DEMENTIA Flashcards
1
Q
WHAT IS DEMENTIA?
A
Progressive clinical syndrome characterised by range of cognitive and behavioural symptoms
2
Q
WHAT ARE THE COGNITIVE SYMPTOMS OF DEMENTIA?
A
o Memory loss
o Lack of concentration
o Disorientated
o Difficulty with speech
o Problems with reasoning and communication
o Change in personality
o Reduced ability to carry out daily activities
3
Q
MOST COMMON FORM OF DEMENTIA
A
AD
4
Q
NAME 4 OTHER COMMON TYPES OF DEMENTIA
A
Vascular dementia
Dementia with Lewy bodies
Mixed dementia
Frontotemporal dementia
5
Q
Why does vascular dementia occur
A
due to cerebrovascular disease
6
Q
6 RF for dementia
A
Ageing
Mild cognitive impairment
Genetics
PD
Cerebrovascular disease
CVD
7
Q
4 modifiable risk factors for dementia
A
Smoking
DM
Lack of physical activity
Obesity
8
Q
what is a warning sign of dementia?
A
onset of depression later on in life
9
Q
Does AD occur on its own
A
often co-exits with other forms of dementia e.g. vascular dementia
10
Q
AD example
A
a patient who has:
- loss of recent memory
- first and episodic memory (e.g. memory loss for recent events)
- repeated questioning
- difficulty learning new info
11
Q
Dementia with Lewy bodies example
A
- memory impairment may not be apparent in early stages
- recurrent visual hallucinations
- REM sleep behaviour disorder
- One or more symptoms of Parkinsonism (e.g. bradykinesia, rest tremor, rigidity)
- Core clinical features of fluctuating cognition
12
Q
Vascular dementia example
A
a pt who has:
- focals (e.g. visual field defects)
- abrupt change
- stepwise increase in severity of symptoms such as gait and attention problems
- changes in personality
13
Q
Frontotemporal dementia example
A
- 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
- think frontal lobe developing…
14
Q
abrupt change or stepwise decline could point to ….
A
vascular cause
15
Q
why is medical history important in pt suspected of having dementia
A
- increased cholinergic burden = increased cognitive impairment e.g. from BZDPNs, anticholinergics, opioids
- consider minimising use of meds associated with increased anticholinergic burden, and if possible look for alternatives
16
Q
INCREASING WHAT NEUROTRANSMITTER ALLEVIATES DEMENTIA?
A
Acetylcholine
* We use acetylcholine esterase inhibitors.
* INHIBITING THE PROTEIN THAT BREAKS IT DOWN
17
Q
NON DRUG TREATMENT: MILD - MODERATE DEMENTIA
A
- participate in structures group cognitive stimulation programme
- group reminiscence therapy (life stories to improve phsychological well being)
- cognitive rehab
- occupational therapy to support daily functional ability
18
Q
TREATMENT: MILD-MODERATE DEMENTIA
A
Monotherapy with an ACh-esterase inhibitor:
Donepezil
Rivastigamine
Galantamine
19
Q
treatment of mild to moderate dementia with Lewy bodies
A
- unlicensed indications - donepezil or rivastigmine
- galantamine (unlicensed) only if treatment with above not tolerated
- memantine (unlicensed) as alternative if Achesterase inhibitors CI or not tolerated
20
Q
treatment of vascular dementia
A
- unlicensed indications - donepezil or rivastigmine
- galantamine (unlicensed) only if treatment with above not tolerated
- memantine (unlicensed) as alternative if Achesterase inhibitors CI or not tolerated
21
Q
treatment of PD dementia
A
- mild to moderate: offer ach-esterase inhibitor (donep, galant, rivast)
- consider the above for pt with severe PD
22
Q
What
A
ACh-esterase inhibitors are unlicensed indications apart from:
1. rivastigmine capsules
2. oral solution
for treatment of mild to moderate dementia in pt with PD
23
Q
treatment of PD dementia if Ach-esterase inhibitors are not tolerated or CI
A
consider memantine (unlicensed indication)
24
Q
treatment of vascular dementia
A
- Ach-esterase inhibitors or memantine (both unlicensed indication) should only be considered in vascular dementia if they have suspected co-morbid AD, PD dementia or dementia with Lewy bodies
25
Ach-esterase inhibitors or memantine are not recommended in pt with … (2)
frontotemporal dementia or cognitive impairment caused by MS
26
DONEPEZIL
o Caution: cardiac conduction disorders, asthma, COPD
o SFx: neuroleptic malignant syndrome, EPSEs
27
DONEPEZIL MOA AND DRUG CLASS
Ach-esterase inbibitor
28
DONEPEZIL DOSE
initally 5mg OD for one month
increase if necessary to 10mg OD
to be taken at night
29
what time of the day do you take DONEPEZIL?
