Dementia and Alzheimer’s Disease Diagnosis, treatment and pharmaceutical care Flashcards
What is dementia?
- Dementia is a clinical syndrome that includes difficulties in memory, language, and behaviour which lead to a deterioration in the ability to perform activities of daily living
Whilst cognition may decline gradually as someone ages, dementia may be suspected when the speed and/or nature of this decline is distinct from the natural ageing process
What is cognition?
- Memory
- Language
- Awareness and orientation
- Learning and understanding
- Attention/concentration
- Reasoning
- decision making/Problem solving
Symptoms of dementia:
A spectrum of symptoms describe the dementias:
- Loss of concentration/attention
- Orientation problems
- Memory problems (initially short term)
- Mood and behaviour changes (and personality)
- Impaired decision making and judgement
- Later: Speech and swallowing difficulties
- Later: Incontinence and mobility issues
Three stages of dementia severity:
Mild: short term memory loss. Core activities of daily living (ADL) maintained but higher level functions impaired
Moderate: worsening cognition. Core ADL now affected. Challenging behaviours may become more prominent
Severe: apathy and dependency prominent. Long term memory loss. Many patients receiving 24 hour care
What is vascular dementia:
Decline can be gradual or sudden (stroke/TIA)
Memory may be better preserved
Physical symptoms include slurred speech, dizziness, inability to recognise objects, difficulty performing motor tasks
Emotional lability/depression common
What is Alzheimer’s disease:
Memory impairment most prominent feature early on Difficulty finding words Disorientation Memory loss Problems performing ADL
What is Dementia with Lewy Bodies (DLB):
- Cognitive slowing important feature
- Degeneration of motor function
- Confusion, attention deficit, executive function and visuospatial ability problems common early in illness, not memory problems
Three core features: - Fluctuating cognition, pronounced variation in attention/alertness
Recurrent visual hallucinations
Spontaneous Parkinsonianism
Diagnosing dementia:
- An accurate and comprehensive history is vital, including physical and mental state exam
- Check routine haematology, biochemistry, thyroid, vitamin B12 and folate
- Check mid-stream urine, X-Ray/ECG if required
- Opportunistic screening – e.g. hospital admission, NHS Health Checks
- CT and MRI scans can be used to exclude space occupying lesions such as tumours
According to ICD-10
- 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
Need to inform DVLA on diagnosis
According to NICE, 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
Diagnosis tests of cognition in dementia:
Mini mental state examination (MMSE)- ‘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.]
7 minute screen:
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.
6 item cognitive impairment test: Count backwards from 20-1
[Correct – 0 points] [one error – 2 points] [ >1 error – 4 points]
Treating dementia – general principles:
- 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)
- 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
Attempts should be made to facilitate community living wherever possible
Never stop trying to involve dementia patients in day to day decisions
Language very important part of providing services to those living with dementia
Speak to patients about Lasting Power of Attorney and Advance Decisions/Statements
Pharmacological treatment for dementia:
Drug treatments are only licensed for AD so diagnosis is important
- Acetlycholinesterase inhibitors (AChE-I) are the main drug treatment
- -> Rivastigmine (also targets ButE), donepezil, galantamine. Drugs can prolong current level of functioning or improve symptoms
- Memantine is a NMDA antagonist and is the only other drug licensed
- No major differences in effectiveness between different AChE-I’s
Use AChE-I’s with caution in the following:
- 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
Adverse drug reactions (ADRs) of AChE inhibitors are often self limiting and include:
- GI: N&V, anorexia, ulceration, upset
- CNS: Alertness and agitation, hallucinations, dizziness, insomnia, seizures
- GUS: Urinary incontinence
- Cardiac: Bradycardia, sinoatrial/atrioventricular block
ADRs of memantine include: headache, dizziness, constipation, hypertension, somnolence
Non-pharmacological treatment for dementia
Lifestyle factor modification is a significant part of dementia prevention/amelioration
- Stop smoking, tackle obesity, reduce alcohol, 5-a-day, proper exercise, sugar/salt/fat management
Familiarity and routine are important for maintaining independence and function
- Keep a diary or use reminder charts
- Remember rooms are designed to look like by-gone era’s
Enhancing visibility another avenue
- Use colour and size to make things stand out, e.g. telephones, toilets and doorways
- Orientation boards containing date, weather symbols and time
