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Patient Semester 2 > Dementia > Flashcards

Dementia Flashcards

1
Q

What is Alzheimer’s disease?

A
  • neurodegenerative disease leading the patient to a state of depersonalisation and complete dependence
  • best known cause of dementia, about 2/3 of cases
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2
Q

Risk factors for Alzheimer’s?

A
  • age
  • genetic inheritance
  • lifestyle and general health
  • environmental factors
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3
Q

Two main types of symptoms of Alzheimer’s?

A
  1. cognitive deficits
  2. non-cognitive impairments
    - depression, psychosis, agitation, apathy, insomnia, sexual disinhibition
    - 90% of people will develop these symptoms at some point in their lives
    - associated with increased caregiver burden, higher costs of care etc.
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4
Q

What is BPSD?

A

Behavioural and Psychological Symptoms of Dementia (the non-cognitive impairments)

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5
Q

What are the two abnormal proteins that build in the brain in Alzheimer’s?

A
  • B-amyloid plaques

- Tau tangles

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6
Q

What is the Amyloid Cascade hypothesis?

A
  • APP cut by alpha secretase which releases useful proteins (neurogenic and neurotrophic)
  • when APP is cut by beta secretase, releases amyloid which deposit and turn into plaques - leading to neurodegeneration
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7
Q

What happens to amyloid beta that causes damage?

A

forms:

  • Oligomers
  • Protofibrils
  • Oligomers form protofibrils and annular aggregates

These then form amyloid fibrils which lead to plaques

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8
Q

Place of cholinesterase inhibtors in Alzheimer’s?

A

useful for patients with mild to moderate disease
inhibit breakdown of acetylcholine so increase amount of neurotransmitter in the brain
don’t slow disease progression but can help to improve function

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9
Q

What are the three cholinesterase inhibs used in Alzheimer’s?

A

Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)

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10
Q

What are three novel approaches in treating Alzheimer’s?

A
  1. Secretase modulators (decrease amyloid beta production)
  2. Anti-aggregants (prevent amyloid beta aggregation)
  3. Immunotherapies (clear amyloid beta depositions)
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11
Q

What are the difficulties in trialling Alzheimer’s treatment in terms of biomarkers?

A

Amyloid beta is almost completely accumulated by the time the patient is clinically significant, so difficult to intervene before the plaque buildup

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12
Q

What is a current focus of alzheimer’s research?

A

Understanding how Aβ oligomers target synapses

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13
Q

Effect of resveratrol on amyloid beta oligomers?

A

Reduces oligomers, far less binding and attack of neurones

disrupts binding of amyloid beta to neurones

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14
Q

What are the spectrum of symptoms that describe dementia?

A
  • loss of concentration
  • orientation problems
  • memory problems
  • mood and behaviour changes
  • impaired decision making and judgement
  • later: speech/swallowing difficulties, incontinence and mobility issues
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15
Q

What occurs at mild dementia?

A

prominent memory loss. Core activities of daily living (ADL) maintained but higher level functions impaired

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16
Q

What happens at moderate dementia?

A

worsening cognition. Core ADL now affected. Challenging behaviours may become more prominent

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17
Q

What happens at severe dementia?

A

apathy and dependency prominent. Many patients receiving 24 hour care

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18
Q

Characteristics of vascular dementia?

A
  • decline can be gradual or sudden (e.g. stroke)
  • memory may be better preserved
  • physical symptoms include slurred speech, dizziness, inability to recognise objects, difficulty performing motor tasks
  • emotional liability
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19
Q

Characteristics of Alzheimer’s disease?

A
  • memory impairment is the most prominent feature early on

- difficulty finding words, disorientation, memory loss, problems performing activities of daily living

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20
Q

Characteristics of Lewy Body dementia?

A
  • cognitive slowing is an important feature
  • degeneration of motor function
  • confusion, attention deficit, executive function etc, not memory problems
    Three key features:
  • fluctuating cognition
  • recurrent visual hallucinations
  • spontaneous Parkinsonianism
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21
Q

How is dementia diagnosed?

