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Geriatrics > Dementia > Flashcards

Dementia Flashcards

1
Q

What is dementia?

A

A clinical syndrome characterized by progressive cognitive decline that interferes with the individual’s ability to function independently

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2
Q

What is the new name of dementia/

A

Major Neurocognitive Disorder

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3
Q

What are the 6 cognitive domains that may be affected by dementia?

A

Complex attention
Executive function
Learning and memory
Language
Perceptual motor funciton
Social cognition

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4
Q

What is mild cognitive impairment?

A

May be subjective or may be observable on cognitive testing
* This decline does NOT interfere with ability to function independently

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5
Q

What are the key distinguishing factors between delirium vs dementia?

A
  • Delirium develops quickly (within hours to days)
  • The key cognitive disturbance in delirium is inattention (unable to focus on a
    conversation or task)
  • Symptoms of delirium fluctuate from one hour to the next
  • Delirium is generally reversible as long as the underlying cause is identified and treated
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6
Q

What are some potentially reversible contributors to cognitive impairment? (DEMENTIA)

A
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7
Q

What role do anticholinergics have with dementia?

A
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8
Q

What are the 5 types of dementia?

A
  1. Alzheimer’s Disease
  2. Vascular Dementia
  3. Frontotemporal Dementia
  4. Parkinson disease Dementia
  5. Lewy body dementia
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9
Q

What is the most common form of dementia?

A

Alzheimers

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10
Q

What is the general patho of alzheimers?

A

Short term memory leading all ears of functioning

Associated with B-amyloid plaques and neurofibrillary tangles on atuopsy

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11
Q

What is the general apperance upon CT with Alzheimers?

A

Cerebral atrophy

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12
Q

What is the etiology of alzheimers?

A

likely a mix of genetic, environmental, and lifestyle
factors

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13
Q

What are the risk factors of alzheimers?

A
  • ↑age
  • Family history/genetics (APOE4 ↑ risk)
  • Rare genetic mutations -> early onset-Alzheimer’s disease (<1%)
  • History of severe head trauma
  • Mild cognitive impairment
  • Lifestyle - ↓ exercise, smoking, obesity, HTN, poorly controlled diabetes, dyslipidemia
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14
Q

What can protect people with alzheimers?

A

Educational attainment, social engagement and lifelong learning

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15
Q

What is vascular dementia?

A

Results from interrupted blood flow in parts of brain

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16
Q

What are the risk factors of vascular dementia?

A

hypertension, high cholesterol, smoking, diabetes, heart disease

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17
Q

Onset of vascular dementia is?

A

Abrupt (After an event) or gradual.

May have periods of relative stability interspersed with periods of more rapid decline
(“stepwise” decline)

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18
Q

Which form of dementia has strong genetic components?

A

Frontotemporal dementia

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19
Q

What is the onset of frontotemporal dementia?

A

earlier onset (40-50, and no increase prevalence with age

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20
Q

Where is damage usually incurred with frontotemporal dementia?

A
  • Changes in speech, language, personality occur BEFORE memory
    changes
  • Speech is more unusual, choppy, repetitive
  • Poor judgement, disinhibited behaviour
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21
Q

What is parkinson’s dementia?

A

Develops after a clinical diagnosis of parkinsons disease

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22
Q

What does parkinsons dementia look like/cause impairment where?

A
  • Impairment in attention, visuospatial skills, and planning and
    completing complex tasks occurs early on
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23
Q

Doapminergic treatment for PD may ____ behavioural and psychological symptoms of dementia

A

exacerbate

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24
Q

What is Lewy body dementia?

A

Lewy bodies = abnormal deposits of alpha-synuclein protein in neurons

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25
Q

What is the presentation of Lewy Body dementia?

A

Present with cognitive impairment and visual hallucinations FIRST or CONCURRENTLY with PD motor symptoms.

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26
Q

What are the distinct clinical features of lewy body dementia? (4)

A
  • Early postural instability and repeated falls are common
  • Detailed, recurrent visual hallucinations
  • Pronounced fluctuations in cognition
  • Extremely sensitive to antipsychotics
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27
Q

How is dementia diagnoised

A

Imaging, cognitive assessment, rule out other causes,

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28
Q

What is the FAQ?

