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PR3153: Central Nervous System > Dementia > Flashcards

Dementia Flashcards

1
Q

According to DSM-5, what is major neurocognitive disorder?

A

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)

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2
Q

According to DSM-5, what is minor neurocognitive disorder?

A

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

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3
Q

Which areas are manifestations of dementia?

A

Cognitive, psychological, behavioural, sleep, physical

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4
Q

What is the earliest manifestation of dementia?

A

Cognitive - ST memory loss

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5
Q

What are the stages of AD according to MMSE scores?

A

Mild: 20-24
Moderate: 10-19
Severe: <10

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6
Q

What are the different types of dementia?

A

Alzheimer’s Disease
Vascular dementa
Lew body dementia
Frontotemporal Dementia
Mixed type

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7
Q

What are hallmarks of AD?

A

Neuritic plagues containing B-amyloid and neutrofibrillary tangles containing phosphorylated tau

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8
Q

What are non modifiable RF for AD?

A

Age
Female
Black, Hispanic
Genetics: apolipoprotein E (APOE4)

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9
Q

What are modifiable RF for AD?

A

HTN
Diabetes
Binge drinking
Smoking
Limited physical activities
Obesity
Hearing loss
Depression

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10
Q

What is done to clinically evaluate suspected dementia?

A
  • 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
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11
Q

What brief cognitive screening tool is used?

A

MMSE

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12
Q

How does MoCA scores relate to cognitive impairment?

A

Mild: 18-25
Moderate: 10-17
Severe: <10

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13
Q

What pharm tx classes for AD?

A

Anticholinesterase inhibitors
NMDA RA

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14
Q

Examples of NMDA

A

Mementine

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15
Q

Examples of anticholinesterase inhibitors

A

Donepzil, rivastigmine

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16
Q

MOA of acetylcholinesterase inhibitor

A

Inhibit acetylcholinesterase enzyme - thereby promoting relative increases in acetylcholine abundance at the synaptic cleft for cholinergic neurotransmission

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17
Q

How should acetylcholinesterase inhibitors be titrated?

A

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

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18
Q

How to monitor efficacy of acetylcholinesterase inhibitor?

A

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)

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19
Q

When is memantine considered?

A

Mod-sev dementia (switch therapy or 1st line in new diagnosis)

For pts who cant tolerate AI

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20
Q

How to monitor efficacy of memantine

A

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)

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21
Q

Dose of donepezil

A

Start: 5mg/day for 6wk
If tolerated: 10mg/day

Max: 23mg/day

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22
Q

SE of donepezil and what to caution/CI

A

N/V, loss appetite, incr bowel movement, vivid dreams, insomnia

Caution in seizures, PUD
CI in bradycardia

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23
Q

Which AD drugs comes in a patch?

A

Rivastigmine - transdermal patch

24
Q

What is memantine dose?

A

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

25
Q

SE of memantine

A

headache, constipation, confusion, dizziness

26
Q

SE of rivastigmine

A

N/V, loss of appetite, incr bowel freq, vivid dreams, insomnia

patch: local skin rxn

27
Q

What other consideration relating to pt can be considered?

A
  • 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)
28
Q

What non pharm approaches?

A
  • 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)
29
Q

What is BPSD

A

spectrum of non-cognitive and non-neurological symptoms of dementia, such as agitation, aggression, psychosis, depression and apathy.

30
Q

What are the first BPSD smx of dementia

A

Depression and anxiety

while agitation and aggression more commonly occur later, especially as the person’s ability to communicate and influence their environment diminishes.

31
Q

What is 1st line approach for BPSD smx?

A

Non-pharm

32
Q

How would agitation and aggression present in AD

A

Verbal: complaining, moaning, angry statements
Physical: resisting carers, restlessness, spitting, hitting

33
Q

Non pharm for agitation and aggression

A

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).
34
Q

How would depression present in AD?

A

Sadness, pessimistic thoughts, withdrawal, inactivity, fatigue

35
Q

Non pharm for depression

A

Recommend exercise, social connection and engaging activities. Cognitive behavioural therapy (CBT) may be helpful in early stages.

Severe depression: refer

36
Q

How would anxiety present in AD?

A

Exaggerated response to separation from family, different settings or reduce capacity to make sense of env.

37
Q

Non pharm for anxiety

A

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.

38
Q

How would apathy present in AD?

A

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..

39
Q

Non pharm for apathy

A

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.

40
Q

How would psychotic smx present in AD?

A

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

41
Q

Non pharm for psychotic smx

A

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.

42
Q

How would wandering present in AD?

A

Wandering may be circular, pacing between two points, random or direct to a location without diversion.

43
Q

Non pharm for wandering smx

A

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.

44
Q

How would nocturnal disruptions present in AD

A

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.

45
Q

Non pharm for nocturnal disruptions

A

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

46
Q

What medications can contribute to BPSD

A
  • Medicines with Anticholinergic actions
  • Systemic CS
  • Anticonvulsants
  • Medicines with sedative action
  • Anti parkinsonian meds
47
Q

What medical conditions contribute to BPSD

A

Delirium
Untreated pain
Constipation or urinary impairment
Fatigue
Hearing/visual impairment
Depression
Anxiety
Dehydration

48
Q

What environmental or social factors contribute to BPSD

A

Unfamiliar env
Separation
Noise
Crowding
Loneliness

49
Q

Is pharm tx effective for BPSD

A

Pharmacological interventions have a limited role in the management of BPSD – consider adverse effects and indication for use

50
Q

If medicines for BPSD are use, what to take note of?

A
  • 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
51
Q

How long should pharm tx be for BPSD smx

A

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

52
Q

What pharm tx can be given for depression and anxiety in AD

A

SSRIs - citalopram

Consider dose-dependent risk of increased QT prolongation and worsening cognition

53
Q

Should TCAs be given to pts with dementia?

A

No. anticholinergic effects may further disrupt cognition

54
Q

Can antipsychotic be given to pts with BPSD?

A

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.

55
Q

What concerns are there in given antipsychotics to pt with AD

A

Increased risk of stroke, cardiovascular events and excess mortality over a relatively short time frame (esp older ppl w dementia).

56
Q

What is most common cause of death in elderly taking antipsychotic meds

A

Pneumonia
Stroke
Cardiac arrest

PR3153: Central Nervous System (9 decks)

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