Dementia - Block 2 Flashcards
What is the difference between delirium and dementia?
Delirium: attention and awareness, acute, reversible
Dementia: memory and cognitive function, slow, irreversible
What are the causes of delirium?
- Illness
- Infection
- Med
- Metabolic disorders
- Vitamin def
- Alcohol
- Hypothyroidism
Meds that can cause delirium?
- TCA
- Antihistamines
- Antipsych
- Benzo
- Sedatives
- Antiparkins
- Alcohol
- CS
What is dementia?
Chronic syndrome of cognitive deficits that effect memory, intellectual, and behavioral functions
What are the types of dementia?
AD
VD
Lewy body
Parkinson
Chronic progressive neurodegenerative disorder that results from neurofibrillary tangles or beta amyloid plaques that interfere with cholinergic transmission and other neurochemical changes in the brain
AD
A form of dementia that typically presents with Parkinsonian features as well as symptoms such as falls and hallucinations
LBD
Most common type of dementia? Prevalence?
AD; increases with age, affect women > men
What is the patho behind AD?
- Neurofibrillary tangles from hyperphosphorylated tau proteins
- Neuritic plaques from b-amyloid1-42
- Loss in dendrites and synapses
- Neuronal atrophy
- Loss of cortical neurons
WHat are the neuochemical changes in AD?
Cholinerigc: decrease Ach -> cognitive and memory deficits
Glutaminergic: decrease glutamate -> cognitive and memory deficits
Serotonergic: Degeneration of serotonergic nuclei due toneurofibrillary tangles -> behavioral changes and psychosis
Noradrenergic: affects info processing
Changes in 5-HT and NE -> depression
What is the genetic predisposition of early and later onset of AD?
Early: APP-chromosone 21
* Presenillin 1 (chromosone 1 and 14)
Later: >65YO
* ApoE4 (chromosone 19)
Down’s syndrome who live lon will most likely develop AD
What are the RF of AD?
1. Increased age
2. Down’s syndrome
3. Cormorbidities
4. Depression
5. Decreased brain activity
What are the clinical presentations of AD?
Onset: gradual
Progression: progressive
Age:
* Early: ≤65YO
* Late: ≥65 YO
What are the warning signs of AD?
- Memory loss
- Challenges in solving problems
- Difficulty completing familiar tasks
- Confusion
- Visual and spatial unawareness
- Problems with speaking and writing
- Misplacing things
- Poor judgement
- Social withdrawl
- Mood/personality changes
What is the classification of mild AD?
MMSE: 21-30
* Cofusion
* Memory loss
* Personality changes
* Disorientaton
What is the classification of moderate AD?
MMSE: 10-20
* difficulty in completing everyday tasks
What is the classification of severe AD?
MMSE: ≤10
* Loss in speech
* Loss in appetite
* Loss in bladder control
* Caregiver dependence
How do we diagnose or cassify AD?
DSM-V TR: lists the causes and functional thresholds
WHat are your types of screening tools for cognitive impairment?
- Mini-cog
- MIS
- GPCOG
What are the issues of diagnosing AD?
- Insidious onset
- MUST ensure the problems are NOT due to other causes
- Important to diagnose or confirm diagnosis of AD as early as possible
- Diagnosis of exclusion (probable AD) until autopsy
What are the elements of a diagnostic work-up for AD?
- Cognitive family and med hx
- Mental status test (MMSE)
- Physical and neurological exams
- Lab
- Brain imaging
What is the most commonly used mental status test?
MMSE
What is the MMSE?
30 point test assessing orientation, memory, attention, recall, and lanuage
What is FAQ?
Assessment of activities of daily living (completion of normal tasks)
Dependent in 3 or more activies -> impairment
0-30 possible score
What is the clock draw test?
CDT of 4 approximates a MMSE of near 30 or mild cognitive impairment
CDT of 2 suggests moderate impairment with MMSE scores in high teens.
CDT of 1 reflects moderate-to-severe scores on MMSE (low teens)
What are the therapeutic goals of AD?
Slow the progression of the dx:
1. Enhance QoL
2. Improve the ability to complete ADLs
3. Improve mood and behavior
4. Slow down cognitive loss
When do we treat AD?
ASAP to maximize maintenance of cognitive function to carry ou ADLs
* Continue tx till they are bedridden or unable to carry out ADLs
What are the tx of AD?
Cognitive sx: AChEIs, NMDA receptor blockers
Behavioral sx: Non-pharm, pharm
What are yor AChEIs?
Donepizil (Aricept)
Rivastigimine (Exelon)
Galantamine (Razadyne)
Donepizil
PiT, CI, Dosing, ADR
PiT: mild-severe AD
CI: CV, asthma/copd, bleeding, sz, low body weight (<50kg)
Dosing: PO, patch, ODT
* Initial: 5 mg PO QD for 1 month
* Maintenance: May increase 10 mg after 4-6 weeks x 3 months, Increase 23 mg after 3 months
ADR: N/V/D, weight loss/anorexia, insomnia, bradycardia
Does donepezil require dosage adjustment?
No, only for hemodialysis (2.3 mg -> 5mg)
What are the counseling points for donepeziL?
- QHS to decrease nausea
- QAM if insomnia occurs
- Do NOT crush or chew the 23 mg tablets
- Let the ODT dissolve on your tongue then follow with water
- If patch falls off or a dose is missed, apply a new patch immediately and then replace this patch 7 days later to start a new one-week cycle.
