Dementia Flashcards
What are key features of dementia vs delerium?
dementia: Chronic, non-fluctuating
delerium is medical emergency and is acute
Key DDx of dementia:
dementia, neurodegenerative disease, chornic pysch disease
DDx for Acute mental status change that is non-flucutating, toxic metabolic derangment,
delerium
List of instramental ADL
• Cooking • House cleaning • Laundry • Management of medications • Management of the telephone • Management of personal accounts • Shopping • Use of transportation
Activities of Daily living
• Dressing • Eating • Ambulating • Toileting • Hygiene (Bathing)
Laundry list of Ddx for dementia
- Alzheimer’s disease • Vascular disease • Lewy Body disease • CVA • Depression • Frontotemporal degeneration • Hypothyrodism • Traumatic brain injury
- Substance abuse • Medication adverse reaction/side effect • HIV infection • Prion disease • Parkinson’s disease • Huntington’s disea
3 steps of mini-cog assesment
- remember three unrelated words
- Draw face of clock w/ 10 after 11:00
- Ask pt to recall words
Scoring of mini-cognitive exam
3 recalled words Negative for cognitive impairment
1-2 recalled words + normal clock Negative for cognitive impairment
1-2 recalled words + abnormal clock Positive for cognitive impairment
0 recall words Positive for cognitive impairment
What labs should we order for all pts with dementia?
CBC
Electrolytes
Creatine
Glucose
Vit B12
TSH
What is the cutoff for normal mental status in the MOCA test (out of 30)
below 26 suggest mental
What is the DSM-5 criteria for Dementia/Major Neurocognitive Disorder
A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
- Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function;
AND 2. A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
The cognitive deficits interfere with ___________
The cognitive deficits do not occur exclusively in ______
The cognitive deficits are not________
independence in everyday activities
the context of a delirium
better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).
What functional regions of the brain are implicated in dementia?
- Complex attention
- Executive function
- Learning and memory
- Language
- Perceptual-motor
- Social cognition
Gradual onset, Affected: Memory Language Visuospatial, Late Motor involvement with Gradual (8-10 y) progression and Atrophy, small hippocampal volume on imaging
Alzheimer’s Disease
Sudden & gradual onset, domain of brain affected and motor inovlement depends on area of brain: on imaging see ischemia pattern Cortical or subcortical MRI changes
Vascular dementia
Prevelence of dementia by age:
65-75:
>75
>85
65-75: 2-6%
>75: 12-13%
>85: 31%
Annabelle Arnold is a 90 year old female with a five year history of an insidious onset of slowly progressive dementia. She now requires assistance with bathing and dressing. Her husband manages her medications and finances. Her past medical history is significant for breast cancer, diabetes, and hypertension. Physical examination is positive only for kyphosis and slow gait aided with a walker. BMP, CBC, TSH, Vitamin B12 all WNL. MRI of the brain is most likely to show…
Atrophy of gyri, widening of sulci; lower brain weight,
• Diffuse plaque: extracellular accumulation of Aβ protein
Diffuse Plaque: amyloid plq seen in alzeihmers
extracellular accumulation of Aβ protein and tau containing neurites
• Neuritic plaque: amyloid plaque in alzeihmers
- Intraneuronal accumulation of an abnormally phosphorylated form of tau, a normal microtubule associated protein
- are not unique to AD: also found in other degenerative diseases
Neurofibullary Tangles (NFT)
Prognosis of Alzeihmers
•Estimates of median survival have traditionally ranged from 5 to 9 years with more recent data suggesting median survival close to 3 years with a range of 2.7 to 4 years
Alivia Arnold is a 75 year old female with clinical findings concerning for underlying Alzheimer’s disease. Which of the following are the most likely findings in the brain tissue upon autopsy?
