Dementia Flashcards
What is dementia?
A clinical syndrome characterized by progressive cognitive decline that interferes with the individual’s ability to function independently
What is the new name of dementia/
Major Neurocognitive Disorder
What are the 6 cognitive domains that may be affected by dementia?
Complex attention
Executive function
Learning and memory
Language
Perceptual motor funciton
Social cognition
What is mild cognitive impairment?
May be subjective or may be observable on cognitive testing
* This decline does NOT interfere with ability to function independently
What are the key distinguishing factors between delirium vs dementia?
- 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
What are some potentially reversible contributors to cognitive impairment? (DEMENTIA)
What role do anticholinergics have with dementia?
What are the 5 types of dementia?
- Alzheimer’s Disease
- Vascular Dementia
- Frontotemporal Dementia
- Parkinson disease Dementia
- Lewy body dementia
What is the most common form of dementia?
Alzheimers
What is the general patho of alzheimers?
Short term memory leading all ears of functioning
Associated with B-amyloid plaques and neurofibrillary tangles on atuopsy
What is the general apperance upon CT with Alzheimers?
Cerebral atrophy
What is the etiology of alzheimers?
likely a mix of genetic, environmental, and lifestyle
factors
What are the risk factors of alzheimers?
- ↑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
What can protect people with alzheimers?
Educational attainment, social engagement and lifelong learning
What is vascular dementia?
Results from interrupted blood flow in parts of brain
What are the risk factors of vascular dementia?
hypertension, high cholesterol, smoking, diabetes, heart disease
Onset of vascular dementia is?
Abrupt (After an event) or gradual.
May have periods of relative stability interspersed with periods of more rapid decline
(“stepwise” decline)
Which form of dementia has strong genetic components?
Frontotemporal dementia
What is the onset of frontotemporal dementia?
earlier onset (40-50, and no increase prevalence with age
Where is damage usually incurred with frontotemporal dementia?
- Changes in speech, language, personality occur BEFORE memory
changes - Speech is more unusual, choppy, repetitive
- Poor judgement, disinhibited behaviour
What is parkinson’s dementia?
Develops after a clinical diagnosis of parkinsons disease
What does parkinsons dementia look like/cause impairment where?
- Impairment in attention, visuospatial skills, and planning and
completing complex tasks occurs early on
Doapminergic treatment for PD may ____ behavioural and psychological symptoms of dementia
exacerbate
What is Lewy body dementia?
Lewy bodies = abnormal deposits of alpha-synuclein protein in neurons
What is the presentation of Lewy Body dementia?
Present with cognitive impairment and visual hallucinations FIRST or CONCURRENTLY with PD motor symptoms.
What are the distinct clinical features of lewy body dementia? (4)
- Early postural instability and repeated falls are common
- Detailed, recurrent visual hallucinations
- Pronounced fluctuations in cognition
- Extremely sensitive to antipsychotics
How is dementia diagnoised
Imaging, cognitive assessment, rule out other causes,
What is the FAQ?
Functional activities questionnaire
What is BEHAVIOURAL AND PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA
Non-cognitive symptoms of disturbed thoughts, perception, mood, or behavior
that may occur with dementia (particularly in the later stages)
What is important to remember about behaviour?
Responsive behaviours are communicating something
What may be involved in the various types of behaviour?
There is behavioural and psychological
What may trigger psychological behaviour?
fear of danger or being abandoned, distress,
loss of autonomy/control, paranoia, misinterpretation
What may trigger environment behaviour?
not liking who is around, boredom,
confusing surroundings, change in routine, loneliness,
noise/sounds, low lighting
What may trigger medical behavior?
pain, constipation, dehydration, hunger,
hypothyroidism, infection, urinary retention, metabolic or
electrolyte disturbances
What may trigger medicaiton behavior?
- Anticholinergics
- Benzodiazepines, sedatives, hypnotics
- Opioids
- Cannabinoids
- Anticonvulsants
- Some antibiotics (fluoroquinolones, clarithromycin)
- Psychoactive NSAIDs (indomethacin, diclofenac)
What is the approach to manage dementia/
- 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
What are the categories for dementia management?
Treatment of dementia
Management of behavioural and psychological symptoms of demential
What are the main treatment options for dementia? (3)
- Cholinesterase Inhibitors
- N-methyl-D-aspartate (NMDA) antagonist
- ?Emerging treatments
What are the treatment options for the management of behavioural associated with dementia?
- Antipsychotics
- Other medications as indicated e.g. antidepressants, pain medications, laxatives
What is the goal of treatment with dementia?
To improve the quality of life for the
individual and caregivers, maintain optimal
function and provide maximum comfort
What are the three cholinesterase inhibitors?
Donepezil, galantamine, rivastigmine
What do cholinesterase inhibitors do?
- Prevent breakdown of acetylcholine
What may cholinesterase inhibitors do?
