dementia Flashcards
most common type of dementia
AD
what is it
progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms
state some cognitive and behavioural symptoms (4)
Memory loss
Problems with reasoning and communication
Change in personality
Reduced ability to carry out daily activities e.g. washing and dressing
AD is the most common type. Name 4 other common types.
Vascular dementia (due to cerebrovascular disease)
Dementia with Lewy bodies
Mixed dementia
Frontotemporal dementia
vascular dementia occurs due to
cerebrovascular disease
6 RF for dementia
Ageing
Mild cognitive impairment
Genetics
PD
Cerebrovascular disease
CVD
4 modifiable risk factors for dementia
Smoking
DM
Lack of physical activity
Obesity
Does AD occur on its own
often co-exits with other forms of dementia e.g. vascular dementia
what is a warning sign of dementia?
onset of depression later on in life
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?
AD
for this type of dementia, memory impairment may not be apparent in early stages
dementia with lewy bodies
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
vascular dementia
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
dementia with Lewy bodies
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
frontotemporal dementia
abrupt change or stepwise decline could point to ….
vascular cause
insidious onset with slow progressive course points to…
degenerative process
why is medical history important in pt suspected of having dementia
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
non drug treatment for all types of mild to moderate dementia presenting with cognitive symptoms
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
drugs with antimuscarinic effects increase cognitive impairment. give some examples of 4 classes and examples of drugs for each
Antidepressants e.g. amitriptyline, paroxetine
Antihistamines e.g. chlorphenamine, promethazine
Antipsychotics e.g. olanzapine, quetiapine
Urinary antispasmodic e.g. solifenacin, tolterodine
Treatment of AD in newly diagnosed pt - who can start it?
only initiate drug treatment under advice of specialist clinican experienced in management of AD
AD mild to moderate 1st line + alternative 2nd line
monotherapy with donepezil, galantamine or rivastigmine (ACh-esterase inhibitors)
if these are not tolerated or CI, an alternative in MODERATE AD is memantine
treatment of severe AD
memantine
In patients already recieving an Achesterase inhibitor (donep, rivast, galant) and they develop moderatre or severe disease, what can you do
consider adding memantine
this can be initiated in primary care w/o advice from specialist
In patients with moderate AD, what effect can discontinuation of Achesterase inhibitors have
Can cause a substantial worsening in cognitive function
Do not discontinue treatment based on disease severity alone
treatment of mild to moderate dementia with Lewy bodies
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
treatment of vascular dementia
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
Ach-esterase inhibitors or memantine are not recommended in pt with … (2)
frontotemporal dementia or cognitive impairment caused by MS
treatment of PD dementia
- 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
What is actually licensed to treat PD dementia ?
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
treatment of PD dementia if Ach-esterase inhibitors are not tolerated or CI
consider memantine (unlicensed indication)
use of antipsychotics in eldely with dementia
- 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
if you do give antipsychotics in dementia, how often do you need to review
regularly at least every 6 weeks
management of non cognitive symptoms - agitation aggression, distress, psychosis
non drug treatment
Pt with dementia should be offered psychosocial and environmental interventions e.g. counselling and management of pain & delirium to reduce distress
antipsychotics can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions in these TWO types of dementia.
dementia with Lewy bodies or PD dementia
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
- risperidone
- haloperidol
review at least every 6 weeks!!!!
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
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!
Depression and anxiety non drug management
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
when should antidepressants be used
Antidepressants should be reserved for pre-existing severe mental health problems
sleep disturbances management non drug
Offer non-drug treatment approaches to manage sleep problems and insomnia, including sleep hygiene education, exposure to daylight, and increasing exercise and activity
driving and dementia
- pt has mild cognitive impairment (not mild dementia) and there is no likely driving impairment. can they drive
Group 1 and Group 2 may drive and do not need to notify DVLA
Mild cognitive impairment (not mild dementia) where there is possible driving impairment - can they drive?
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
dementia and/or any organic syndrome affecting cognitive functioning - can they drive?
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
5 drug classes and examples - use with cautionin dementia
TCAs
Antiemeitcs e.g. metoclopramide
Analgesics e.g. pethidine, tramadol
Sedatives e.g. LA benzodiazepenes or antipsyhtocis
Antihtiasmines e.g. chlorphenamine
