmarks of AD?
Neuritic plagues containing B-amyloid and neutrofibrillary tangles containing phosphorylated tau
What are non modifiable RF for AD?
Age
Female
Black, Hispanic
Genetics: apolipoprotein E (APOE4)
What are modifiable RF for AD?
HTN
Diabetes
Binge drinking
Smoking
Limited physical activities
Obesity
Hearing loss
Depression
What is done to clinically evaluate suspected dementia?
- Medical Hx from family
- Cognitive exam eg. MOCA
- Medical Hx eg. family, medicines
- Physical exam
- Neuropsychological testing
- Lab testing: check thyroid func and B12 lvls
- CT/MRI
What brief cognitive screening tool is used?
MMSE
How does MoCA scores relate to cognitive impairment?
Mild: 18-25
Moderate: 10-17
Severe: <10
What pharm tx classes for AD?
Anticholinesterase inhibitors
NMDA RA
Examples of NMDA
Mementine
Examples of anticholinesterase inhibitors
Donepzil, rivastigmine
MOA of acetylcholinesterase inhibitor
Inhibit acetylcholinesterase enzyme - thereby promoting relative increases in acetylcholine abundance at the synaptic cleft for cholinergic neurotransmission
How should acetylcholinesterase inhibitors be titrated?
Slow-titration dosing regimen over 4 to 8 weeks is recommended to reach the target dose and minimize adverse effects
If adverse effects encountered, lower dosage temporarily (eg, days to weeks) before reescalating more slowly and monitoring for recurrence of adverse effects
Alternatively, the drug can be discontinued and a different AI
How to monitor efficacy of acetylcholinesterase inhibitor?
A good response would result in the caregiver noticing a slight improvement in day-to-day life (eg, improved ability to function at home)
Routine cognitive tests (e.g. such as the MoCA)
When is memantine considered?
Mod-sev dementia (switch therapy or 1st line in new diagnosis)
For pts who cant tolerate AI
How to monitor efficacy of memantine
Caregiver feedback: improvement in day-to-day life activities (eg, improved ability to function at home)
Routine cognitive tests (e.g. such as the MoCA)
Dose of donepezil
Start: 5mg/day for 6wk
If tolerated: 10mg/day
Max: 23mg/day
SE of donepezil and what to caution/CI
N/V, loss appetite, incr bowel movement, vivid dreams, insomnia
Caution in seizures, PUD
CI in bradycardia
Which AD drugs comes in a patch?
Rivastigmine - transdermal patch
What is memantine dose?
Start: 5mg/day for 1 wk
If tolerated: 5mg BD then 5mg OM and 10mg ON then 10mg BD at 1wk intervals
Target: 10mg BD
SE of memantine
headache, constipation, confusion, dizziness
SE of rivastigmine
N/V, loss of appetite, incr bowel freq, vivid dreams, insomnia
patch: local skin rxn
What other consideration relating to pt can be considered?
- Reduce polypharmacy (take out drugs they dont need)
- Review medications that may contribute to cognitive impairment eg. antihistamine -> anticholinergic effect
- Assist caregiver on medication management issues
e.g. simplify medication regimen, arrangement for medication refill (TDS -> BD? XR?, arrange delivery services)
-Evaluate risk/benefit of existing medications (e.g. antithrombotics)
What non pharm approaches?
- Cognitively stimulating activities (eg, reading, games)
- Physical exercise (eg, aerobic and anaerobic)
- Social interactions with others (eg, family events)
- Healthy diet such as the Mediterranean diet (eg, high in green leafy vegetables)
- Adequate sleep (eg, uninterrupted sleep and with sufficient number of hours)
- Proper personal hygiene (eg, regular bathing)
- Safety, including inside the home (eg, using kitchen appliances) and outside (eg, driving)
- Medical and advanced care directives (eg, designation of power of attorney)
- Long-term health care planning (eg, for living arrangements in the late stage of dementia)
- Financial planning (eg, for allocation of assets)
- Effective communication (eg, for expressing needs and desires, such as with visual aids)
- Psychological health (eg, participating in personally meaningful activities, such as playing music)
What is BPSD
spectrum of non-cognitive and non-neurological symptoms of dementia, such as agitation, aggression, psychosis, depression and apathy.
What are the first BPSD smx of dementia
Depression and anxiety
while agitation and aggression more commonly occur later, especially as the person’s ability to communicate and influence their environment diminishes.
What is 1st line approach for BPSD smx?
Non-pharm
How would agitation and aggression present in AD
Verbal: complaining, moaning, angry statements
Physical: resisting carers, restlessness, spitting, hitting
Non pharm for agitation and aggression
May be due to underlying depression, unmet needs, boredom, discomfort, perceived threat or violation of personal space.
- Make environmental or management modifications to resolve these issues.
- Non-specific calming and positive experience interventions may be beneficial such as music or touch therapy, e.g. hand massage, a mechanical pet or a twiddle muff (sleeve or glove with attached materials, buttons, etc, for sensory stimulation).
How would depression present in AD?
Sadness, pessimistic thoughts, withdrawal, inactivity, fatigue
Non pharm for depression
Recommend exercise, social connection and engaging activities. Cognitive behavioural therapy (CBT) may be helpful in early stages.
