Dementia

Question 1

How long from onset of sx is enough to be considered as dementia?

Answer 1

≥6m

Question 2

Main pathophysiology of dementia?

Answer 2

• senile plaques
• neurofibrillary tangles
• brain atrophy (decrease cholinergic)

Question 3

Symptoms of dementia?

Answer 3

Areas affected: cognitive, psychological, behavioural, sleep, physical

• memory loss
• word-finding difficulties & loss of language
• delusion, depression, aggression, hallucinations
• wandering
• altered sleep wake cycle
• Parkinsonism

Question 4

Mini Mental State Examination scale?
- mild
- moderate
- severe

Answer 4

• mild: 20-24/30
• moderate: 10-19/30
• severe: <10/30

Question 5

Goals of therapy for dementia?

Answer 5

• slow progression
• delay the need to institutionalisation
• improve QOL of pt & caregiver

Question 6

Nonpharm for dementia?

Answer 6

• exercise, diet, sleep, social interactions
• psychological (e.g. participate in personally meaningful activities)
• cognitively stimulating activities

Question 7

Treatment options for Alzheimer’s dementia?

Answer 7

• anticholinesterase inhibitors (AI): donepezil, rivastigmine, galantamine
• non-competitive NMDA receptor antagonist: memantine

Question 8

At what stage of Alzheimer’s dementia can meds be used?

Answer 8

• donepezil: all stages
• rivastigmine: mild-moderate a/w parkinson disease
• galantamine: mild-moderate
• memantine: moderate-severe

Question 9

MOA of AI?

Answer 9

inhibit acetylcholinesterase enzyme -> increase acetylcholine at synaptic cleft for cholinergic neurotransmission

Question 10

SE of AI?

Answer 10

• N/V/D (cholinergic hyper activation), loss of appetite, increase frequency of bowel movements, increase gastric juice secretion
• vivid dreams, insomnia
• muscle cramp
• bradycardia

Question 11

AI CI?

Answer 11

• bradycardia

Question 12

When should AI be used with caution for dementia?

Answer 12

• PUD
• resp disease
• seizure disorder
• urinary tract obstruction

Question 13

Dose of donepezil?

Answer 13

PO 5mg OD (6w) -> 10mg OD (max 23mg OD)

Question 14

Dose of rivastigmine?

Answer 14

Tablet: PO 1.5mg BD (2w) -> 3mg BD (2w) -> 4.5mg BD (2w) -> 6mg BD (max)

Patch: 4.6mg/24h (4w) -> 9.5mg/24h (4w) -> 13.3mg/24h (max)

Question 15

Dose of galantamine?

Answer 15

PO extended: 8mg OD (4w) -> 16mg OD (4w) -> 24mg OD (max)

PO immediate: 4mg BD (4w) -> 8mg BD (4w) -> 12mg BD (max)

Question 16

Does galantamine or rivastigmine have a longer half life?

Answer 16

Galantamine

Question 17

How are galantamine and rivastigmine metabolised?

Answer 17

• galantamine: liver
• rivastigmine: renal

Question 18

Dose of memantine?

Answer 18

PO extended: 7mg OD (1w) -> 14mg OD (1w) -> 21mg OD (1w) -> 28mg OD (max)

PO immediate: 5mg OD (1w) -> 5mg BD (1w) -> 5mg OM & 10mg ON (1w) -> 10mg BD (max)

Question 19

SE of memantine?

Answer 19

• HA
• confusion
• dizzy
• hallucination
• constipation

Question 20

When should memantine be used in caution in pts with dementia?

Answer 20

• CVD
• seizure disorder
• severe hepatic / renal impairment

Question 21

For behavioural & psychological sx of dementia, what is the first line of treatment?

Answer 21

Non pharm

Question 22

What are some behavioural & psychological sx of dementia?

Answer 22

• agitation & aggression
• depression
• anxiety
• apathy
• psychotic sx (hallucinations, delusion)
• wandering
• nocturnal disruption

Question 23

How long should meds be used for BPSD?

Answer 23

3m, then slowly withdraw if sx improve

Question 24

Treatment options for vascular dementia?

Answer 24

• AI
• memantine

Question 25

Treatment options for dementia with Lewy bodies?

Answer 25

• AI
• memantine

Question 26

Treatment options for frontotemporal dementia?

Answer 26

• SSRIs
• memantine
• AI

Question 27

When should pt come back for follow-up when on cognitive enhancers?

Answer 27

• 3-6m after starting therapy
• Q1y after that