Rivastigmine
PiT, Dosing, ADR
PiT:Mild-mod AD 9(PO, patch)
* Severe AD (patch)
Dosing: PO 2-4 weeks dose adjustment, 4 weeks for patch
* If dosing is interrupted for > 3 days, re-titrate
* BID
* No dosage adj PO, hepatic adj for patch (4.6mg)
ADR:
* N/V/D, anorexia
* Insomnia
* Bradycardia
Counseling points for rivastigmine?
PO: Take w/ food
Patch:
* less ADR
* QD same time everydaya
* Upper and lower back, chest, upper arm
* Rotate application site
* Don’t cut patches
Galantamine
PiT,Dosing, ADR
PiT: mild-moderater AD
Dosing: 4 weeks adj
* IR BID, ER QD
* Hepatic and renal adj
ADR:
* N/V/D, anorexia
* Insomnia
* Bradycardia
COunseling points for Galantamine?
Take w/ food
Oral solution may be mixed wih liquid, drink immediately
Memantine
PiT, Dosing, ADR
PiT: mod-severe dementia
Dosing: QW adj
* Renal adj, avoid hemodialysis
ADR: D/Constipation, confusion, dz, HA, hyper-hypotension, coughing
Counseling points for memantine?
- Take w or w.o food
ER: don’t crush or chew,
* Can be opened and sprinkled on applesauce
Oral solution:
* Do NOT mix with other liquids
* Use dosing device provided
* Squirt slowly into the corner of the mouth
Namzaric
PiT, Dosing, Counseling
Mematnine + Donepezil
PiT: Mod-severe dementia
Dosing: weekly adj
* Renal adj for 5-29 mL/min
Counseling:
* Give with or without food
* Do NOT crush or chew
* May be opened and sprinkle on applesauce; take immediately
What are you beta-amyloid mAb?
Aducanumab (Aduhelm)
Lecanemab (Leqembi)
Aducanumab
BBW, PiT, Dosing, ADR
BBW: ARIA
PiT: mild dementia only w/ confirmed amyloid beta patho
Dosing: every 4 weeks (min: 21 days)
ADR: ARIA, angioedema, Uticaria, HA, falls, diarrhea
Lecanemab
BBW,PiT, Dosing, ADR, DDI
BBW: ARIA
PiT: mild dementia only
Dosing: every 2 weeks
ADR: ARIA, inj site rx, HA, skin rash, D/N/V, aaphylaxis, angioedema
DDI: antiplatelets and anticoags
How much Vit E can be given to AD patients?
Should not exceed >400IU/d
How often should you reassess dx progression?
6 months
How is AChEIs assessed?
ADAS-cog in patients with mild-mod AD for up to 1 yr compared to those on placebo or not tx
When would we switch someone from AChEIs?
- Intolerance
- Clear deterioration of symptoms over the first 6 months
- Loss of response over time
How effective is AChEIs?
- Slows cognitve decline
- Delay nursing home placement
What do we use in patients with AChEI intolerance?
Memantine
When do we DC AChEI?
Once a patient is bedridden or unable to complete ADLs
According to ADAS-cog what is considered clinically significant?
> 4 points/yr change
What constitutes successful tx according to MMSE? Unsuccessful?
Successful: <2 point/yr decline
Un: >2-4 point decline after 1 year
What are examples of non-cognitive sx?
- Psychotic (hallucinations, delusions)
- Anxiety/Depression
- Sleep disturbances
- Behavioral disturbances
How do we decide on a treatment for non-cognitive symptoms?
- Do the symptoms prevent the patient from functioning?
- Do the symptoms pose harm to the patient or those around the patient?
- Can the symptoms be managed with non-drug interventions alone?
What are non-pharm tx for non-cog sx?
- Teach caregivers to reduce behavioral disturbances
- Utilize 3 Rs (Repeat, Reassure, Redirect)
- Utilize familiar routine
- Register patient to Azheimer’s association safe return program
What is the cornerstone of treating behavioral sx?
Non-pharm
How do we manage patients with AD?
- Let patient be independent
- Focus on enjoyment not achievement
- Safety, simplificcation, rouine
What are the pharm tx for behavioral sx?
- Antipsychotics
- Antidepressants
- Mood stabilizers
What are traditonal antipsychotics?
- Holoperidol
What are ex of atypical antipsychotics?
Quetiapine, Olanzapine, Risperidone, Ariprazole, Clozapine
What type of antipsychotic is preferred?
Atypicals: better ADR profile, less anticholinergic effects
What are antipsychotics good for treating?
Hallucinations, delusions, aggression, suspiciousness
What are antipsychotics not effective in treating?
Wandering, cognitive sx
BBQ for antipsychotics?
The use of antipsychotics for
“Dementia with Psychotic/Agitated Features” is an “off label” use
BBW: Increased risk of death, not approved for dementia-related psychosis, must show risk vs benefits
Most commonly used antidepressant for AD?
SSRI: Fluoxetine, paroxetine, sertraline, escitalopram, citalopram
What is the preferred tx for non-cog sx?
SSRI
When would trazodone be used?
Insomnia
When would mirtazapine be used?
Weight loss
What type of anti-anxiety med is preferred in elderly?
Short-acting Benzo: Alprazolam, Lorazepam, Oxazepam
When would mood stabilizers be used?
Add-ons for patients not responding to antipsychotics
Ex of mood stabilizers?
- Carbamazepine
- Trazodone
- Gabapentin
- Valproate
When are antidepressant used used?
Depression, apathy, insomnia, decreased appetite