Severe depression: refer
How would anxiety present in AD?
Exaggerated response to separation from family, different settings or reduce capacity to make sense of env.
Non pharm for anxiety
Focus on identifying and eliminating the trigger, rather than symptom control. Maintain structure and routine and reduce the need for stressful decision- making. Assess if sensory overstimulation may be contributing. Music and CBT have the greatest amount of evidence showing benefit.
How would apathy present in AD?
Lack of initiative, motivation, reduce emotional response
Reduced motivation can be a feature of depression, but a pure apathy syndrome can be distinguished from depression by the absence of sadness and other signs of psychological distress..
Non pharm for apathy
Reading to the person and encouraging them to ask questions, small group and individual activities, e.g. puzzles, games, sensory stories may all be helpful. Music, exercise, multi- sensory stimulation with touch, smell and sound, and spending time with pets can also be effective. The key is to provide enriched prompts and cues to overcome the apathy and generate positive behaviour.
How would psychotic smx present in AD?
Delusions, hallucinations
In dementia, delusions are usually reflective of the underlying memory loss or changes in perception, e.g. accusation of theft of personal items, infidelity of a spouse or that family members are imposters, rather than delusions normally associated with mania or schizophrenia. Vivid visual hallucinations are common, particularly in Lewy Body dementia, but auditory hallucinations are less common
Non pharm for psychotic smx
Confirm that the patient’s claims are not occurring, e.g. items are not being stolen. Use memory aids, e.g. photographs to cue the person to reality. Distraction can sometimes be effective.
How would wandering present in AD?
Wandering may be circular, pacing between two points, random or direct to a location without diversion.
Non pharm for wandering smx
Wandering can have positive effects via exercise, e.g. improving sleep, mood and general health, and may prevent the person from feeling confined. Consider how to make wandering safe; supervised walks, secured space to roam, exercise equipment, GPS watch. Try to determine if there is a purpose to the wandering, e.g. trying to return home, looking for a person, escaping a perceived threat.
How would nocturnal disruptions present in AD
Sleep disturbance can occur secondary to depression, anxiety, agitation or pain and may cause other BPSD to be exacerbated at night, e.g. wandering. Occurs more frequently in people with Lewy Body dementia. Sundowning, i.e. increased agitation in the late afternoon, is also common.
Non pharm for nocturnal disruptions
Assess for underlying cause, including thirst or hunger. Restrict caffeine in the evening, limit fluid intake in the hours before bed, establish a night-time routine, minimise light and noise intrusion, ensure adequate stimulating activities during daytime
What medications can contribute to BPSD
- Medicines with Anticholinergic actions
- Systemic CS
- Anticonvulsants
- Medicines with sedative action
- Anti parkinsonian meds
What medical conditions contribute to BPSD
Delirium
Untreated pain
Constipation or urinary impairment
Fatigue
Hearing/visual impairment
Depression
Anxiety
Dehydration
What environmental or social factors contribute to BPSD
Unfamiliar env
Separation
Noise
Crowding
Loneliness
Is pharm tx effective for BPSD
Pharmacological interventions have a limited role in the management of BPSD – consider adverse effects and indication for use
If medicines for BPSD are use, what to take note of?
- Prescribed for target symptoms or behaviours for which there is evidence of effectiveness, i.e. they should not be used for other indications or to sedate patients who are difficult to manage
- Only considered once potentially reversible causes have been excluded and non-pharmacological interventions have been trialled; unless there is an immediate risk to the patient or others, or the patient is very severely distressed
- Always used in combination with non-pharmacological interventions
How long should pharm tx be for BPSD smx
Routinely withdrawn, slowly, after three months of improved symptoms unless symptoms were severe or due to a co-morbid psychiatric disorder, e.g. bipolar disorder or major depression
Re-started at the lowest effective dose, if symptoms return following a withdrawal, and schedule a further trial withdrawal in three to six months
What pharm tx can be given for depression and anxiety in AD
SSRIs - citalopram
Consider dose-dependent risk of increased QT prolongation and worsening cognition
Should TCAs be given to pts with dementia?
No. anticholinergic effects may further disrupt cognition
Can antipsychotic be given to pts with BPSD?
Only appropriate for patients with BPSD if aggression, agitation or psychotic symptoms are causing severe distress or an immediate risk of harm to the patient or others or if the patient has a pre-existing, co-morbid mental illness where antipsychotics are indicated.
Only modestly effective in managing BPSD, and the level of effectiveness varies between patients
Unlikely to be beneficial for wandering, calling out, social withdrawal or inappropriate sexualised behaviour in people with dementia
Less likely to be effective for intermittent but challenging behaviours that are closely related to clear environmental triggers (non-pharm rather than antipsychotic), e.g. aggression that only occurs during personal cares.
What concerns are there in given antipsychotics to pt with AD
Increased risk of stroke, cardiovascular events and excess mortality over a relatively short time frame (esp older ppl w dementia).
What is most common cause of death in elderly taking antipsychotic meds
Pneumonia
Stroke
Cardiac arrest
