dementia and epilepsy Flashcards
what is dementia
progressive clinical syndrome characterised by impairment of mental function
what are the 5 different types of dementia? which is the most common?
which one has no cure?
- alzheimers [most common]
- vascular [reduced blood flow to the brain due to things like stroke]
- dementia with levy bodies [clumps of protein in brain that affect memory/movement eg parkisnons]
- mixed dementia [2 diff types of dementia at once]
- frontotemporal dementia [ degeneration of frontal and temporal lobes of brain] NO CURE
what are the cognitive and behavioural symptoms of dementia?
cognitive: memory loss, difficulty concentrating, problem solving difficulty
behavioural: difficulty with daily living, aggression, agitation, distress
what is the aim of treatment of dementia?
promote independence, manage symptoms
what is the treatments for mild to moderate ALZHEIMERS dementia?
1st line - acetylecholinesterase inhibitors monotherapy [eg donepezil, galantamine, rivastigmine
2nd line - if these not tolerated then alternative is memantine
what is the treatment for moderate to severe ALZHEIMERS disease?
1st line: glutamate receptor antagonist [memantine] WITH an acetylcholinesterase inhibitor
what is the treatment of mild to severe dementia WITH LEVY BODIES?
1st line: acetylcholinesterase inhibitors [ONLY donepezil, rivastigmine]
2nd line: alternative is galantamine
3rd line: if these arent tolerated give memantine
what is the treatment of VASCULAR DEMENTIA?
acetylcholinesterase inhibitors OR memantine
what is the treatment for FRONTOTEMPORAL dementia?
no cure
antidepressants and antipsychotics to reduce symptoms
what is the MHRA warning and associated advice regarding antipsychotics in elderly people with dementia?
increased risk of stroke and death [esp if they have risk of stroke/TIA or history of CVD]
give lowest possible dose for shortest possible time and review every 6 weeks
when can antipsychotics ONLY be considered in the elderly with dementia?
if they have a risk of harming others or themselves or have hallucinations/delusions that can worsen symptoms
which 2 types of dementia can antipsychotics worsen?
- dementia with levy bodies
- parkinsons disease
[antipsychotics can worsen motor symptoms]
how does acetylcholinesterase inhibitors work?
list some side effects [5]
reversible inhibitor of acetylcholinesterase
agitation, aggression, decreased appetite, common cold, diarrhoea
what are the side effects of memantine? [6]
headache constipation balance impaired dizziness/drowsiness dyspnoea [difficulty breathing]
which antiepileptic drugs have a long half life and should be taken ONCE daily at bedtime?
LP3
lamotrigine
phenobarbital
perampanel
phenytoin
what is the 1st line, 2nd line, 3rd line and 4th line overall treatment in epilepsy management?
1st line - monotherapy with 1st line antiepileptic drug
2nd line - mono-therapy with alternative anti-epileptic drug. be careful when switching, must gradually withdraw one drug first before introducing another. wait till pt stable on 2nd drug before withdrawing 1st drug. do NOT abruptly withdraw because can cause rebound seizures
3rd line: combination therapy with with 2 or more anti-epileptic drugs
4th line: if combination therapy fails, go back to the regimen that worked best for the pt. always try to stick to one drug a day as much as possible
what are the 2 MHRA warnings with antiepileptics?
1 - small increase risk of suicidal thoughts and behaviours
2 - potential harm may be caused by switching brands
what does ‘category 1’ mean for anti-epileptic drugs?
which drugs are included in this category?
category 1 drugs must be maintained on the same brand when indicated for epilepsy
CP3 carbamazepine [eg tegretol, carbagen] phenytoin phenobarbital primidone
what does ‘category 2’ mean for anti-epileptic drugs?
which drugs are included in this category? [5]
category 2 drugs - doesnt need to be maintained on same brand, depends on pt and prescriber
valproate lamotrigine topiramate clobazam clonazepam
what does ‘category 3’ mean for anti-epileptic drugs?
which drugs are included in this category? [7]
category 3 drugs do not need to be brand specific only when theres concerns for pt anxiety/adherence/confusion etc
levetiracetam gabapentin pregabalin vigabatrine ethosuximide tiagabine brivaracetam
what is anti-epileptic hypersensitivity syndrome and what is the action if it occurs?c
rare but fatal syndrome that can occur between 1-8 weeks of starting an anti-epileptic drug
must monitor pt in first 2 months
if syndrome occurs DISCONTINUE drug and asap refer to GP
which drugs can cause anti-epileptic syndrome? [6]
carbamazepine, phenytoin, primidone, phenobarbital [CP3]
rufinamide
lamotrigine
lacosamide
what symptoms may present with anti-epileptic hypersensitivity syndrome?
rash, fever liver dysfunction renal/lung abnormalities multi-organ failure
what 2 things must the pt be monitored for in the first few weeks of starting an anti-epileptic drug?
