Depression, Dementia, Delirium Flashcards
What is the prevalence of Major Depressive Disorder (MDD)?
- Lifetime incidence: 20% in women, 12% in men
- Depression is the 4th MC presenting complaint in the primary care setting
- Affects 5-10% of patients in primary care setting
Give the DSM-V criteria for MDD
At least 5 of the following, during the same 2 week period, representing a change from previous functioning:
- Fatigue
- Depressed mood
- Decreased interest or pleasure
- Feelings of worthlessness or guilt
- Decreased concentration/indecisiveness
- Weight gain or loss
- Psychomotor agitation or retardation
- Suicidal ideation
**must include depressed mood or loss of interest or pleasure
Give the symptom DSM-V criteria for MDD
- Must cause clinically significant distress or impair functioning
- Are NOT:
- -D/t the direct physiologic effects of a substance or general medical condition
- -Better accounted for by bereavement
List the risk factors for MDD
- Older age
- Alzheimer disease (40% develop MDD)19
- Recent childbirth
- Recent stressful events
- Personal or family history of depression
- Chronic disease (25% develop MDD)
What factors increase MDD in the elderly?
- Being female
- Being single, unmarried, divorced, or widowed
- Lack of a supportive social network
- Stressful life events
- Damage to body image (amputation, heart attack, cancer…)
What is the course of MDD?
- Relapsing, remitting illness in most patients
- 40% recurrence in the two years following a first episode
- After two episodes, 75% recurrence over the next five years
Etiology of MDD in the elderly
- Affects about half of nursing home patients
- MCC of weight loss in elderly is depression
- *Somatic complaints**
- May present with a general decline in functioning or confusion
What is the classic presentation of MDD in the elderly?
- Vague complaints of pain
- Deny depression
- Minimize severity of symptoms
- Hesitant to admit illness
What are the 5 questions used for the geriatric depression scale?
- Are you basically satisfied with your life?
- Do you often get bored?
- Do you feel helpless?
- Do you prefer to stay at home rather than going out and doing new things?
- Do you feel pretty worthless the way you are now?
*a score > 2 suggests diagnosis of depression
What is BDI-II?
- Beck Depression Inventory—2nd edition
- 21 item questionnaire
- Provides an objective measure to evaluate depression
List the risk factors for suicide (many)
- Male sex
- Age older than 55
- Comorbid physical illness
- Social isolation (divorced, widowed…)
- Depression, especially with severe melancholic or delusional symptoms
- Substance abuse or dependence
- Family history of suicide and/or MDD
- Command hallucinations
- Access to firearms
- White race
- Chronic and inadequately treated pain
- Terminal illness
List the diff dx for MDD
- Alzheimer disease
- Endocrinologic disorders (addison, cushing, hyper/hypothyroidism, prolactinomas, hyperparathyroidism)
- Neoplastic lesions of CNS (can cause psychiatric sxs prior to any focal neurologic signs)
- Inflammatory conditions (SLE)
- Sleep apnea
- Infectious processes (Lyme disease, syphilis, HIV encephalopathy)
- Substance use, abuse or dependence
- Other psychological disorders: Seasonal affective disorder (SAD), Dysthymia, Anxiety disorders, Eating disorders, Personality disorders
List the meds that can cause depression
- Beta-blockers
- CCB
- Steroids
- Drugs that affect sex hormones (estrogen, progesterone, testosterone, GnRH antagonists…)
- Ranitidine, cimetidine
- Sedatives
- Muscle relaxants
- Appetite suppressants
- Chemotherapy agents
What events can cause “grief” from your diff dx? What is tx of grief?
- Death, divorce, abrupt serious illness, job loss…
- If the impact of the event on the patient’s functional status is in keeping with expected cultural norms, it is described as normal bereavement
- Consider psychotherapy + medication if pt has symptoms of depression and impaired function
Define persistent complex bereavement disorder and what it includes.
