Dementia and delirium Flashcards
What is dementia?
- major neurocognitive disorder
- term used to describe a cluster of sxs including:
forgetfulness (progressive)
difficulty doing familiar tasks
confusion
poor judgement
decline in intellectual fxning
*dementia isn’t part of normal aging
Dx criteria for dementia?
sig cognitive impairment in at least one of the following cognitive domains:
- learning and memory
- language
- executive fxn
- complex attention
- perceptual motor fxn
- social cognition
- the impairment must be acquired and represent a significant decline from a previous level of fxning
- cognitive deficits must interfere with independence in everday activities
- cog. deficits result in fxnl impairment (social/occupational)
- cognitive deficits don’t occur exclusively solely during a delirium
- not due to other medical or psychiatric conditions
Causes of dementia?
- alzhemier’s disease (approx 70%)
- vascular dementia (strokes, TIAs)
- parkinson’s
- frontotemporal dementia (FTD)
- normal pressure hydrocephalus (NPH)
- dementia with lewy bodies
- delirium/depression
- other, less common causes
What are modifiable causes of dementia?
- meds (anticholinergics): link b/t long-term use of otc anticholinergics like diphenhydramine and dementia
- alcohol
- metabolic (B12, thyroid, hyponatremia, hypercalcemia, hepatic and renal dysfxn)
- depression - severe
- CNS neoplasms, chronic subdural hematoma
- NPH
What is Alzheimer’s disease?
- progressive neuro disorder that results in memory loss, personality changes, global cognitive dysfunction, and fxnl impairments
- loss of short term memory most prominent early***
- most common form of dementia in elderly (60-80% of cases)
- est to affect more than 4 mill Americans
Dx of alzheimers?
- dx of exclusion
sxs and behaviors: - short term memory loss (early)
- long term memory loss preserved until late
- poor judgement and indecisiveness (early)
- disorientation/inability to adapt new environments
- personality change and disinhibition
- communication disorders: comprehension and expression
- demanding and repetitive behaviors (early to mid)
- behavior changes with aggression, delusions, and hallucinations
AD dx?
clinical dx:
- thorough detailed hx
- mental status eval
- depression screen
- physical exam, underlying vision and hearing screen
- limited lab testing
- neuroimaging
- more extensive neuropsychological testing
- an MRI finding of hippocampal atrophy suggest AD, but not specific or sensitive
- lab testing includes CBC, CMP, serum B12, and TSH
Assessment of AD - MMSE score, what do these scores mean? What score is suggestive of dementia?
- 20-26 mild fxnl dependence
- 10-20 moderate, more immediate dependence
- score: less than 10 - severe, total dependence
- 24/30 suggestive of dementia, not sensitive for mild cognitive impairment
- results affected by educational level, low SES, language skills, literacy, impaired vision/hearing
Addition eval of AD?
- short assessments with good validity: 3 items recall and clock face
- neuro exam (focality, frontal release signs such as grasp, apraxia, cogwheeling, eye movements)
pathology of AD? Hallmarks?
- 3 consistent neuropathological hallmarks:
amyloid-rich senile plaques
neurofibrillary tangles
neuronal degeneration - these changes eventually lead to clinical sxs, but they begin years b/f the onset of sxs
Dx AD - possible AD?
- deficit in only 1 area of cognition
- atypical course
- other dementia causes present
Dx AD - probable AD?
- deficits in 2 or more areas of cognition
- onset 40-90 (usually older than 65), progressive course
- other causes excluded
Dx AD - definite AD?
- histopathological evidence (requires autopsy)
- course and exam characterist of AD
Dx Ad - unlikely AD?
- sudden onset
- focal signs
- seizures or gait disturbances early in course
7 stages of AD - stage 1?
- normal:
pt may potentially be free of objective or subjective sxs of cognition and fxnl decline and also free of assocd behavioral and mood changes - pathology has already begun
Stage 2 of AD?
- normal aged forgetfulness
- half or more pop over 65 - experience subjective complaints of cog and/or fxnl difficulties. Nature of these subjective complaints is characteristic
- elderly persons with these sxs believe they can no longer recall names as well as they could 5-10 yrs previously
- Also intermittently experience difficulties in concentration and in finding correct word when speaking
Stage 3 of AD?
- mild cognitive impairment
- persons at this stage manifest deficits which are subtle, but which are noted by persons who are in close contact such as:
repeated questions,
showing compromise in their ability to perform executive fxns, job performance may decline, hard to master new job skills - ex: grandma has hard time hosting family christmas
Stage 4 of AD?