at night
30
DONEPEZIL: CAUTIONS
- Cardiac conduction disorder
- Asthma
- COPD
- sick sinus syndrome
- SV conduction abnormalities
- susceptibility to peptic ulcers
31
DONEPEZIL: SFx
- Neuroleptic malignant syndrome
- EPSEs
- diarrhoea, GI disorders, nausea, vomiting
32
DONEPEZIL: INTERACTIONS
- beta blockers
- RL CCBs
- anti-arrhtyhmics e.g. dronedarone, amiodarone, fleicanide
- digoxin
33
What RIVASTIGAMINE FORMULATION is licensed in mild to moderate dementia in Parkinsons disease
rivastigmine caps or oral solution
34
RIVASTIGAMINE DRUG CLASS AND MOA
Ach-esterase inhibitor
a reversible non-competitive inhibitor of Achesterase
35
which RIVASTIGAMINE FORMULATION is not licensed for Parkinson’s disease dementia
Patches [unlicensed]
36
if treatment with rivastigmine PATCHES is interrupted for more than 3 days , what do you do?
need to re titrate from lowest strength patch (4.6mg/24h).
37
if treatment with rivastigmine by mouth is interrupted for more than several days, what do you do
re titrate from 1.5mg BD .
38
HOW DO YOU REDUCE THE GI SFX OF RIVASTIGMINE?
transdermal administration
- patches
39
RIVASTIGAMINE: CAUTIONS
asthma
copd
peptic, duodenal, gastric ulcers
bladder outflow obstruction
sick sinus syndrome
susceptibility to ulcers
40
RIVASTIGAMINE: INTERACTIONS
BB
anti-arrhtyhmics
digoxin
41
RIVASTIGAMINE: SFX (PO)
confusion
gait abnormal
hallucinations
hyperhidrosis
hypersalivarion
malaise
parkinonism
sleep disorders
42
RIVASTIGMINE: MONITORING
o SFx: GI SFx
o Stop if pt becomes dehydrated from prolonged vomiting or diarrhoea
o Less SFx with transdermal administration
o Monitor body weight
43
GALANTAMINE MOA AND DRUG CLASS
- Ach-esterase inbibitor
- reversible inhibitor of Ach-esterase and also has nicotinic receptor agonsit properties
44
GALANTAMINE DOSE
dose in mild to moderately severe dementia in AD
IR PREPS
initally 4mg BD for 4 weeks
increase to 8mg BD for at least 4 weeks
maintenane 8-12mg BD
45
GALANTAMINE DOSE
dose in mild to moderately severe dementia in AD -
MR CAPSULES
initally 8mg OD for 4 weeks
increased to 16mg OD for at least 4 weeks
maintenance 16-24mg daily
46
GALATAMINE
o Avoid in: GI obstruction, urinary outflow obstruction
o SFx: Steven-Johnson Syndrome, Severe cutaneous adverse reactions (SCARs) – signs of skin reactions
47
GALANTAMINE: AVOID IN
- GI obstruction
- Urinary outflow obstruction
- whilst recovering from bladder surgery
- whilst recovering from GI surgery
48
GALANTAMINE: SFX
- Steven-Johnson Syndrome,
- Severe cutaneous adverse reactions (SCARs) – signs of skin reactions
49
Interactions with galantamine - increased risk of bradycardia with
- betablockers
- anti-arrhythmics
- digoxin
50
TREATMENT: MODERATE-SEVERE DEMENTIA
Memantine
51
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
52
WHAT DRUG CLASS IS MEMANTINE?