*Unusually disabling or prolonged response to bereavement
May include the following:
- Indefinitely yearning for the deceased
- Preoccupation with the circumstances of the death of the deceased
- Intense distress/sorrow that does NOT improve over time
- Difficulty trusting others
- Depression
- Desire to join the deceased
- Impairment in social, occupational, and other areas of life
Explain the relationship between depression and anxiety
- Anxiety is a common symptom of depressive disorders
- If the anxiety is only present during depressive episodes, it does not warrant a separate diagnosis of anxiety disorder unless there are symptoms of other disorders (panic disorder, OCD, PTSD…)
Physical findings of MDD
- None, typically
- In patients with more severe symptoms, a decline in grooming and hygiene can be observed
- Weight gain or loss
- Psychomotor retardation (slowing or loss of spontaneous movement and reactivity)
- Flattening or loss of reactivity in the patient’s affect
- Speech:
- -May be normal, slow, monotonic, or lacking in spontaneity and content
- -Pressured speech should suggest mania
- -Disorganized speech should suggest psychosis
List the lab studies of MDD
- None for diagnosis, but can order studies to eliminate other etiologies:
- CBC
- TSH
- CMP
- RPR
- HIV
- ANA
- Drug test
What is the treatment of MDD?
- Psychotherapy
- Medication
- Patients with mild-moderate depression benefit equally from both
- Patients with severe depression benefit more from antidepressant medications than psychotherapy alone
Considerations for MDD medications
- 2-6 weeks at a therapeutic dose are needed to assess efficacy
- 50% of patients receiving an antidepressant show a response (compared to 30% of patients on placebo)
- Only 40% of patients in primary care respond to the first antidepressant medication
- There are NO clinical differences in response rates among commonly prescribed antidepressants
List factors for medication selection
- Safety & tolerability (affect compliance)
- Provider familiarity: aids in patient education, helps anticipate adverse effects
- Patient prior medication history
- Cost
- Patient preference
List the causes of medication failure
- Often, not caused by clinical resistance
- Medication noncompliance
- Inadequate duration of therapy
- Inadequate dosing
General info for SSRIs
- Selective Serotonin Reuptake Inhibitors
- In general, good starting SSRI’s are sertraline and escitalopram
- Easy dosing
- Low toxicity in overdose
SSRI ADRs
- GI upset (n/v/d)
- Sexual dysfunction (decreased libido, anorgasmia, ED)
- Changes in energy level (fatigue, restlessness, agitation)
- Increased risk of upper GI bleed
NOTE: Metabolized by cytochrome P-450 system - may have drug interactions
List the SSRIs
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Sertraline (Zoloft)
Which SSRI does not have weight gain, but may have weight loss?
Fluoxetine (Prozac)
Which SSRI can cause hyponatremia?
Paroxetine (Paxil)
General info for SNRIs
- Serotonin and Norepinephrine Reuptake Inhibitors
- Safety & tolerability similar to SSRIs
- Second-line agents when SSRIs fail
- Can be used as first-line agents, especially in patients with significant pain syndromes
SNRI ADRs
- tachycardia
- dry mouth
- HTN
- mydriasis
List the SNRIs
- Venlafaxine (Effexor)
- Duloxetine (Cymbalta)
- Desvenlafaxine (Pristiq)
- Levomilnacipran (Fetzima)
- Milnacipran (Savella)
Which SNRI is good for chronic pain, neuoropathy, and fibromyalgia?
Duloxetine (Cymbalta)
Which SNRI is good for fibromyalgia?
Milnacipran (Savella)
What is serotonin syndrome?
- Produced by high levels of serotonin in the body
* Can be life-threatening
What are the symptoms of serotonin syndrome?
- Restlessness
- Abdominal pain
- Palpitations
- Flushing
- Muscle rigidity
- Sweating
- Seizures
- Hyperthermia
- Hallucinations
- Mental status changes
Tx of serotonin syndrome
- Discontinuation of offending medication
- Often resolves within 24 hours of stopping med
- May require hospitalization depending on severity of symptoms
Relationship between MAOI and SSRI
Must discontinue any MAOI for two weeks before SSRI initiation
List the serotonin modulators
SSRI + 5-HT1A receptor agonist
- Vilazodone (Viibryd)
- Vortioxetine (Brintellix)
- Nefazodone (Serzone)
- Trazodone (Desyrel)
What are the ADRs of SSRI + 5-HT1A receptor agonists?
Primarily GI
Pros of serotonin modulators
- Low toxicity in overdose
- Less sexual dysfunction than SSRIs
Which serotonin modulator can be used as a sleep aid?
Trazodone (Desyrel)
- very sedating
- NOTE: Can cause priapism in men (0.03%)
Which serotonin modulator shows no significant weight gain or sexual dysfunction?
