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AGPCNP > dementia > Flashcards

dementia Flashcards

1
Q

What are some complications of dementia?

A

delirium
behavioral &psych disturbances
caregiver stress
concerns for advance care planning

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2
Q

Define dementia

A

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

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3
Q

Define mild neurocognitive disorder

A

Mild: Modest impairment and decline in cognitive performance

that does not interfere with ADLs

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4
Q

define major neurocognitive disorder

A

Major: Decline in 1 or more cognitive domains, 2 SDs below

norms, that interferes with ADLs

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5
Q

What are the 6 neurocognitive domains?

A 
Language
learning and memory
social cognition
complex attention
perceptual-motor function
executive function
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6
Q

What are examples of language domain?

A 
Object naming
word finding
fluency
grammar and syntax
receptive language
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7
Q

What are examples of learning and memory

A 
Free recall
cued recall
recognition memory
semantic and autobiographical long term memory
implicit learning
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8
Q

What are examples of social cognition?

A

recognition of emotions
theory of mind
insight

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9
Q

What are examples of complex attention?

A

Sustained attention
divided attention
selective attention
processing speed

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10
Q

What are examples of perceptual-motor function?

A

Visual perception
visuoconstructional reasoning
perceptual-motor coordination

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11
Q

What are examples of executive function?

A 
planning
decision-making
working memory
responding to feedback
inhibition
flexibility
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12
Q

What are the 5 types of dementia?

A
  1. mild cognitive impairment (MCI)
  2. alzheimer’s disease
  3. vascular dementia
  4. frontotemporal dementia
  5. dementia with Lewy bodies
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13
Q

What is MCI?

A
  • impairment in one or more cognitive domain
  • more than normal aging
  • declines from baseline
  • does not interfere with ADLS
  • amnestic vs non-amnestic MCI
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14
Q

How do you manage MCI?

A
  1. r/o modifiable causes
  2. non-pharm management
  3. frequent monitoring for progression
  4. support in coping
  5. discuss advance care planning
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15
Q

What is vascular dementia?

A
  • 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
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16
Q

How does one manage vascular dementia?

A

Mitigate risk factors
– Smoking, DM, obesity, hypercholesterolemia, atrial fibrillation and atherosclerosis
– Heart healthy life style
– Non-pharmacological management depending on presentation
– Monitor for progression

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17
Q

What is alzheimer’s disease?

A 
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
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18
Q

What causes alzheimer’s disease?

A

Caused by beta amyloid plaque
and neurofibrillary tau tangles
Hippocampal
volume loss

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19
Q

What might you see in mild alzheimer’s disease?

A 
Forgetting words or names
- Difficulty at work
- Forgetting material just read
- Losing or misplacing
valuables
- Difficulty with planning and
organizing
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20
Q

What might you see in moderate alzheimer’s disease?

A 
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
21
Q

What might you see in severe alzheimer’s disease?

A

Increasing disorientation

  • Physical changes
  • Limited communication
  • Complications
22
Q

Describe frontotemporal dementia

A 
Progressive atrophy of frontal
and/or temporal lobes
Changes in behavior,
personality, and/or language,
while memory is persevered
Earlier onset
23
Q

What comprises behavioral variant frontotemporal dementia?

A 
personality changes
executive dysfunction
behavior changes
apathy
perseveration
stereotyped behaviors
24
Q

What are different primary progressive aphasias?

A 
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
25
Q

What are two types of dementia with lewy bodies?

A

Parkinson’s Disease with Dementia
- Cognitive impairment > 1 year
Lewy Body Dementia
- Cognitive impairment < 1 year

26
Q

What are core features and suggestive features of dementia with lewy bodies?

A 
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
27
Q

What are supportive features of dementia with lewy bodies?

A 
Supportive Features
Repeated falls and syncope
Transient, unexplained loss
of consciousness
Autonomnic dysfunction
Hallucinations
Visuospatial abnormalities
Other psychiatric
disturbances
28
Q

What comprises a good health history for dementia?

A
  1. determine reliable historian
  2. assess age
  3. personal history (past medical, trauma, stroke, chromosome abn, social, ETOh, ID, veteran, sports),
  4. med review (anticholinergics, sedating, herbals),
  5. family history (first degree relatives with dementia, movement disorder, stroke)
29
Q

HPI and ROS for dementia

A
  1. CC; insight
  2. progression/timing –> precipitating events, insidious, progressive, worse than baseline
  3. assess severity with ADLS
  4. ask about each cognitive domain: memory, language, visuospatial function, attention, executive function, behavior/personality
  5. psych RO –> anx/depression, insomnia
  6. r/o other causes –> metabolic, mood, trauma, infectious
30
Q

Physical exam

A
  • complete neuro exam
  • psych exam
  • other symptoms to r/o suspected causes
  • cognitive assessment
31
Q

describe the mini cog test

what score means needs further assesssment?

A
  1. Say these words after me and try to remember them.
  2. Draw a clock with all the numbers. Then put the hands at ten past eleven.
  3. What were those words I asked you to remember?
    * *further assess <3 points, some say <4.
32
Q

What is the Montreal cognitive assessment? (MoCA)

A 
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 &amp; no need for permission
**naming, drawing, words recall, animals
33
Q

St. Louis University Mental Status Exam?

A

Also 5/6 domains, another option

34
Q

Mini mental status exam? benefits/drawbacks

A

only good for alzheimers, mostly for memory domain.

35
Q

What biomarkers/labs to draw?

A

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

36
Q

Risk reduction strategies for dementia

A 
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
37
Q

Pharmacological Management

CAVEATS

A

Not disease modifying
– Slow or delay worsening symptoms
– Medications are not indefinite
– Only useful in certain types of dementia

38
Q

What are Acetylcholinesterase inhibitors approved for mild to moderate dementia?

A

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

39
Q

NMDA receptor antagonist: Approved for moderate to severe dementia

A

– 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

40
Q

non-pharm management

A

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

41
Q

What is the ABC method?

A

Antecedent
Behavior
Consequence

42
Q

What are interventions to improve comprehension?

A 
Speak slowly
– Use shorter and simpler sentences
– Speak redundantly
– Speak in context
– Use gestures
– Use picture cards
– Speech therapy
43
Q

Interventions to facilitate speech?

A

– Give it time
– Written communication
– Computer assistive devices
– Timing your support

44
Q

Interventions to Assist with Spatial Orientation:

A

– Mark problem areas
– Stairs
– Remove throw rugs and toys
– Driving!

45
Q

Interventions to Assist with Apraxia:

A

– Consider Physical Therapy

– Consider Occupational therapy

46
Q

What are triggers for reassessment?

A

Safety concerns
Sudden change in behavior
significant caregiver distress

47
Q

Pharmacological Management

Behavioral & Psych Symptoms

A

– 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

48
Q

Pharmacological Management

Psychiatric Symptoms

A 
– 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
49
Q

End of life concerns

A 
– 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

AGPCNP (30 decks)

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