Consider holistic needs
- Cultural, religious, falls risk, SALT, dementia patients cannot change
- Treat co-morbid depression/anxiety and sleep disorders
- Cognitive stimulation therapy (CST)
Challenging behaviours
- Animal therapy, massage, music, multisensory stimulation
NICE guidance
Treating Alzheimer’s Disease (AD):
AChE inhibitors rivastigmine, galantamine and donepezil recommended for mild-moderate AD
- Use drug with lowest acquisition cost, but can also consider ADR profile, adherence, interactions and co-morbidities
NMDA antagonist memantine recommended as monotherapy for:
- Moderate AD, in those who cannot take a AChE (intolerance or contraindication)
- Severe AD
Combination therapy with memantine should be:
- Considered if moderate disease
- Offered if severe disease
Only specialists in dementia should initiate treatment and carer’s views should be sought
Continue only if a worthwhile effect on cognitive, global, functional, behavioural symptoms
Review treatment regularly by specialist team
NICE guidance
Treating Vascular dementia (VD) and Dementia with Lewy Bodies (DLB)
DO NOT use AChE inhibitors or memantine for treatment of VD, except if co-morbid AD
Risk factor control continues to be central to VD treatment
Treating hypertension effective
However, not much conclusive evidence that treating hyperlipidaemia (with statins) or blood clotting abnormalities (with aspirin) have an effect on VD incidence or progression
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
Pharmaceutical care of dementia:
- All licensed treatments available as generics, but be wary of substitution
One third of AD patients may not respond to AChE-I at all
- One third may show transient improvements before declining
- One third may show steady state functioning before declining
- In those who do not respond to AChE-I initially, switching useful for ~50%
Poor tolerability to one AChE-I does not mean poor tolerability to the others
When starting treatment, use low doses initially and increase after:
- 1/12 for galantamine and donepezil, 2/52 for rivastigmine, 1/52 for memantine
NICE: Do not stop AChE-I because of disease severity alone.
- Treatment interruptions result in rapid losses of effects, often not recoverable
Other hints and tips:
- Change site of rivastigmine patch daily, avoiding previous sites for 14 days
- Rivastigmine and galantamine should be ideally be given away from food
Need to consider swallowing ability for dementia patients
Covert administration of medicines
Remembering (and understanding need) to take tablets
Dementia drug formulations available:
Tablets – donepezil, rivastigmine, galantamine (also capsules), memantine
Soluble tablets – donepezil
Liquid – rivastigmine, galantamine, memantine
Patch – rivastigmine
Drugs to avoid in dementia where possible:
Anticholinergic (antimuscarinics) Hyoscine hydrobromide (NOT butylbromide) Procyclidine Oxybutynin Promethazine Orphenadrine Antidepressants Antipsychotics Alpha blockers Prazosin Tamsulosin Opiates Benzodiazepines Sedating antihistamines Chlorphenamine, cyclizine, promethazine
Limited evidence for alternative remedies
See your directed reading – e.g. ACB scale
BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD)
As well as cognitive decline, dementia patients may suffer with behavioural and psychological symptoms (BPSD)
These include agitation, wandering, aggression, abnormal vocalisations, mood changes, sleep disturbance and psychosis
Agitation may include Verbal / physical Antisocial behaviours Sexual arousal/aggression Self harm Apathy / withdrawal
First line treatment is non-drug measures and watchful waiting, with a central goal of preventing suffering and harm
Prevent self harm and harm to others
Non-pharmacological management of BPSD:
Try to rule out other causes for BPSD
Use the acronym PAIN
- Physical problems – infection, pain, constipation, dehydration, malnourishment?
- Activity related – washing, dressing, bored?
- Iatrogenic – side effects of medication, inappropriate care?
- Noise and other environmental factors such as lighting
Non-drug treatments
- Talking down and distraction, aromatherapy, music therapy
- Snoezelen
- Massage, reflexology
- Psychoeducation for carers – understanding individual patients
- Incontinence pads
- Sleep – bright light therapy, routine
Pharmacotherapy for BPSD?
Even without overt signs of pain, 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
Risperidone is the only drug licensed for BPSD in the UK
Covert administration of medication may be required
Antipsychotics and BPSD – avoid wherever possible
Older antipsychotics usually avoided
Parkinson’s symptoms, EPSE, falls and drowsiness, cognitive blunting
Lewy Body Dementia (DLB) and Parkinson’s dementia high risk groups
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
Effect is modest at best
If used, must have clear target symptoms, use lowest effective dose, review after 1-2 weeks (NICE – 6 weeks)
