Dementia Flashcards
how is dementia characterized?
Dementia is Characterized by a decline in cognition in at least one cognitive domain, such as: o Learning and memory o Language o Executive function o Complex attention o Perceptual-motor o Social cognition
Dementia Must be ____ and represent a decline from previous level of function
acquired
Major dementia syndromes
o Alzheimer disease (AD) o Dementia with Lewy bodies (DLB) o Frontotemporal dementia (FTD) o Vascular (multi-infarct) dementia (VaD) o Parkinson disease with dementia (PDD)
Alzheimer Disease (AD) has what hallmark pathologies associated with it?
o Amyloid plaques
o Neurofibrillary tangles of tau protein
o Loss of cortical neurons
Alzheimer Disease (AD) Leads to reduced cerebral content of choline acetyltransferase, which leads to a decrease in ______ synthesis and impaired cortical cholinergic function. - Involves other neurotransmitters including glutamate and 5-HT.
acetylcholine
primary desired outcome when treating patients with Alzheimer Disease (AD)
symptomatically treat cognitive difficulties and preserve function as long as possible
Secondary desired outcome when treating patients with Alzheimer Disease (AD
treat the psychiatric and behavioral sequelae
do current treatments for AD prolong life, cure AD, halt or reverse the pathophysiologic processes?
NO
Current treatments DO NOT prolong life, cure AD, halt or reverse the pathophysiologic processes
Alzheimer Disease (AD) targets of therapy
o Improve cholinergic transmission within the CNS
o Prevent excitotoxic actions caused by overstimulation of NMDA-glutamate receptors in select brain areas
patients with Alzheimer Disease (AD) Should be managed initially with ______ instead of medications
behavioral interventions
examples of behavioral interventions for patients with Alzheimer Disease
o Maintain consistent, structured environment with appropriate stimulation level
o Provide frequent reminders, explanations, and orientation cues
o Avoid confrontation: remain calm, firm, and supportive when patient becomes upset
o Reduce choices and avoid complex tasks
o Consider vision and hearing impairments- can accelerate agitation and aggression
o Maintain general health
which test has Better sensitivity, MoCA or MMSE?
MoCA
what is an Abnormal score for MoCA testing?
<26
what is the maximum MMSE score?
30
what MMSE score suggests mild dementia
20 to 24
what MMSE score suggests moderate dementia
13 to 20
what MMSE score indicates severe dementia
Less than 12
what are MILD scores for MoCA, MMSE, and CDR?
MoCA-12-16
MMSE-19-26
CDR-3
what are MODERATE scores for MoCA, MMSE, and CDR?
MoCA-4-11
MMSE-10-18
CDR-2
what are SEVERE scores for MoCA, MMSE, and CDR?
MoCA-<4
MMSE-<10
CDR-1
in a patient with Mild to moderate disease, consider starting with ________.
cholinesterase inhibitor
in a patient with Moderate to severe disease consider using/adding ________.
NMDA antagonist
Acetylcholinesterase (AChE) is an enzyme that breaks down ACh in the_____.
synapse
AChE Inhibitors drugs used to treat Alzheimer Disease
o Donepezil
o Rivastigmine
o Galantamine
Donepezil, Rivastigmine, Galantamine all have similar ______.
Similar efficacy and ADR profile
AChE Inhibitors: ADRs
- GI: n/v/d
- Anorexia and weight loss:
- Bradycardia and hypotension
- Sleep disturbances: insomnia, vivid dreams
- Other cholinergic ADRs as we’ve previously discussed
AChE Inhibitors should be avoided in patients that have issues with what things?
should be avoided in patients with baseline issues or known cardiac conduction system disease (meds that can be problematic with this: BB, CCB, anti arrhythmics)
Which neurons degenerate to cause AD?
Acetylcholine and glutamate
What is the hallmark of dementia?
a. Psychosis
b. depression
c. cognitive decline
d. CNS excitation
c. cognitive decline
what is most common ADR with AChE inhibitors?
