dementia Flashcards
What are some complications of dementia?
delirium
behavioral &psych disturbances
caregiver stress
concerns for advance care planning
Define dementia
A decline in one or more cognitive domains from previous functioning
that is severe enough to interfere with everyday activities
– Insidious onset and progressive decline
– No other medical or psychiatric explanation
Define mild neurocognitive disorder
Mild: Modest impairment and decline in cognitive performance
that does not interfere with ADLs
define major neurocognitive disorder
Major: Decline in 1 or more cognitive domains, 2 SDs below
norms, that interferes with ADLs
What are the 6 neurocognitive domains?
Language learning and memory social cognition complex attention perceptual-motor function executive function
What are examples of language domain?
Object naming word finding fluency grammar and syntax receptive language
What are examples of learning and memory
Free recall cued recall recognition memory semantic and autobiographical long term memory implicit learning
What are examples of social cognition?
recognition of emotions
theory of mind
insight
What are examples of complex attention?
Sustained attention
divided attention
selective attention
processing speed
What are examples of perceptual-motor function?
Visual perception
visuoconstructional reasoning
perceptual-motor coordination
What are examples of executive function?
planning decision-making working memory responding to feedback inhibition flexibility
What are the 5 types of dementia?
- mild cognitive impairment (MCI)
- alzheimer’s disease
- vascular dementia
- frontotemporal dementia
- dementia with Lewy bodies
What is MCI?
- impairment in one or more cognitive domain
- more than normal aging
- declines from baseline
- does not interfere with ADLS
- amnestic vs non-amnestic MCI
How do you manage MCI?
- r/o modifiable causes
- non-pharm management
- frequent monitoring for progression
- support in coping
- discuss advance care planning
What is vascular dementia?
- presentation based on extent and location of cerebrovascular event
- stepwise declines
- history of vascular risk facotrs, CVA or TIA
- caused by small vessel ischimic (SVID) disease, reduced blood flow leading to cell death
- MRI shows infarct & white hyper-intensities
How does one manage vascular dementia?
Mitigate risk factors
– Smoking, DM, obesity, hypercholesterolemia, atrial fibrillation and atherosclerosis
– Heart healthy life style
– Non-pharmacological management depending on presentation
– Monitor for progression
What is alzheimer’s disease?
Impairment in one or more cognitive domain, primarily memory – More than normal aging – Decline from baseline – DOES interfere with ADLs Early changes are primarily recent and episodic memory, later progressing to difficulty with visuospatial function & language
What causes alzheimer’s disease?
Caused by beta amyloid plaque
and neurofibrillary tau tangles
Hippocampal
volume loss
What might you see in mild alzheimer’s disease?
Forgetting words or names - Difficulty at work - Forgetting material just read - Losing or misplacing valuables - Difficulty with planning and organizing
What might you see in moderate alzheimer’s disease?
Forgetting personal history - Changes in mood, less social interaction - Disorientation to day or location - Inappropriate clothing choice - Some difficulty controlling bowel or bladder - Changes in sleep - Increased wandering - Personality changes
What might you see in severe alzheimer’s disease?
Increasing disorientation
- Physical changes
- Limited communication
- Complications
Describe frontotemporal dementia
Progressive atrophy of frontal and/or temporal lobes Changes in behavior, personality, and/or language, while memory is persevered Earlier onset
What comprises behavioral variant frontotemporal dementia?
personality changes executive dysfunction behavior changes apathy perseveration stereotyped behaviors
What are different primary progressive aphasias?
1. Semantic Dementia or semantic variant PPA - Fluent speech - Impairment in semantic categories 2. Progressive Non-fluent Aphasia or agrammatic PPA - Non-fluent speech - Speech errors 3. Logopenic variant of PPA - Slow, effortful speech - No motor loss or grammar errors
What are two types of dementia with lewy bodies?
Parkinson’s Disease with Dementia
- Cognitive impairment > 1 year
Lewy Body Dementia
- Cognitive impairment < 1 year
What are core features and suggestive features of dementia with lewy bodies?
Core Features Fluctuation cognition with pronounced variations in attention and alertness Complex visual hallucinations Parkinsonism Suggestive Features REM sleep behavior disorder Sensitivity to anti-psychotics Low dopamine uptake
What are supportive features of dementia with lewy bodies?
Supportive Features Repeated falls and syncope Transient, unexplained loss of consciousness Autonomnic dysfunction Hallucinations Visuospatial abnormalities Other psychiatric disturbances
What comprises a good health history for dementia?
- determine reliable historian
- assess age
- personal history (past medical, trauma, stroke, chromosome abn, social, ETOh, ID, veteran, sports),
- med review (anticholinergics, sedating, herbals),
- family history (first degree relatives with dementia, movement disorder, stroke)
HPI and ROS for dementia
- CC; insight
- progression/timing –> precipitating events, insidious, progressive, worse than baseline
- assess severity with ADLS
- ask about each cognitive domain: memory, language, visuospatial function, attention, executive function, behavior/personality
- psych RO –> anx/depression, insomnia
- r/o other causes –> metabolic, mood, trauma, infectious
Physical exam
- complete neuro exam
- psych exam
- other symptoms to r/o suspected causes
- cognitive assessment
describe the mini cog test
what score means needs further assesssment?
- Say these words after me and try to remember them.
- Draw a clock with all the numbers. Then put the hands at ten past eleven.
- What were those words I asked you to remember?
