Dementia Hour 1 Flashcards
Age associated cognitive changes:
- Difficulty retrieving words and names
- Slower processing speed
- Difficulty sustaining attention when faced with competing environmental stimuli
- Learning something new takes a bigger effort
- No functional impairment
Mild Cognitive Impairment: Definition
- Memory complaint corroborated by an informant
- Objective memory impairment for age and education
- Preserved general cognition
- Normal activities of daily living
- Not demented
Amnestic MCI:
- Memory loss not meeting criteria for dementia
- Could be earliest phase of AD
- Clinical diagnosis: no “MCI test”
Dementia (neurocognitive disorder and specified as mild or major)
- Memory decline/impairment and at least one of the following: aphasia, impaired executive function, apraxia, agnosia; DSM 5 says decline in memory, complex attention, exec function, learning/memory, language, perceptual/motor, social cognition
- Cognitive deficits must impact social and occupational function (Major not capable of independent living, minor does not)
- Diagnosis must be made in the presence of a clear sensorium (ie not out of surgery)
Early-onset AD:
- occurs b/w ages 30-60
- Rare
- Familial in most cases
- Abnormal presenilin 2 (1), presinilin 1 (14), abnormal APP (21)
Late-onset AD:
- most common form
- develops after age 60
- combo of factors usually responsible like diabetes, increased cholesterol, hyperlipidemia, but think apo E4 gene on chromosome 19
AD risk factors
- increasing age
- females
- FH of dementia
- Fewer years of education
- Lower occupational status
- Depression, other emo illnesses
- Head injury
- Low folate, B12
- Elevated plasma homocysteine levels
- Presence of apo E4 allele
- Postop delirium
- Alcohol abuse
Early symptoms of AD:
- Early cognitive symptoms (trouble keeping appointments, difficulty finding words, misplacing objects)
- Early functional symptoms (difficulty driving, difficulty selecting clothes, missing appointments, problems at work)
- Early behavioral symptoms could include (subtle changes in personality, social withdrawal, depression)
Depression vs. Dementia:
Patients with primary depression:
- Demonstrate less motivation during cognitive testing
- Express cognitive complaints that exceed measured deficits
- Maintain language and motor skills
Brain imaging, when would you consider?
Not routinely indicated when suspecting Alzheimer’s
1. focal findings on exam
2. rapid onset/decline
3. falls, head trauma by history;
nonspecific findings in AD and vasc D: lacunar infarcts, small vessel and white matter disease
Frontotemporal dementia (Pick’s Disease) vs. Alzheimer’s:
- Insidious onset, gradual progression
- early decline in social interpersonal conduct
- early impairment in regulation of personal conduct with loss of insight
- Early emotional blunting
- Characterized by behavioral abnormalities
- Memory loss occurs later
Frontotemporal dementia: Rx
- No role for cholinesterase inhibitors
- Careful use of atypical antipsychotics (pines and dones, since these could make person worse)
- Divalproex for behavior control
- SSRIs for irritability, depression, impulsive behaviors
Durgs for treating neuropsychiatric disturbances in AD patients:
- Antipsychotics (risperidone, haloperidol): use this at lowest possible dose for a short period of time
- antidepressants (sertraline, venlafaxine): depression could precede or follow AD
- Anxiolytics (buspirone, lorazepam): reduce any confusion or depression among a patient
Vascular dementia facts; how to control it
- Most common dementia after Alzheimer’s
- Step-wise progression (can be abrupt after CVA)
- Usually seen with cardiovascular risk factors
- “Mixed” dementia with AD or Lewy Body NOT unusual
- Emotional lability
- Max BP control
- Statins (but need enough fats and lipids to myelinate)
- Stop smoking
- Control blood sugar
- Diet
- Exercise: cognitive or physical
Situation in DC is a MESS!!!!
Dementia with Lewy Bodies:
- Sporadic (usually late onset)
- Memory frequently less affected compared to AD
- Motor symptoms VARIABLY present, since you’re worried more about issues with frontal and subcortical areas
- Frontal and subcortical features: deficits in attention and alertness
- Neuropsychiatric symptoms: vivid visual hallucinations, delusions
Lewy Body Dementia:
- Short term memory loss, gradual onset
- VISUAL HALLUCINATIONS
- Cognitive fluctuations
- REM sleep disorder common (lose paralysis)
- Frequent falls
- Autonomic dysfunction
Lewy Body Dementia Rx
- Cholinesterase inhibitors could provide symptomatic support (rivastigmine)
- Trial of carbidopa/levodopa for severe movement symptoms
- AVOID ANTIPSYCHOTIC DRUGS because of increased sens
- For REM sleep disorder: clonazepam
MMSE:
- screening: not a diagnostic tool
- Not specific for dementia type and could actually be impacted by AGE, EDUCATION, ETHNICITY
- normal (30-27), mild (30-20), moderate (20-10), severe (10 or lower)
ADLs: IADLs
ADL: 1. dressing 2. eating 3. ambulating 4. toileting 5. hygiene;
IADL: 1. shopping 2. housekeeping 3. accounting 4. food preparation 5. transportation
Importance of early diagnosis of Alzheimer’s:
- rule out reversible causes (maybe B9, B12, thyroid, BP, diabetes; maybe they’re on anticholinergics)
- Initiate appropriate therapy
- Enrollment for clinical trials
- Advance directives and planning
Donepezil:
Mech: inhibits AChE
Doses per day: 1 (don’t need food)
Metabolism: Cyt P450
Adverse reactions: N/V, sleep problems; worse SE’s are bizarre dreams and syncope at higher doses
Rivastigmine:
Mech: inhibits AChE and BuChE
Doses/day: 2
Metabolism: hydrolysis by cholinesterase
Adverse rxns: see donepezil
Galantamine
Mech: inhibits AChE; allosteric modulator of nicotinic receptors
Doses per day: 2 or 1
Metabolism: Cyt P450
Adverse rxns: see donepezil and rivastigmine
Memantine:
Mech: partial antagonist of NMDA receptor
Doses/day: 2
Metabolism: most excreted unchanged in urine
Adverse rxns: dizziness, confusion, headache, constipation (went from a defensive coordinator to head coach)
Infarcts associated with hypertensive small vessel disease and progressive cognitive impairment
Think LACUNAR INFARCTS: also maybe arteriosclerosis of small arteries and arterioles supplying deep grey and white matter
In context of dementia with LB’s, what LB’s can be found?
- Cortical-type LB’s in frontal, temporal, insular cortex (also limbic areas)
- Nigral LBs
- Lewy neurites (hippocampus and striatum)
- Look for plaques and tangles, and then there’s dual diagnosis of DLB and AD
MoCA stands for; some characteristics?
Normal >26, Mild 18-26, Moderate 10-17, Severe <10;
focus on the fact that executive function is tested better!!
Adult homes:
- room and meals provided
- add on assistance with daily activities
- No complex medical problems
- Not always licensed or monitored by local authorities
- CASH only
Assisted living facilities:
- assist with INSTRUMENTAL activities of daily living
- Add some basic activities of daily living for extra fees (help with taking meds, taking bath, walking to dining hall)
- No med or nursing care onsite
- Cash only: NOT COVERED by Medicaid or Medicare
Skilled nursing facilities:
- Daily skilled nursing care; onsite med care
- Dependent in ALL basic activities of daily living (DEATH)
- Most patients with ADVANCED DEMENTIA
- Cash until money is depleted; most residence on Medicaid!!!
