dementia therapeutics and treatment Flashcards
what is dementia
A syndrome caused by a number of brain disorders which cause cognitive decline:
Memory loss
Impaired reasoning/problem solving
Decline in language use
most common dementia
Alzheimers
less common causes
Substance misuse Alcohol excess Hypothyroidism Normal Pressure Hydrocephalus Syphilis Vitamin B12 deficiency Vitamin B3 deficiency (pellagra) Folate deficiency
what modification can you take in mind to reduce dementia risk
be physically active eat healthily don't smoke drink less alcohol exercise your mind
dementia management of symptoms fall into different groups that need to be managed separately these include
cognitive impairment - difficulties with memory language and attention and thinking and problem solving
psychiatric or behavioural disturbances - changes in personality, emotional control and social behaviour, depression agitation, hallucinations and delusions
difficulties with activates of daily living - includes driving shopping , eating and dressing
what are some non pahrmalogical therapies
talking
reminsiensce
dignity therapy
singing nd musical memory often retained when most lost - can trigger
multi-sensory stimualtion - for advanced dementia - bright colours sounds and tactile object catch attention
what drugs could exacerbate patients symptoms
Anticholinergics – Oxybutynin, Tolterodine
Sedatives – Benzodiazepines (Valium)
Dopamine agonists – Pramipexole
Antidepressants – Amitriptyline
acetylcholinesterase inhibitors liscended fro sue in dementia
donepezil
rivastigmine
galantamine
they improve motivation, anxiety levels , confidence and memory and thinking
however side effects include appetite decreased, diarrhoea and dizziness with fatigue and nausea
memantine is what class
non-competitive antagonist of NMDA receptors ( type of glutamate receptor )
over activation of NMDA receptors cause excessive calcium influx via receptor channel pore - causes neurotoxicity
presecibed for moderate to severe AD
side effects include balance impaired, contipation, dizziness and dowdiness and dyspnea and headache and hypertension
no treatments for vascular dementia
are there any secondary risk reductions we can take
Manage blood pressure Treat diabetes Manage lipid profile Stop smoking Exercise Weight management
Antiplatelet drugs (Microbleeds)??
frontotemrpoal dementia Treatment of symtpposm
Stop drugs which may be exacerbating memory problems/confusion (e.g. anticholinergics)
Selective serotonin reuptake inhibitors (SSRIs) may be helpful in modifying behavioural symptoms.
Atypical antipsychotics are used if severe behavioural problems e.g. agitation and psychosis (cautious: risk of extrapyramidal side-effects)
avoid Benzos
Dorothy is an 78-year old lady referred you in the memory clinic. She attends with her son.
On the pre-clinic questionnaire her son reports that there has been a deterioration in all aspects of Dorothy’s cognitive function over the past year.
Dorothy is able to give a moderately detailed biography. She accurately recalls details of her wedding and former workplace, but struggles with some specific details since her retirement.
Dorothy reports that she likes to read the paper everyday, but struggled to recount any major news events from the past month.
For the past few years, she has been helping to pick up her son’s children from school. Twice in the past 3 months she has lost her way and had to get the children to direct her home.
Examination
Blood markers are normal.
A CT scan reveals minimal white matter change, with some brain shrinkage broadly in line with her age.
Neurological examination reveals normal sensory and motor responses. Gait, limb movements and gaze are normal.
Physical examination reveals no major pathologies.
Cognitive testing
Dorothy’s mini-mental state examination (MMSE) score is 20.
She loses marks on multiple domains of cognition.
Diagnosis: Most likely Alzheimer’s dementia?
Why:
The progressive nature of symptom development described by the family.
MMSE score is in the right window for early-to-mid stage Alzheimer’s.
Classic Alzheimer’s symptoms include:
a) Anterograde amnesia (inability to form new memories). This is indicated by her lack of memory for very recent events from the news.
b) Graded retrograde amnesia (impaired memory recall which is worst for most recent events). This is indicated by accurate recall of latent (early) memories but worse memory for more recent events.
c) Impaired navigational (spatial) memory ability. Indicated by Dorothy getting lost on a familiar car journey.
Blood markers reduce probability that inflammation, dietary deficiency, hyperthyroidism or hyperammonaemia could be cause of symptoms.
Largely normal CT reduces likelihood that hydrocephalus or vascular lesions are the cause.
Normal neurological examination reduces likelihood of Parkinson’s disease.
Treatment:
Drug: acetylcholinesterase inhibitors (but should also check blood pressure and electrocardiogram as contraindications).
Support: put in touch with local councillors and dementia support groups.
Advice: advise that Dorothy should stop driving and inform the DVLA of her diagnosis.
Follow-up: follow-up within a few months to determine whether the treatment has improved cognitive performance and whether the side effects (e.g. incontinence) have been well tolerated.