* *further assess <3 points, some say <4.
What is the Montreal cognitive assessment? (MoCA)
Assesses 5 out of 6 Cognitive Domains - Memory - Visuospatial functioning - Executive functioning - Attention - Language - Does NOT assess for behavior or personality changes - Add ONE point for education level <12 - Health professionals can use the test free of charge & no need for permission **naming, drawing, words recall, animals
St. Louis University Mental Status Exam?
Also 5/6 domains, another option
Mini mental status exam? benefits/drawbacks
only good for alzheimers, mostly for memory domain.
What biomarkers/labs to draw?
Labs: CBC, blood sedimentation rate, electrolytes, calcium, glucose,
renal and liver functions, thyroid functions, vitamin B12, folic acid,
syphilis, human immunodeficiency virus, and urinalysis
CSF: tau, β-amyloid, 14-3-3
Genetics: Apo E, C9, MAPT, GRN
Imaging: CT, MRI, SPECT, PET (amyloid PET & DaT)
Definitive diagnosis only occurs on autopsy
Risk reduction strategies for dementia
Heart health = brain health – Physical activity – Management of cardiovascular risk factors (diabetes, obesity, smoking, HTN) – Education – “Cognitive Reserve” – Social determinants – Social and Cognitive Engagement – Traumatic Brain Injury avoidance – Seat belts, helmets, high risk sports, veteran status
Pharmacological Management
CAVEATS
Not disease modifying
– Slow or delay worsening symptoms
– Medications are not indefinite
– Only useful in certain types of dementia
What are Acetylcholinesterase inhibitors approved for mild to moderate dementia?
Acetylcholinesterase inhibitors: approved for mild to moderate dementia
– Donepezil (Aricept)
– Mild: Start 5 mg po at bedtime for 4-6 weeks, then increase to 10 mg po at bedtime
– Moderate: Start 5 mg po at bedtime for 4-6 weeks, then increase to 10 mg po at bedtime for 3 months, then increase to 23
mg at po at bedtime (do not crush 23 mg dose)
– Rivastigmine (Excelon)
– Capsule (give with food)
– Mild to Moderate: Start 1.5 mg po bid, increase by 1.5 mg/dose every 2 weeks as tolerated. Max 12 mg/day
– Transdermal
– Apply 4.6 mg/24 hrs patch every day for 4 weeks, then increase to 9.5 mg/24 hr x 4 weeks, then increase to 13.3 mg/24 hr
– If converting from 6-12 mg of oral go straight to 9.5 mg/24 hr patch
– Galantamine (Razadyne)
– Immediate Release (give with food): Start 4 mg po bid, increase by 4 mg bid every 4 weeks until 12 mg bid
– Extended Release (give with food): Start 8 mg po q am and increase 8 mg daily every 4 weeks until max dose 24 mg
NMDA receptor antagonist: Approved for moderate to severe dementia
– Memantine (Namenda)
– Immediate Release (tablet or liquid): Start 5 mg daily and increase by 5 mg/day every week
as tolerated until at max dose of 20 mg/day Give doses > 5 mg/day in bid
– Extended Release (tablet only, do not crush or chew): Start 7 mg po daily, increase by 7 mg
daily every week as tolerated until at max dose of 28 mg daily.
– May switch from 10 mg IR bid to 21 mg ER then increase to 28 mg
non-pharm management
Maintain Behavior Log
– Determine when symptoms are likely to occur
– Determine precipitants of symptoms & avoid triggers
– Plan interventions to reduce the precipitantsActivities
– Caregiver education and support
– Communication
– Simplify the environment
– Simplify the tasks
What is the ABC method?
Antecedent
Behavior
Consequence
What are interventions to improve comprehension?
Speak slowly – Use shorter and simpler sentences – Speak redundantly – Speak in context – Use gestures – Use picture cards – Speech therapy
Interventions to facilitate speech?
– Give it time
– Written communication
– Computer assistive devices
– Timing your support
Interventions to Assist with Spatial Orientation:
– Mark problem areas
– Stairs
– Remove throw rugs and toys
– Driving!
Interventions to Assist with Apraxia:
– Consider Physical Therapy
– Consider Occupational therapy
What are triggers for reassessment?
Safety concerns
Sudden change in behavior
significant caregiver distress
Pharmacological Management
Behavioral & Psych Symptoms
– Antipsychotics (check baseline EKG)
– Seroquel: Start 12.5 mg at bedtime, double as tolerated (max: ??)
– Risperidone: Start 0.5 mg at bedtime (max 2 mg)
– Zyprexa: Start 2.5 mg at bedtime (max 10 mg)
– Anticonvulsants
– Carbamazepine: 200 - 600 mg
– Valproic acid: 500 – 1000 mg
Pharmacological Management
Psychiatric Symptoms
– Antidepressants – Sertraline: Start 25 mg (max 100 mg) – Fluvoxamine: Start 25 mg (max 100 mg) – Trazodone: Start 25 mg at bedtime (max 300 mg) – Anxiolytics – NOPE
End of life concerns
– Advance Care Planning early! – Discuss the patients wishes – What gives them quality? – Do you want hospice involved? – Health care proxy and/or power of attorney– Treatment decisions making – CPR – Artificial nutrition – Intubation – Exit Ramps – Frequent aspiration pneumonias – Frequent and/or debilitating falls – Significant dysphagia leading to weight loss and cachexia – Pressure ulcers with septicemia