- mild alzheimer’s disease
- dx of probable alzheimers disease can be made with considerable accuracy in this stage. The most common fxning deficit in these pts is a decreased ability to manage instrumental (complex) activities of daily life (hard to manage finances)
- mean duration: 2 years
Stage 5 of AD?
moderate alzheimers disease:
deficits are of sufficient magnitude as to prevent catastrophe free, independent community survival
- Deficits in basic ADLs: inable to choose proper clothing for weather or just wear same outfit every day
- Can’t recall such major events and aspects of their current lives: presidnet, weather for that day, correct current address
- May not recall names of some of schools which they attended, hard to count backward from 20 by 2s
- stage lasts: 1.5 years
stage 6 of AD?
- moderately severe alzheimer’s disease:
ability to perform basic ADLs becomes compromised Require assistance dressing - cognitive deficits: not be able to maintain living at home
- lasts 2.5 years
stage 7 of AD?
- severe AD
- speech ability is limited to only few words, later all intelligible speech is essentially lost/ Ambulatory ability is lost, pt requires assistance
- can’t even sit up
- lasts 1 year, pts who surive subsequently lose ability to smile
- only grimacing facial movements are observed in places of smiles. Will also lose ability to hold up their head
- with approp care - pts can survvie in final stage for period of years
- physical rigidity occurs due to immobility. Reflex changes become evident
- Emergence of infantile or primitive reflexes (babinski)
- Commonly die during this stage
Most common cause of death in AD?
- aspiration pneumonia
- also; infected decubital ulcerations
- pts in 7th stage more vulnerable to stroke, heart disease, cancer
- some pts just succumb to AD
AD tx?
- no cure
- pharm therapy to maintain and max. pt fxn
- behavioral therapy: option to deal with behavioral issues that aren’t tx with medication
MOA of cholinesterase inhibitors?
- curb breakdown of acetylcholine
- help increase levels of acetylcholine in brain, this may slow progression of sxs for about 1/2 people taking them for about 6-12 months
Donepezil (Aricept)?
- cholinesterase inhibitor
- only tx approved by FDA for all stages of AD
- well tolerated
- qid dosing - hs
- can improve neuropsychiatric sxs
Rivastigmine (Exelon)? Cholinesterase inhibitors
- approved for use in mild to mod ADs and is available in skin patch, capsules, and liquid form
- BID dosing for capsules and liquid, give with food
- slow titration up of drug to help with SEs
Galantamine (Reminyl), Razadyne?
CIs?
SEs?
Cholinesterase inhibitors
- approved for mild to mod AD and available as extended release capsule, immed release tablet, and liquid forms
- BID dosing
- CIs: severe renal and hepatic impairment
- common SEs: usually mild, N/V/D, fatigue insomina, loss of appetite and wt loss
NMDA receptor antagonists - memantine (Namenda)?
SEs?
- approved to tx mod-severe AD
- may play protective role in brain by regulating activity of glutamate. GLutamate also plays role in learning and memory
- brain cells in people with AD release too much glutamate. Namenda helps regulate glutamate activity
- SEs: dizziness, confusion, hallucinations
Selegiline (Eldepryl)?
- prevents breakdown of dopamine
- not clearly shown to be helpful and has many SEs (dizziness, dry mouth, difficulty falling or staying asleep, muscle pain, rash, nausea, and constipation, severe HA, tachycardia, arrhythmia, hallucinations, chorea
Vitamin E?
SEs?
- antioxidant properties
- 1000 IU BID
- SEs: weakness, hypercholesterolemia, bleeding
Use of antidepressants?What meds are recommended?
- high incidence of depression in AD
- sometimes diff to dx
- SSRI’s recommended:
- sertraline (zoloft) - max 200 mg/day
- paroxetine (paxil) max 50 mg
- citalopram (celexa) max 40 mg
Why are antipsychotics used in Dementia? Agents? SEs?
- for hallucinations, delusions, aggression, hostility, and uncooperativeness
- newer “atypical” agents:
aripiprazole (abilify), olanzapine (zyprexa), quetiapine (seroquel) - atypical antipsych: sown an increased risk of sudden death, should only be used after discussion with pt’s internist or neurologist
Antiepileptics used in dementia?
- depakote and gabapentin have limited roel in tx neuropsych sxs of dementia, and have no substantial studies
- can be helpful in FTD
What drugs should be avoided in dementia pts?
- benzodiazepines
- antihistamines (can worsen sxs)
- anticholinergics (worsen sxs)
- all have limited value in pts with dementia
- not recommended for management of neuropsych sxs of dementia, an can actually worsen sxs