NFTs
What meds can we use to tx cognitive issues of Alzeihmers
Cholinesterase inhibitors: Donepezil; Rivastigmine; Galantamine
– NMDA noncompetitive antagonist: Memantine
What meds can we use to tx behavioral symptoms of Alzeihmers
– Cholinesterase inhibitors and NMDA antagonists have some modest efficacy
– Atypical antipsychotics
– Mood stabilizers
– Antidepressants
Medications associated w/ delerium
Anticholingeric medications: plasma conc of these meds are directly related to increased delerium risk
What can we use to treat AD, dementia with Lewy bodies, vascular dementia
First line therapy to treat cognitive impairments in mild to moderate dementia
Drugs: Donepezil; Rivastigmine; Galantamine
Modest improvement, many side effects (1/3 have GI problems), muscle cramping and abnormal dreams
Used with caution in patients with bradycardia or syncope, because of vagotonic properties
What type of drugs are: Rivastigmine, Galantimne and Doneprizil and what are their sides?
What pts do we need to be careful of when prescribing
Reversible, centrally-acting cholinesterase inhibitors
(1/3 have GI problems), muscle cramping and abnormal dreams
Used with caution in patients with bradycardia or syncope, because of vagotonic properties
MOA and reasoning for useing Memantidine to tx Alzeihmers
Reversible, centrally-acting cholinesterase inhibitors
useful d/t excitotoxicity, oxidative stress and neuroinflammation seen from AD
Sides = dizzy and headache
Common behavioral and pysch stuff in AD pts
– Irritability and agitation – Paranoia and delusional thinking – Wandering – Anxiety
- Efficacious therapy for agitation and psychosis
- Psychotic symptoms are generally treated with low doses; sometimes with short intervals
- Use is often limited by adverse effects; eg parkinsonism, sedation and falls
Atypicals: risperidone, olanzapine, quetiapine
The use of atypical antipsychotics in elderly patients with dementia-related psychosis is associated with higher risk for____ and ____
• 1.6-1.7 FOLD INCREASE IN MORTALITY COMPARED TO PLACEBO
stroke and overall mortality
Why do elederly w/ dementia have big black box warning for atypicals?
- Mortality is due to heart failure, sudden death or pneumonia
- Equivalent risk for typical and atypical suggests that it is reduced D2 receptor signaling
MOod stabalizers for pts w/ AD
- Carbamazepine: some benefits, but numerous risks in elderly
- Lithium: Some benefit, but narrow therapeutic window in elderly patients
- Benzodiazepines: Occasional control of acute agitation; not good for long-term treatment because of adverse effects on cognition
- Haloperidol: useful for acute aggression; sedation and EPS limit long-term use
What antidepressants should we use on AD pts?
SSRIs
not TCA’s dt anticholinergic effects
Tx summary for AD
- Upon presentation, ________ treatment is initiated
- As disease progresses,______ can be added
- Mild behavioral problems:_____
- Severe behavioral symptoms:______
cholinesterase inhibitor
memantine
SSRI
atypical antipsychotics
What meds can aggravate cognitive impairments
• Anticholinergics • Benzodiazpines • Sedative/hypnotics
What meds are seen in studies to lower risk for AD
NSAIDS or estrogen
The labs were negative including BMP, LFT, TSH, vit. B12, RPR, Lyme disease. MMSE was performed and he scored 18/30 with impairment in orientation, drawing, delayed recall, comprehension and attention. The physical exam was remarkable for kyphosis, masked facies, shuffling gate, mild rigidity, psychomotor retardation and hypophonic speech. Wife disclosed that motor symptoms started four months after he started experiencing the cognitive decline and that her husband has fallen several times. At night while asleep, he is sometimes restless. He looks like he is fighting in his dreams and has accidently hit his wife a couple times
think Parkinsons
Second most common type of degenerative dementia.
- Accounts for 10-20% of dementias.
- More frequent in men and mean age of onset is 75 years.
- Most cases are sporadic, however there is an autosomal dominant inherited form associated with the alpha synuclein gene in some families.
Dementia with Lewy Body
Gradual cognitive decline. Dementia often presenting symptom.
- Early in course: attention, visuospatial and executive function, poor job performance getting lost.
- Later in a course memory is impaired.