NMDA glutamate receptor antagonist
53
MEMANTINE: CAUTIONS
epilepsy, history of convulsions
54
2 severe interactions with memantine - increased risk of CNS toxicity
amantadine - caution or avoid
ketamine - avoid
55
MEMANTINE: INTERACTIONS
predicted to increase the effects of levodopa, ropinirole, pramiprexole, rotigotine
it is a dopaminergic drug so this makes sense - it is a antagonist at the NMDA receptors
56
MEMANTINE: SIDE EFFECTS
balance impaired
constipation
dizziness
drowsiness
dyspnoea
headache
hypertension
hypersensitivity
57
Some commonly prescribed drugs are associated with increased antimuscarinic (anticholinergic) burden and therefore cognitive impairment. Their use should be minimised
Antidepressants
- Amitriptyline, paroxetine
Antihistamine
- Chlorphenamine
- Promethazine
Antipsychotic
- Olanzapine
- Quetiapine
Urinary antispasmodics
- Solifenacin
- Tolterodine
58
WHAT ANTIDEPRESSANTS CAN BE USED TO MANAGE COGNITIVE SYMPTOMS IN DEMENTIA?
o Amitriptyline, paroxetine
59
WHAT ANTIHISTAMINE CAN BE USED TO MANAGE COGNITIVE SYMPTOMS IN DEMENTIA?
o Chlorphenamine, promethazine
60
WHAT URINARY ANTISPASMODIC CAN BE USED TO MANAGE COGNITIVE SYMPTOMS IN DEMENTIA?
o Solifenacin
o Tolterodine
61
WHAT ANTIPSYCHOTIC CAN BE USED TO MANAGE COGNITIVE SYMPTOMS IN DEMENTIA?
o Olanzapine
62
MANAGEMENT OF NON-COGNITIVE SYMPTOMS
Treated with benzos or antipsychotics
1. risperidone
2. haloperidol
63
WHAT ARE NON-COGNITIVE SYMPTOMS?
* Agitation, aggression, distress, psychosis
64
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
- under specialist supervision
- lowest effective dose, use for shortest possible time
- reassess pt at least every 6 weeks to see if still needed
- Antipsychotics thocis have an increased risk of cerebrovascular adverse events and greater mortality
65
ANTIPSYCHOTICS IN ELDERLY PATIENTS WITH DEMENTIA
Increased risk of stroke, small increased risk of death when using
o Lowest effective dose for shortest time
o Regular review at least every 6 weeks
66
When can you offer pt with dementia antipsychotics?
- only offer to pt if at risk of harming themselves or others
- experiencing agitation, hallucinations or delusions that are causing severe distress
67
if you do give antipsychotics in dementia, how often do you need to review
regularly at least every 6 weeks
68
ANTIPSYCHOTICS AND DEMENTIA
Can use antipsychotics in patients with dementia, but not in parkinson’s or dementia with Lewy bodies
Increased ACh = Parasympathetic SFx – rest and digest and secrete
Diarrhoea
Urinary incontinence
Muscle weakness
Bradycardia
Bronchospasms
Emesis
Lacrimation
Salivation
69
TREATMENT OF SYMPTOMS OF DEPRESSION AND ANXIETY IN DEMENTIA
CBT, Antidepressants reserved for pre-existing severe mental health
70
Sleep disturbances management non drug
- including sleep hygiene education
- exposure to daylight
- increasing exercise and activity
71
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
72
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
73
Group 2 licence and dementia
Group 2 licence - large lorries and buses
A person diagnosed with dementia cannot have a group 2 licence
74
dementia and/or any organic syndrome affecting cognitive functioning - can they drive?
Based on the doctor’s report, medical advisers at DVLA/DVA will decide if the person can keep driving.
There are several possible results at this stage. DVLA/DVA may:
1. renew the person’s licence, usually for one year
2. cancel or ‘revoke’ it straightaway (see section 5 ‘When DVLA/ DVA decides that the person must stop driving’ on page 8)
3. ask for more information, such as more medical details
4. ask the person to take an on-road driving assessment before making a decision (see ‘Driving assessment’ below). This is the least common of the possibilities.
75
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