N/V/D
If a patient is tolerating an AChE inhibitor, how long would you wait to see if it is effective?
a. 1 week
b. 1 month
c. 2 months
d. 6 months
c. 2 MONTHS
what is recommended to reserve use for more moderate to severe dementia?
a. Memantine
b. Donepezil
c. Rivastigmine
d. Galantamine
Memantine
if you are wanting to prescribe AChE Inhibitors, you should Avoid concurrent use of ______.
anticholinergic medications
AChE Inhibitors Gradual dose titration should be over _____.
months
Factors influencing drug choice for AChE Inhibitors
o Cost o Ease of use o Patient tolerability o Safety issues such as DDIs o Provider experience
what AChE Inhibitors is typically used first line due to fewer DDIs
Rivastigmine: fewer DDIs due to no CYP450 metabolism –>commonly used first line
how can you monitor AChE Inhibitors effectiveness?
Use MoCA as well as caregiver impressions of change
o Also can use recall of four-word list at 30 seconds and 5 minute along with semantic fluency (e.g., naming as many animals as possible in one minute)
o MMSE is not specific enough
when pts are on AChE Inhibitors you should have patient Follow-up at ______to assess tolerance and response
3-6 months
when pts are on AChE Inhibitors you should have patient Follow-up Every______ once on a stable dose
6-12 months
what drug is a NMDA Receptor Antagonists used for treating AD
Memantine
- N-methyl-D-aspartate (NMDA) receptors can be activated by excitatory neurotransmitters like _________.
glutamate and aspartate
this drug blocks nearly all NMDA receptors and is severely psychotoxic
phencyclidine (PCP)
Memantine ADRs
o Confusion, agitation, restlessness, hallucinations- May be indistinguishable from AD symptoms
o HTN, constipation, HA, cough
Recommendations support the management of vascular brain disease and its associated risk factors as part of AD treatment. if vascular brain disease is present, recommend _______ therapy
low-dose ASA
Recommendations support the management of vascular brain disease and its associated risk factors as part of AD treatment
If present, recommend low-dose ASA therapy.
What are some non drug therapy options?
o Physical, mental, social activity
o Low-fat, low-cholesterol diet
o Manage weight, BP, cholesterol, and glucose
AD patients exhibit a decline in ability to metabolize glucose in the brain. what is the name of a medical food you can prescribe patients?
Caprylidene (Axona)
Caprylidene is a Formulation of caprylic ______.
triglyceride
what antioxidant has been shown to be helpful with patients that have AD?
Vitamin E
Benefits of Vitamin E are likely modest and could be offset by combination therapy with _______.
memantine
Vitamin E has Reasonable intervention with mild-moderate disease at ______ IU daily
2000
Selegiline Has antioxidant properties but has not been shown to be helpful yet in__.
AD
ginkgo biloba has been Extensively studied with some positive results when using a specific extract , what is the extract?
EGb 761
ginkgo biloba Can have significant ADRs especially potent ___________.
antiplatelet effects
what are some Behavioral Symptoms that are Extremely common in dementia and should be screened at every visit?
o Aggression o Delusions o Hallucinations o Wandering o Depression o Sleep disturbances o Sexually inappropriate behavior
what are some Common paranoid delusions AD patients tend to have?
o House is being invaded
o Personal objects have been misplaced or stolen
o Family members have been replaced by impostors (Capgras syndrome)
o Spouse has been unfaithful
visual hallucinations early in course suggests Dementia with _______?
Lewy bodies
Elderly patients who become depressed are at increased risk for developing _______.
dementia
when dementia patients have agitation and paranoia what antidepressant may be warranted?
citalopram (Celexa)
what kinds of nonpharmacologic management should you start with when a dementia patients is suffering from sleep disorders?
Sleep hygiene, daytime physical activity, avoid naps, limiting evening beverages, avoid EtOH and caffeine in evening, delaying bed time
sleep disorders in dementia patients have many causes including what 4 things?
o Depression and/or anxiety
o Decreased daytime physical activity
o Nocturia
o ADRs of medications