A
  • accurate and comprehensive history
  • routine haemotology and biochemistry, thyroid, b12, folate
  • mid-stream urine, X-ray, ECG
  • opportunistic screening, e.g. hospital admission, NHS health checks
  • MRI scans can be used to exclude space occupying lesions
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22
Q

ICD-10 criteria for dementia diagnosis?

A
  • Memory loss must be present
  • Plus decline in one other domain of cognition (e.g. judging, reasoning, planning) such as that it interferes with activities of daily living (ADLs)
  • Some change in social behaviour (e.g. irritable, apathy, lability)
  • Decline lasting at least 6 months
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23
Q

NICE guidance on diagnosing dementia?

A

diagnosis should be supported by a referral to a specialist service such as a memory clinic, who perform a range of tests including those for cognition

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24
Q

Dementia tests: Mini mental state examination

A

Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are… apple [pause], penny [pause], table [pause]. Now repeat those words back to me.’
[Repeat up to 5 times, but score only the first trial.]

25
Q

Dementia tests: 7 minute screen

A

Benton Temporal Orientation Test: identify the correct day, month, year, date, time of day. Answers adjusted for how close they are to the correct answer.

26
Q

Dementia tests:

A

Count backwards from 20-1

[Correct – 0 points] [one error – 2 points] [ >1 error – 4 points]

27
Q

General principles of treating dementia?

A
  • Treatment is not curative
  • Multiple drug and non-drug treatments may be needed to control the illness
  • Treatment should be guided by a holistic view of the patient and their carer(s)
  • try to facilitate community living
  • always try to involve in decisions
  • speak to patients about lasting power of attorney
28
Q

Holistic treatment factors to consider for dementia?

A
  • Identify and accommodate specific cultural, dietary, spiritual, age related and gender issues
  • Consider learning disability, communication difficulties, sensory impairment
  • Identify and address problems with nutrition and self-care
  • Ensure co-morbidities managed appropriately
29
Q

What are the two main types of drugs licensed for dementia treatment?

A
  • Acetylcholinesterase (AChE) inhibitors are the main drug treatment
  • Memantine is a NMDA antagonist and is the only other drug licensed
30
Q

Which AChE inhibitors are the most effective?

A

None - no major differences in efficacy

31
Q

When are AChE inhibitors cautioned?

A

Sick sinus syndrome or cardiac conduction conditions (e.g. sinoatrial block)
Those at risk of ulcers
History of asthma/COPD
Renal/hepatic impairment, more specific advice for memantine

32
Q

Side effects of AChE inhibitors?

A

GI: N&V, anorexia, ulceration, upset
CNS: Alertness and agitation, hallucinations, dizziness, insomnia, seizures
GUS: Urinary incontinence
Cardiac: Bradycardia, sinoatrial/atrioventricular block

33
Q

Side effects of memantine?

A

headache, dizziness, constipation, hypertension, somnolence

34
Q

Non-pharmacological treatments for dementia?

A
  • Lifestyle interventions
  • Familiarity and routine
  • Enhancing visibility
  • Consider holistic needs
  • Treat comorbidities
  • Cognitive stimulation
  • Challenging behaviours
35
Q

Lifestyle interventions for dementia?

A

stop smoking, weight reduction, reduce alcohol, 5-a-day, proper exercise, sugar/salt/fat management

36
Q

Familiarity and routine to implement for dementia?

A
  • Keep a diary or use reminder charts

- Remember rooms are designed to look like by-gone eras

37
Q

How to enhance visibility in dementia?

A

Use colour and size to make things stand out, e.g. telephones, toilets and doorways
Orientation boards containing date, weather symbols and time

38
Q

How can you treat challenging behaviours in dementia?

A

Animal therapy, massage, music, multisensory stimulation

39
Q

When are AChE recommended according to NICE for dementia?

A

mild to moderate Alzheimer’s

40
Q

When are NMDA antagonists recommended for dementia according to NICE?

A
  • moderate Alzheimer’s when AChE not possible

- severe Alzheimer’s

41
Q

When can combination therapy in Alzheimer’s be considered?