Vilazodone (Viibryd)
List the atypical antidepressants
- Bupropion (Wellbutrin)
- Mirtazapine (Remeron)
What are the pros of atypical antidepressants?
- Low toxicity in overdose
- Less sexual dysfunction and GI distress than SSRIs
Buproprion (Wellbutrin)
- class
- contraindications
- ADRs
- NE and dopamine reuptake inhibitor (NDRI)
- Contraindicated in patients with seizure history
- Also used in patients for smoking cessation (Zyban)
- ADRs: agitation, insomnia
Mirtazipine (Remeron)
- affects
- ADRs
- Affects serotonin, norepinephrine, and histamine
- ADRs:
- -Drowsiness (taken at bedtime)
- -Weight gain
- -Tend to improve over time and with higher doses
Burspirone (Buspar)
- class
- uses
- tolerance
- Partial 5-HT agonist with serotonergic and some dopaminergic effects in CNS
- Good for anxiety and may have antidepressant effect at doses above 45 mg/d
- May be used as adjunct therapy with SSRI or TCA
- Tolerated better than benzodiazepines
General info for tricyclic antidepressants
- Used less commonly
- Need to titrate to effective dose
- Considerable toxicity in overdose
- Use with caution if patient has cardiac arrhythmia
ADRs of tricyclic antidepressants
*d/t anticholinergic and antihistaminic actions: sedation, confusion, dry mouth, orthostasis, constipation, urinary retention, sexual dysfunction, weight gain, arrhythmias, MI
List the tricyclic antidepressants
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Desipramine (Norpramin)
- Clomipramine (Anafranil)
- Doxepin (Sinequan)
- Protriptyline (Vivactil)
- Trimipramine (Surmontil)
- Imipramine (Tofranil)
General info for MAOIs
- Widely effective in broad range of affective and anxiety disorders
- Hypertensive crisis risk, have to follow a low-tyramine diet
ADRs of MAOIs
insomnia, anxiety, orthostasis, weight gain, and sexual dysfunction
List the MAOIs
- Phenelzine (Nardil)
- Selegiline (Emsam)
- Isocarboxazid (Marplan)
- Tranylcypromine (Parnate)
Suggestions based on antidepressant effects
-cause weight gain
- Mirtazapine
- Amitriptyline
Suggestions based on antidepressant effects
-enuresis
imipramine
Suggestions based on antidepressant effects
-anxiety
Escitalopram
- Paroxetine
- Duloxetine
- Venlafaxine
Suggestions based on antidepressant effects
-Smoking
Buproprion
Suggestions based on antidepressant effects
-Insomnia
- Mirtazipine
- Trazodone
General info for St. John’s Wort
- Considered a first-line antidepressant in many European countries
- Studies in US do not show efficacy; thus it is NOT FDA approved
- Acts as an SSRI
- 300mg three times a day with meals
- Has MANY drug interactions
General info for Antipsychotics
- Often used to augment response to SSRI
- Good option in patients with psychotic symptoms
- Indicated for treatment-resistant depression
List the antipsychotics
- Aripiprazole (Abilify)
- Quietiapine (Seroquel)
- Symbyax (Olanzapine (Zyprexa) + fluoxetine (prozac))
Risk of antipsychotic use in the elderly
- Pneumonia
- Life-threatening arrhythmias
- Orthostatic hypotension resulting in falls
- Diabetes
Considerations for continuation of medications
- Once an episode is resolved successfully, treatment should be continued for 6 months to 1 year to reduce the risk of relapse of symptoms
- The decision to continue treatment beyond that time depends on patient preference and past history of recurrences
Rules of medication discontinuation
- Taper over 2-4 weeks to minimize side effects
- General rule: reduce dose by 25% per week
Define discontinuation syndrome
- For antidepressants that affect serotonin
- The likelihood that a patient will develop this is related to dose and agent (not duration of treatment)
Discontinuation syndrome symptoms
- Flu-like symptoms
- Insomnia
- Imbalance
- Sensory disturbances (brain zaps)
- Irritability
List the 3 types of the psychotherapy
- Cognitive behavioral therapy
- Interpersonal therapy
- Problem-solving therapy
*therapists often use all 3 methods
Define cognitive behavioral therapy
Enables patients to correct false self-beliefs that can lead to negative moods and behaviors
Define interpersonal therapy
- Targets interpersonal conflicts
- Useful only if patient has capacity for insight
Define problem-solving therapy
Teaches patients how to improve their ability to deal with their specific everyday problems
Explain nonpharmacological treatments - Electroconvulsive therapy (ECT)
- Highly effective
- Indicated when:
- -Rapid response is needed
- -When drug therapies have failed
- -When there is a history of good response to prior ECT
- -There is a patient preference
- More rapid onset than drug therapy
When should you refer for psych consult?