A

Functional activities questionnaire

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29
Q

What is BEHAVIOURAL AND PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA

A

Non-cognitive symptoms of disturbed thoughts, perception, mood, or behavior
that may occur with dementia (particularly in the later stages)

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30
Q

What is important to remember about behaviour?

A

Responsive behaviours are communicating something

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31
Q

What may be involved in the various types of behaviour?

A

There is behavioural and psychological

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32
Q

What may trigger psychological behaviour?

A

fear of danger or being abandoned, distress,
loss of autonomy/control, paranoia, misinterpretation

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33
Q

What may trigger environment behaviour?

A

not liking who is around, boredom,
confusing surroundings, change in routine, loneliness,
noise/sounds, low lighting

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34
Q

What may trigger medical behavior?

A

pain, constipation, dehydration, hunger,
hypothyroidism, infection, urinary retention, metabolic or
electrolyte disturbances

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35
Q

What may trigger medicaiton behavior?

A
  • Anticholinergics
  • Benzodiazepines, sedatives, hypnotics
  • Opioids
  • Cannabinoids
  • Anticonvulsants
  • Some antibiotics (fluoroquinolones, clarithromycin)
  • Psychoactive NSAIDs (indomethacin, diclofenac)
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36
Q

What is the approach to manage dementia/

A
  • Optimize management of co-morbid conditions
  • Attempt to ↓/stop meds that may be contributing to cognitive
    impairment
  • Refer to Alzheimer Society Saskatchewan (or local)
  • Encourage regular exercise and a healthy diet
  • Encourage cognitive and social activity
  • Caregiver support
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37
Q

What are the categories for dementia management?

A

Treatment of dementia
Management of behavioural and psychological symptoms of demential

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38
Q

What are the main treatment options for dementia? (3)

A
  • Cholinesterase Inhibitors
  • N-methyl-D-aspartate (NMDA) antagonist
  • ?Emerging treatments
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39
Q

What are the treatment options for the management of behavioural associated with dementia?

A
  • Antipsychotics
  • Other medications as indicated e.g. antidepressants, pain medications, laxatives
40
Q

What is the goal of treatment with dementia?

A

To improve the quality of life for the
individual and caregivers, maintain optimal
function and provide maximum comfort

41
Q

What are the three cholinesterase inhibitors?

A

Donepezil, galantamine, rivastigmine

42
Q

What do cholinesterase inhibitors do?

A
  • Prevent breakdown of acetylcholine
43
Q

What may cholinesterase inhibitors do?

A

May show small improvements in measures of cognition

44
Q

What is the indication of cholinesterase inhibitors?

A
  • Indication: Mild → Severe Alzheimer’s (varies)
45
Q

What are the common AE of cholinesterase inhibitors? ((5)

A

nausea, loss of appetite, vomiting, diarrhea, insomnia, urinary
urgency/frequency +/- incontinence

46
Q

What are the less common AE of cholinesterase inhibitors?

A

weight loss, agitation, bradycardia, syncope, GI bleed,
behaviour disturbances, nightmares

47
Q

What is syncope

A

temporary loss of consciousness caused by a fall in blood pressure.

48
Q

What may the association of cholinesterase inhibitors be associated with?

A

Dose related, taper slowly. taker with food perhaps an anti-emetic?

49
Q

What are the cardio specific effects of cholinesterase inhibitors?

A
50
Q

What are the respiratory effects of cholinesterase inhibitors?

A
51
Q

What are the Gi Tract effects of cholinesterase inhibitors?

A

Increase GI motility and peristalsis

52
Q

What are the Urinary effects of cholinesterase inhibitors?

A
53
Q

What are the eye effects of cholinesterase inhibitors?

A

Increase contraction of cilliary muscle and iris

54
Q

What are the secretion effects of cholinesterase inhibitors?

A
55
Q

When are cholinesterase inhibitors contraindicated?

A
  • Uncontrolled/severe asthma or severe COPD
  • Cardiac conduction abnormalities, bradycardia (HR < 55 bpm)
56
Q

When should cholinesterase inhbitors be cautioned?

A
  • Peptic ulcer disease or uncontrolled GERD
  • Urinary incontinence
  • Seizure history
  • Concurrent anticholinergics
57
Q

What is the main EDS point with cholinesterase inhibitors?

