dementia

Question 1

most common type of dementia

Answer 1

AD

Question 2

what is it

Answer 2

progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms

Question 3

state some cognitive and behavioural symptoms (4)

Answer 3

Memory loss
Problems with reasoning and communication
Change in personality
Reduced ability to carry out daily activities e.g. washing and dressing

Question 4

AD is the most common type. Name 4 other common types.

Answer 4

Vascular dementia (due to cerebrovascular disease)
Dementia with Lewy bodies
Mixed dementia
Frontotemporal dementia

Question 5

vascular dementia occurs due to

Answer 5

cerebrovascular disease

Question 6

6 RF for dementia

Answer 6

Ageing
Mild cognitive impairment
Genetics
PD
Cerebrovascular disease
CVD

Question 7

4 modifiable risk factors for dementia

Answer 7

Smoking
DM
Lack of physical activity
Obesity

Question 8

Does AD occur on its own

Answer 8

often co-exits with other forms of dementia e.g. vascular dementia

Question 9

what is a warning sign of dementia?

Answer 9

onset of depression later on in life

Question 10

a patient who has loss of recent memory first, as well as loss of episodic memory (e.g. memory loss for revent events, repeated questioning, difficulty learning new info) is likely to have which type of dementia?

Answer 10

AD

Question 11

for this type of dementia, memory impairment may not be apparent in early stages

Answer 11

dementia with lewy bodies

Question 12

a pt who has focals (e.g. visual field defects) and a stepwise increase in severity of symptoms such as gait and attention problems and changes in personality is likely to have

Answer 12

vascular dementia

Question 13

a patient who has recurrent visual hallunications, REM sleep behaviour disorder and one or more symptoms of parkinsonism (e.g. bradykineisa, rest tremor, ridigity) or core clinical features of fluctuating cognition is likely to have

Answer 13

dementia with Lewy bodies

Question 14

for this type of dementia, personality change and behavioural disturbance (e.g. apathy or social/sexual disinhibition) may develop insidiously, while other cogntivie functions such as memory and perception may be relatively preserved

Answer 14

frontotemporal dementia

Question 15

abrupt change or stepwise decline could point to ….

Answer 15

vascular cause

Question 16

insidious onset with slow progressive course points to…

Answer 16

degenerative process

Question 17

why is medical history important in pt suspected of having dementia

Answer 17

increased cholinergic burden = increased cognitive impairment e.g. from BZDPNs, anticholinergics, opoids
consider minimising use of meds associated with increased anticholinergic burden, and if possible look for alternatives

Question 18

non drug treatment for all types of mild to moderate dementia presenting with cognitive symptoms

Answer 18

give pt the oppurtunity to participate in structures group cognitive stimulation programe
also consider group reminiscence therapy (life stories to improve phsychological well being) and cognitive rehab or occupational therapy to support daily functional ability

Question 19

drugs with antimuscarinic effects increase cognitive impairment. give some examples of 4 classes and examples of drugs for each

Answer 19

Antidepressants e.g. amitriptyline, paroxetine
Antihistamines e.g. chlorphenamine, promethazine
Antipsychotics e.g. olanzapine, quetiapine
Urinary antispasmodic e.g. solifenacin, tolterodine

Question 20

Treatment of AD in newly diagnosed pt - who can start it?

Answer 20

only initiate drug treatment under advice of specialist clinican experienced in management of AD

Question 21

AD mild to moderate 1st line + alternative 2nd line

Answer 21

monotherapy with donepezil, galantamine or rivastigmine (ACh-esterase inhibitors)

if these are not tolerated or CI, an alternative in MODERATE AD is memantine

Question 22

treatment of severe AD

Answer 22

memantine

Question 23

In patients already recieving an Achesterase inhibitor (donep, rivast, galant) and they develop moderatre or severe disease, what can you do

Answer 23

consider adding memantine
this can be initiated in primary care w/o advice from specialist

Question 24

In patients with moderate AD, what effect can discontinuation of Achesterase inhibitors have

Answer 24

Can cause a substantial worsening in cognitive function
Do not discontinue treatment based on disease severity alone

Question 25

treatment of mild to moderate dementia with Lewy bodies

Answer 25

unlicensed indications - donepezil or rivastigmine

consider galantamine (unlicensed) only if treatment with above not tolerated

memantine (unlicensed) as alternative if Achesterase inhibitors CI or not tolerated