May show small improvements in measures of cognition
What is the indication of cholinesterase inhibitors?
- Indication: Mild → Severe Alzheimer’s (varies)
What are the common AE of cholinesterase inhibitors? ((5)
nausea, loss of appetite, vomiting, diarrhea, insomnia, urinary
urgency/frequency +/- incontinence
What are the less common AE of cholinesterase inhibitors?
weight loss, agitation, bradycardia, syncope, GI bleed,
behaviour disturbances, nightmares
What is syncope
temporary loss of consciousness caused by a fall in blood pressure.
What may the association of cholinesterase inhibitors be associated with?
Dose related, taper slowly. taker with food perhaps an anti-emetic?
What are the cardio specific effects of cholinesterase inhibitors?
What are the respiratory effects of cholinesterase inhibitors?
What are the Gi Tract effects of cholinesterase inhibitors?
Increase GI motility and peristalsis
What are the Urinary effects of cholinesterase inhibitors?
What are the eye effects of cholinesterase inhibitors?
Increase contraction of cilliary muscle and iris
What are the secretion effects of cholinesterase inhibitors?
When are cholinesterase inhibitors contraindicated?
- Uncontrolled/severe asthma or severe COPD
- Cardiac conduction abnormalities, bradycardia (HR < 55 bpm)
When should cholinesterase inhbitors be cautioned?
- Peptic ulcer disease or uncontrolled GERD
- Urinary incontinence
- Seizure history
- Concurrent anticholinergics
What is the main EDS point with cholinesterase inhibitors?
- Must not be taking concurrent anticholinergic medications at any time
Reassessment after 6 months of therapy
What are the NMDA antagonist?
Memantine (Ebixa)
WHat is the MOA of NMDA antagonist?
Block glutamate (excitatory amino acid) at NMDA receptor (Theory:
persistent activation of NMDA contributes to symptoms)
What is the indicaiton of NMDA antagonist?
Moderate to severe alzheimers
How is NMDA excreeted?
Kidney, threfore need dose adjustments
What are the AE of NMDA antagonists?
What is the elevated risk of using anti-dementia agents?
What are the benefits of using anti-dementia agents
When should anti-dementia agents be discontinued?
Progression to situation where Risk > Benefit (adverse effects, non-
adherence, new conflicting co-morbidities, no or limited clinical response, functional
deterioration despite treatment, $$)
What are the ADLs?
Activities of Daily Living (ADL)
Is there a point of continuing therapy for patients beyond loss of ADLs?
No
How do we take someone off of anti-dementia therapy?
Taper over 2-4 weeks
What evidence is there for preventing dementia via medication?
What are the non-pharmacological preventions for dementia?
What do the new therapies for alzheimers target?
Amyloid plaques
What therapies are there for alzheimers treatment?
Lecanemab
What is the indication for lecanemab?
Indicated for Mild Cognitive Impairment or Alzheimer’s disease at the mild stage
What is the administraiton of lecanemab/
10mg/kg Q2 weeks
What are the -Mab drugs indicated for?
Alzheimers disease as they target the amyloid pathologyu
What adverse effects were found with donanemab and lecanemab?
Headache, confusion, vomiting, visual or gait disturbance
What characteristics of BPSD may be amenable to pharmacotherapy?
Paranoia, aggression, hallucinations, delusions, depression
When should we initiate pharmacotherapy for the management of BPSD?
Pharmacotherapy ONLY if behaviour is causing harm or significant distress to individual, caregivers, or others AND is persistent or recurrent
How often should pharmacotherapy be reevaluated for BPSD?
3 months
What is important with regards to treating BPSD?
Look for underlying causes such as infeciton. pain etc…
What antidepressants may we use for BPSD management?
Citalopram, escitalopram, sertraline, venlafaxine, duloxetine, mirtazapine, bupropion
which agents should we consider for sleep if underlying depression?
mirtazapine or trazodone
Why do we avoid benzo for anxiety or for sedation?
- 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.
With regards to APS what do we typically prefer for least amount of anticholingergic effects?
Risperidoen
For EPS worries which agent do we generally choose out of antipsychotics?
Which APS has lesser QT prolonging effects?
Which APS has lesser sedation?
Which APS has less likelyhood of tardive dyskinesia?
Which APS has less likely for weight gain?
Which adverse should we watch for with regards to APS usage?
weight gain, ↓BP, anticholinergic effects, sedation, falls, EPS, tardive dyskinesia, urinary retention
What is the over arching theme of when initiating APS?
Start low go slow
Which APS is generally used for managing acute delirium?
Haloperidol
What is more effective than stimulants?
External activity and environmental stimulation is
more effective
When do we use sedatives?
Considered when behaviour is thought to be directly correlated with lack of sleep OR behaviours are during night
What is often overlooked for pain management?
A good trial of acetaminophen
