Dementia COPY

Question 1

What is the most common type of dementia

Answer 1

Alzheimers disease

Question 2

What is dementia & name some symptoms

Answer 2

Progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms that may include
○ Memory loss
○ Problems with reasoning and communication
○ Change in personality
○ Reduced ability to carry out daily activities e.g. washing and dressing

Question 3

Other common types of dementia (not AD)

Answer 3

○ Vascular dementia (due to cerebrovascular disease)
○ Dementia with Lewy bodies
○ Mixed dementia
○ Frontotemporal dementia

Question 4

Non-drug treatment

Answer 4

• Pt with ALL types of mild to moderate dementia presenting with cognitive symptoms should be given the opportunity to participate in a structured group cognitive stimulation programme
  
  • Group reminiscence therapy (use of life stories to improve psychological well being) and cognitive rehabilitation or occupational therapy to support daily functional ability, should also be considered

Question 5

Management of cognitive symptoms - considering the drugs they are already prescribed

Answer 5

• Some commonly prescribed drugs are associated with increased antimuscarinic (anticholinergic) burden - THUS cognitive impairment
  ○ Hence their use should be minimised
  ○ Review and stop/use lowest effective dose!

Question 6

Drugs with antimuscarinic effects include

Answer 6

○ Antidepressants e.g. amitriptyline, paroxetine
○ Antihistamines e.g. chlorphenamine, promethazine
○ Antipsychotics e.g. olanzapine, quetiapine
○ Urinary antispasmodic e.g. solifenacin, tolterodine

Question 7

How would you initiate drug treatment in newly diagnosed Alzheimers disease

Answer 7

Newly diagnosed: only initiate drug treatment under advice of specialist clinical experienced in the management of AD

Question 8

Treatment of mild to moderate Alzheimers disease

Answer 8

○ 1st line: Monotherapy with donepezil, galantamine or rivastigmine (ACh-esterase inhibitors)
○ If Ach-esterase inhibitors are not tolerated or contraindicated, an alternative in MODERATE AD is memantine

Question 9

Treatment of severe Alzheimer’s disease

Answer 9

Memantine

Question 10

Step up treatment in AD if they develop moderate or severe disease

Answer 10

• Mild to moderate AD, 1st line: Monotherapy with donepezil, galantamine or rivastigmine (ACh-esterase inhibitors)
• In pt already receiving an ACh-esterase inhibitor to treat AD, consider adding memantine if they develop moderate or severe disease
  ○ Memantine can be initiated in primary care without advice from a specialist clinician

Question 11

Discontinuing ACh-esterase inhibitor treatment in moderate AD

Answer 11

• In pt with moderate AD, discontinuing ACh-esterase inhibitor treatment can cause a substantial worsening in cognitive function
• Do not discontinue treatment based on disease severity alone

Question 12

Treatment of mild to moderate dementia with Lewy bodies

Answer 12

• Donepezil or rivastigmine (both unlicensed indication)
• Consider galantamine (unlicensed indication) only if treatment with the above not tolerated
• If Ach-esterase inhibitors contraindicated or not tolerated, consider memantine (unlicensed indication)

Question 13

Treatment of severe dementia with Lewy bodies

Answer 13

Donepezil or rivastigmine (both unlicensed indications)

Question 14

When should Ach-esterase inhibitors or memantine be considered in vascular dementia

Answer 14

• Both unlicensed indications
• Only consider if they have suspected co-morbid AD, PD dementia or dementia with Lewy bodies

Question 15

Use of Ach-esterase inhibitors or memantine in pt with frontotemporal dementia or cognitive impairment caused by MS

Answer 15

NOT recommended

Question 16

Examples of non-cognitive symptoms

Answer 16

Agitation
Aggression
Distress
Psychosis

Question 17

Management of non-cognitive symptoms

Answer 17

• Pt with dementia should be offered psychosocial and environmental interventions e.g. counselling and management of pain & delirium to reduce distress
• Antipsychotics should only be offered to pt with dementia if they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress

Question 18

MHRA: antipsychotics

Answer 18

○ Increased risk of stroke
○ Small increased risk of death
○ When antipsychotics are used in elderly pt with dementia
- Thus balance risks vs benefit carefully, including PHx of stroke, TIA and any other risk factors for cerebrovascular disease such as hypertension, diabetes, smoking and AF
- Antipsychotics should be used at lowest effective dose & for the shortest time possible
- Regular review at least every 6 weeks

Question 19

Use of antipsychotics in patients with dementia with Lewy bodies or PD dementia

Answer 19

Can worsen the motor features of the condition, and in some cases cause severe antipsychotic sensitivity reactions

Question 20

Side effects of acetylcholinesterase inhibitors

Answer 20

increased ACh = parasympathetic SE (rest, digest, secrete)

Question 21

DUMB BELS

Answer 21

side effects of ACHesterase inhibitors