A

Considered if moderate disease

Offered if severe disease

42
Q

Treatment options for vascular dementia?

A

DO NOT use AChE inhibitors or memantine for treatment of VD, except if co-morbid AD

Risk factor control is central - treating hypertension (though not much evidence statins/anticlotting reduces disease progression

43
Q

Treatment options for Lewy Body dementia?

A

Offer donepezil or rivastigmine to those with mild-moderate DLB, galantamine in reserve. Consider these in severe DLB. Offer memantine if AChE not tolerated/contraindicatred

44
Q

Response rate of Alzheimer’s patients to AChE inhibitors?

A

1/3 show no response at all
1/3 show transient improvements then decline
1/3 show steady state functioning before declining

In those who do not respond, switching is useful in 50%of patients

45
Q

How to increase doses of dementia drugs?

A

Galantamine after 1 month
Rivastigmine after 2 weeks
Memantine after 1 week

46
Q

Counselling points for rivastigmine?

A
  • change site of patch daily, avoid previous sites for 14 days
  • give away from food (galantamine also)
47
Q

NICE guidance on stopping dementia drugs?

A

do not stop due to disease severity alone - effects are lost rapidly and difficult to recover

48
Q

Difficulties in giving medication to dementia patients?

A
  • swallowing ability
  • covert administration
  • remembering and understanding the need for tablets
49
Q

What formulations of dementia medicines are available?

A

Tablets - donepezil, rivastigmine, galantamine (also capsules), memantine
Soluble tablets - donepezil
Liquid - rivastigmine, galantamine, memantine
Patch - rivastigmine

50
Q

Drugs to avoid in dementia?

A

Anticholinergics (Hyoscine hydrobromide (NOT butylbromide), Procyclidine, Oxybutynin, Promethazine, Orphenadrine)
Alpha blockers (Prazosin, tamsulosin)
Opiates
Benzodiazepines
Sedating antihistamines (Chlorphenamine, cyclizine, promethazine)

51
Q

Examples of BPSD?

A

agitation (Verbal / physical, Antisocial behaviours, Sexual arousal/aggression, Self harm, Apathy / withdrawal), wandering, aggression, abnormal vocalisations, mood changes and psychosis

52
Q

First line treatment for BPSD?

A

watchful waiting, central goal of preventing harm and suffering

53
Q

How to rule out other causes of BPSD?

A

PAIN acronym
Physical problems – infection, pain, constipation, dehydration, malnourishment?
Activity related – washing, dressing?
Iatrogenic – side effects of medication, inappropriate care?
Noise and other environmental factors such as lighting

54
Q

Non-drug methods for treating/dealing with BPSD?

A 
Talking down and distraction
Aromatherapy, music therapy
Snoezelen 
Massage, reflexology 
Psychoeducation for carers – understanding individual patients 
Time out
55
Q

Pharmacological treatments for BPSD?

A

a trial of paracetamol might be worthwhile

  • Use pharmacotherapy only if severe distress or an immediate risk of harm to the person with dementia or others
  • Drug treatments include Antipsychotics, AChE inhibitors and memantine. Some evidence for AChE inhibitors of modest positive effects, NICE recommends use in DLB and in AD when other non-pharmacological treatments are not effective or inappropriate, and when antipsychotics are also inappropriate or ineffective. Less evidence for memantine . Antidepressants. Use SSRIs in some cases, evidence is weak

Only licensed UK treatment is risperidone
covert administration may be required

56
Q

Why avoid older antipsychotics in BPSD?

A

Parkinson’s symptoms, EPSE, falls and drowsiness, cognitive blunting

57
Q

Why try to avoid antipsychotic use in BPSD when possible?

A

Increased risk of stroke and mortality with all antipsychotics now limit use - Possible mechanism due to orthostatic hypotension and tachycardia
Most evidence for risperidone/olanzapine in BPSD, but also greatest harm risk

58
Q

Monitoring required when using an antipsychotic for BPSD?

A

If used, must have clear target symptoms, use lowest effective dose, review after 1-2 weeks (NICE – 6 weeks)

Patient Semester 2 (10 decks)

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