Question 26

treatment of vascular dementia

Answer 26

Ach-esterase inhibitors or memantine (both unlicensed indication) should only be considered if they have suspected co-morbid AD, PD dementia or dementia with Lewy bodies

Question 27

Ach-esterase inhibitors or memantine are not recommended in pt with … (2)

Answer 27

frontotemporal dementia or cognitive impairment caused by MS

Question 28

treatment of PD dementia

Answer 28

• mild to moderate: offer ach-esterase inhibitor (donep, galant, rivast)
• consider the above for pt with severe PD
• ACh-esterase inhibitors are unlicensed indications apart from rivastigmine capsules and oral solution for treatment of mild to moderate dementia in pt with PD

Question 29

What is actually licensed to treat PD dementia ?

Answer 29

Ach-esterase inhibitors are unlicensed indications
Only licensed one is rivastigmine caps and oral solution for treatment of mild to moderate dementia in pt with PD

Question 30

treatment of PD dementia if Ach-esterase inhibitors are not tolerated or CI

Answer 30

consider memantine (unlicensed indication)

Question 31

use of antipsychotics in eldely with dementia

Answer 31

• small increased risk of stroke/TIA and death
• only offer to pt with dementia if at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress
• balance risks vs benefits including PHx stroke, TIA and other RF for cerebrovascular disease e.g. hypertension, AF, smoking
• lowest effective dose and for shortest time possible

Question 32

if you do give antipsychotics in dementia, how often do you need to review

Answer 32

regularly at least every 6 weeks

Question 33

management of non cognitive symptoms - agitation aggression, distress, psychosis

non drug treatment

Answer 33

Pt with dementia should be offered psychosocial and environmental interventions e.g. counselling and management of pain & delirium to reduce distress

Question 34

antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions in these TWO types of dementia.

Answer 34

dementia with Lewy bodies or PD dementia

Question 35

These TWO are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off label for this purpose

Answer 35

1. risperidone
2. haloperidol

review at least every 6 weeks!!!!

Question 36

Risperidone and haloperidol are the only antipsychotics licensed for treating non-cognitive symptoms of dementia, although other antipsychotics are often prescribed off label for this purpose. Discuss their use - who can initiate, how to use, and what are the risks

Answer 36

Only initiate under specialist supervision
Use at lowest effective dose, use for shortest possible time and reassess pt atleast every 6 weeks to see if still needed
Antipsythocis have increased rirsk of cerebrovascular adverse events and greater mortality when used in this population!

Question 37

Depression and anxiety non drug management

Answer 37

Psychological treatments (e.g. cognitive behavioural therapy (CBT), multisensory stimulation, relaxation, animal-assisted therapies) should be considered for pt with mild to moderate dementia who have mild to moderate depression or anxiety

Question 38

when should antidepressants be used

Answer 38

Antidepressants should be reserved for pre-existing severe mental health problems

Question 39

sleep disturbances management non drug

Answer 39

Offer non-drug treatment approaches to manage sleep problems and insomnia, including sleep hygiene education, exposure to daylight, and increasing exercise and activity

Question 40

driving and dementia
- pt has mild cognitive impairment (not mild dementia) and there is no likely driving impairment. can they drive

Answer 40

Group 1 and Group 2 may drive and do not need to notify DVLA

Question 41

Mild cognitive impairment (not mild dementia) where there is possible driving impairment - can they drive?

Answer 41

Group 1 and 2 may be allowed to drive subject to medical advice and/or notifying DVLA
decisions on licensing based on medical reports
poor short term memory, disorientation and lack of insight or judgement almost certainly mean not fit to drive
formal driving assessment may be necessary

Question 42

dementia and/or any organic syndrome affecting cognitive functioning - can they drive?

Answer 42

group 1 may be able to, but must notify DVLA
decision on licensing usually baed on medial reports
poor short term memory, disorientation and lack of insight or judgement almost certainly mean not fit to drive
group 1 must NOT drive and must notify DVLA - licensing will be redused or revoked

Question 43

5 drug classes and examples - use with cautionin dementia

Answer 43

TCAs
Antiemeitcs e.g. metoclopramide
Analgesics e.g. pethidine, tramadol
Sedatives e.g. LA benzodiazepenes or antipsyhtocis
Antihtiasmines e.g. chlorphenamine