- suicidal thoughts/behaviours
- anti-epileptic hypersensitivity syndrome
what is the withdrawal advice of anti-epileptics?
do not abruptly withdraw bc can cause rebound seizures [esp benzodiazepines and barbiturates]
- withdraw one drug at a time if pt taking multiple drugs
- withdraw by reducing daily dose by 10-25% every 1-2 weeks
- benzodiazepines may need to be withdrawn over 6 months or longer
what is the DVLA advice for epileptic patients? [6 rules]
- if you have a seizure, stop driving asap and inform dvla
- if you have an unprovoked seziure or single isolated seizure must stop drivoing for 6 months
- if you have established seizure you can drive only if you are not a danger to the public
- you must be seizure free for a year to be allowed to drive
- not allowed to drive if anti-epileptic medication is being withdrawn or changed and for 6 months of ur last dose
- if seizure occurs during medication change/withdrawal then license revoked for 1 year
what is the risk of anti-epileptic drugs in pregnancy?
ALL anti-epileptic drugs can increase risk of teratogenicity esp in 1st trimester. esp if taking more than 1 drug
which anti-epileptic drug has the highest risk in pregnancy/child bearing women and why?
valproate
causes congenital malformations
should not be used in women with child bearing potential unless they on a PPP and there is no other alternative
what risk does topiramate carry in pregnancy?
congenital malformations AND cleft palate in 1st trimester
[topiramATE cleft palATE]
what should pregnant women be advised to take alongside their epileptic drugs esp in the 1st trimester and why?
folate supplementation
to reduce neural tube defects
what are the 2 safest anti-epileptics for pregnancy?
L for labour
levetiracetam
lamotrigine
why should the doses of anti-epileptics be adjusted in pregnancy?
bc the concentration of the drugs changes during pregnancy
what should be monitored in pregnant women taking topiramate?
fetal growth
what routine injection should be given to newborn babies [who’s mother was on anti-epileptics] and why?
vitamin K to minimise risk of neonatal haemorrhage associated with anti-epileptics
what should infants who are being breastfed [by a woman on anti-epileptics] be monitored for?
sedation, weight gain, feeding difficulties,
withdrawal effects if a woman on phenobarbital/primidone/lamotrigine suddenly stops breastfeeding
what are the 2 main types of epilepsy?
generalised
focal
what are generalised seizures and what are the 4 different types of generalised seizures?
which is the most common seizure?
general seizures that affect most of body
- tonic-clonic [most common]
- absence
- myoclonic
- atonic&tonic
describe the symptoms [and what happens] of a tonic-clonic seizure?
body becomes tight/stiff [Tonic=Tight] then loss of consciousness and convulsions/body shakes [clonic=convulsions] loss of bladder control/bowel motions biting of tongue/cheek difficulty breathing
what is 1st line for tonic-clonic seizure?
what is the alternative for pre - menopausal women?
sodium valproate
lamotrigine alternative
describe the clinical symptoms and what happens during an absence seizure?
brief loss of consciousness for few seconds
no convulsions\no falling over
lasts only few seconds
mostly occurs in children
what is the treatment line for absence seizures?
SEAL
sodium valproate, ethosuximide , ALTERNATIVELY lamotrigine
describe the symptoms and what happens during a myoclonic seizure?
jerk/convulsions in just ONE part of the body (normally arms or legs)
what is the treatment line for myoclonic seizure?
SALT
sodium valproate ALTERNATIVELY lamotrigine , topiramate
what are the symptoms and describe what happens during a atonic&tonic seizure?
brief loss of consciousness
MIGHT fall to the ground and MIGHT become stiff
what is the treatment line for atonic & tonic seizure?
SLART
sodium valproate, lamotrigine ALTERNATIVELY rufinamide, topiramate
which drug is the treatment of choice for ALL generalised seizures?
sodium valproate
describe focal seizures with or without secondary generalisation?
localised [focal] symptoms
symptoms depend on which part of brain affected
electrical activity stays in just one part of brain
what is the treatment for focal seizures with or without generalisation?
which drugs are 1st line?
which drugs are alternatives?
FO CA L
carbamazepine and lamotrigine - 1st line
alternatives: oxcarbamzepine, sodium valproate, levetiracetam
if mono-therapy doesn’t work, consider adjunct therapy
what are the 2 types of focal seizures?
describe each one and how they differ
- simple focal seizure:
MAY have muscular jerks, odd taste, pins and needles in one part of body, NO loss of consciousness - complex focal seizure:
affects one part of brain, behave strangely for a few seconds eg mumble, fiddle with things. conscious IS affected, odd visions, emotions etc