Dementia with Lewy Body
Three core Clinical features of lewy body dementia
Flucutaiton in alertness: from seconds to days
Visual hallucinations: simple or complex; often precede motor symptoms
Parkinsonism: bradykinesia, ridgid, tremor less common and these ocur later
• Repeat falls • Neuroleptic sensitivity result in severe parkinsonism, typical more than atypical, it’s not dose related • REM sleep disorder-vivid dreams in REM sleep without muscle atonia, patients act out their dreams
Lewy body Dementia
• Syncope or LOC • Orthostasis-associated with carotid sinus sensitivity • Autonomic dysfunction: urinary incontinence or retention, constipation, impotence. • Auditory hallucinations and delusions • Depression, 40% will have MDD
features of Lewy Body Dementia
How do we dx LBD
- Imaging supportive but not diagnostic
- MRI often shows generalized atrophy, SPECT/PET scan shows decreased perfusion in occipital lobes
-round, eosniophilic, intracytoplasmic inclusions in the nuclei of neurons
Lewy Bodies (seen in LBD)
major component of Lewy bodies
Alpha synuclein
common location for Lewy Body dementia in brain
-found in deep cortical layers throughout the brain -anterior, frontal and temporal lobes -cingulate gyrus and insula
Where is neuron loss of lewy body dementia?
greater in frontal lobes, nucleus basalis of Meynert, substantia nigra and LC
Do we see amyloid plaques or NFTs in DLB? What about NFTs?
- Amyloid plaques are often present but NFTs are rare in DLB.
- Neurofibrillary tangles are sparse or absent
What happens to cortical levels choline acetyl transferase in Lewy Body dementia
DECREASE
Prognosis of Lewy Body Dementia
Prognosis very poor. No therapies are known to alter the natural progression of the underlying neurodegeneration or time of death. Average survival is similar to that of AD, about 8 years.
Recommended management for Lewy Body Dementia
Nonpharmacologic treatments is emphasized: addressing environmental, medical, psychologic and social factors. Also caregiver education and support.
Meds for LBD with REM sleep disorder
Low dose Clonazepam or Melatonin
Antiparkonsin medication that can be used for LBD
Levodopa-carbidopa well tolerated, avoid anticholinergics
What antipyschotics can be used for LBD?
When antipsychotics needed atypical agents are preferred like Olanzapine or Quetiapine with the goal to avoid long term usage.
What medications can we give to pts with LBD for their Parkinsonian syptoms?
What about for REM sleep disorder?
Antiparkinsonian medications: Levodopa-carbidopa well tolerated, avoid anticholinergics.
• REM sleep behavior disorder: low dose of Clonazepam. Melatonin might be helpful.
- MRI often shows generalized atrophy
- SPECT/PET scan typically shows decreased perfusion in occipital lobes
Lewy Body Dementia
MRI shows generalized atrophy, shrinkage of hippocampus, and enlarged ventricles
Alzeihmers disease
MRI often shows white matter lesions
Vascular dementia
What are the three core features of Lewy Body Dementia?
Cognitive fluctuations, Parkinsoniasm, visual hallucinations
What are three supportive features of LBD?
Neuroleptic sensitivity
REM sleep disorder
Delusions
Alpha-synuclein is a major component of…
Lewy bodies
65 year old male has been frustrated as he is forgetting phone numbers and misplaces his keys. Otherwise he is doing well and his daily functioning is not impaired. His father had Alzheimer’s disease. On MMSE he scored 28/30, he lost two points on delayed recall. What is most likely diagnosis
Mild cognitive impairment
What is the second most common type of dementia?
Vascular dementia
Mr. Smith is 60 yo male who was brought by his son for evaluation. Son reported that four years ago his father became socially inappropriate, making sexual comments to his female neighbors. Mr. Smith was evicted from apartment due to poor environmental hygiene and complaints made by his neighbors as he was urinating in a hallway.
On neuropsychology testing Mr. Smith showed executive and visuospatial deficits along with deficits in attention and language. The memory is preserved however he is not able to work or live independently.
Labs were within normal limits. On physical exam he had no focal signs and didn’t exhibit any signs of movement disorder. What is most likely diagnosis?
Frontotemporal dementia (FTD)
70 year old male came for evaluation due to memory problems started a year ago. Physical exam was significant for bradykinesia, rigidity, and pill-rolling tremor. You found in his history that he has parkinsonian features for the past five years and has been taking sinemet. Neuropsychology testing was done and showed deficits in executive function along with visuospatial, memory and language impairment. He has no Hx of stroke. What is most likely diagnosis?
Parkinson’s disease dementia (PDD)