A
  • Must not be taking concurrent anticholinergic medications at any time

Reassessment after 6 months of therapy

58
Q

What are the NMDA antagonist?

A

Memantine (Ebixa)

59
Q

WHat is the MOA of NMDA antagonist?

A

Block glutamate (excitatory amino acid) at NMDA receptor (Theory:
persistent activation of NMDA contributes to symptoms)

60
Q

What is the indicaiton of NMDA antagonist?

A

Moderate to severe alzheimers

61
Q

How is NMDA excreeted?

A

Kidney, threfore need dose adjustments

62
Q

What are the AE of NMDA antagonists?

A
63
Q

What is the elevated risk of using anti-dementia agents?

A
64
Q

What are the benefits of using anti-dementia agents

A
65
Q

When should anti-dementia agents be discontinued?

A

Progression to situation where Risk > Benefit (adverse effects, non-
adherence, new conflicting co-morbidities, no or limited clinical response, functional
deterioration despite treatment, $$)

66
Q

What are the ADLs?

A

Activities of Daily Living (ADL)

67
Q

Is there a point of continuing therapy for patients beyond loss of ADLs?

A

No

68
Q

How do we take someone off of anti-dementia therapy?

A

Taper over 2-4 weeks

69
Q

What evidence is there for preventing dementia via medication?

A
70
Q

What are the non-pharmacological preventions for dementia?

A
71
Q

What do the new therapies for alzheimers target?

A

Amyloid plaques

72
Q

What therapies are there for alzheimers treatment?

A

Lecanemab

73
Q

What is the indication for lecanemab?

A

Indicated for Mild Cognitive Impairment or Alzheimer’s disease at the mild stage

74
Q

What is the administraiton of lecanemab/

A

10mg/kg Q2 weeks

75
Q

What are the -Mab drugs indicated for?

A

Alzheimers disease as they target the amyloid pathologyu

76
Q

What adverse effects were found with donanemab and lecanemab?

A

Headache, confusion, vomiting, visual or gait disturbance

77
Q

What characteristics of BPSD may be amenable to pharmacotherapy?

A

Paranoia, aggression, hallucinations, delusions, depression

78
Q

When should we initiate pharmacotherapy for the management of BPSD?

A

Pharmacotherapy ONLY if behaviour is causing harm or significant distress to individual, caregivers, or others AND is persistent or recurrent

79
Q

How often should pharmacotherapy be reevaluated for BPSD?

A

3 months

80
Q

What is important with regards to treating BPSD?

A

Look for underlying causes such as infeciton. pain etc…

81
Q

What antidepressants may we use for BPSD management?

A

Citalopram, escitalopram, sertraline, venlafaxine, duloxetine, mirtazapine, bupropion

82
Q

which agents should we consider for sleep if underlying depression?

A

mirtazapine or trazodone

83
Q

Why do we avoid benzo for anxiety or for sedation?

A
  • Worsen cognitive impairment, ↑ fall risk, may also worsen disinhibition
  • Occasionally may be used short-term following a stressful event (e.g. change in
    residence, bereavement) OR preventatively before dental work, etc.
84
Q

With regards to APS what do we typically prefer for least amount of anticholingergic effects?

A

Risperidoen

85
Q

For EPS worries which agent do we generally choose out of antipsychotics?

A
86
Q

Which APS has lesser QT prolonging effects?

A
87
Q

Which APS has lesser sedation?

A
88
Q

Which APS has less likelyhood of tardive dyskinesia?

A
89
Q

Which APS has less likely for weight gain?

A
90
Q

Which adverse should we watch for with regards to APS usage?

A

weight gain, ↓BP, anticholinergic effects, sedation, falls, EPS, tardive dyskinesia, urinary retention

91
Q

What is the over arching theme of when initiating APS?

A

Start low go slow

92
Q

Which APS is generally used for managing acute delirium?

A

Haloperidol

93
Q

What is more effective than stimulants?

A

External activity and environmental stimulation is
more effective

94
Q

When do we use sedatives?

A

Considered when behaviour is thought to be directly correlated with lack of sleep OR behaviours are during night

95
Q

What is often overlooked for pain management?

A

A good trial of acetaminophen

96
Q
A

Geriatrics (6 decks)

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