- Uncertain of the diagnosis
- More severe symptoms develop
- Other treatments may be more helpful:
- -Psychotherapy
- -Light therapy
- -Electroconvulsive therapy
- More intensive level of care will be needed:
- Suicidal or homicidal ideation
- Psychosis
- Have multiple psychiatric diagnoses
When should you consider inpatient care?
When there is a risk to the patient, to others or when sufficiently severe to warrant treatment in a more controlled setting:
- Depression with psychotic features
- Homicidality
- Suicidality
- Inability to care for oneself at home
- In need of detoxification or substance abuse treatment
What is the prognosis for MDD?
- 70-80% of MDD patients can achieve a significant reduction in symptoms
- As many as 50% of patients may not respond to the initial treatment trial
Overview of Delirium
- Affects up to 56% of hospitalized patients over
- Sudden, fluctuating, and usually reversible disturbance of mental function
- An abnormal mental state, NOT a disease
- A medical emergency
What is the hallmark delirium symptom?
Inability to pay attention - results in confusion & disorientation
Other symptoms of delirium
- May have fluctuating level of consciousness
- Symptoms can change even from minute to minute
- May have visual hallucinations, paranoia or delusions
- Personality and mood may change
- Can cause coma or death
DSM-5 Diagnostic criteria for delirium
A. Disturbance in attention and awareness (reduced orientation to environment)
B. Disturbance develops over a short period of time, represents a change from baseline, and tends to fluctuate in severity
C. An additional disturbance in cognition (memory deficit, disorientation, perception…)
D. Disturbances in A and C are not explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal
E. There is evidence that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies
Delirium d/t drug use
- MC reversible cause
- Young patients: illegal drugs and alcohol
- Older patients - prescription meds such as:
- Psychoactive drugs: opioids, sedatives, antipsychotics, antidepressants
- OTC antihistamines
- Corticosteroids
- Digoxin
- Many others…
*Can also occur from stopping a drug that has been taken for a long time (alcoholics)
Diff Dx for delirium
Dementia:
- Older patients
- Symptoms only get worse over time (except in reversible cases)
- No change in level of consciousness
Psychosis d/t a psychiatric disorder:
- Attention is unaffected
- Retain memory for recent events
- Usually auditory hallucinations
DELIRIUMS differential dx mnemonic
D-drugs
E-emotional state (acute psychotic and depressive episodes)
L-low oxygen states (anemia, PE, MI, CVA)
I-infection
R-retention of urine and feces
I-ictal states (seizures)
U-undernutrition and dehydration
M-metabolic (organ failure, thyroid disease, B12 deficiency)
S-subdural hematoma
Preventative interventions for delirium
- Frequent reorientation
- Early and recurrent mobilization
- Pain management
- Adequate nutrition and hydration
- Reducing sensory impairments
- Ensuring proper sleep patterns
Tx of delirium
- Hospitalization for testing to find etiology
- Treat etiology
Prognosis of delirium
- Overall prognosis is dependent on etiology
- Hospitalized patients who develop delirium are 10 X more likely to have complications in the hospital (including death)11
- Patients admitted with delirium have mortality rates up to 26%
- Elderly patients may take 8 weeks or more to fully recover
Define dementia
- Progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function8
- Previously called senility and considered a normal part of aging—now is considered pathological, and in some cases is reversible
Etiology of dementia
- 4-5 million people in US: 1% of people aged 60-64 and up to 50% of people over age 85
- Leading cause of placement in nursing homes
- Symptoms progress over years
Overview of Alzheimer’s Dementia (AD)
- Accounts for up to 75% of all dementias
- Mostly sporadic but 5-15% run in families
- Usually present with memory loss
- Course lasts 2-22 years
- Average lifespan after diagnosis is 7-10 years
Alzheimer’s dementia pathology of the brain
Senile plaques and neurofibrillary tangles
Risk factors for AD
- Increasing age
- Smoking
- First degree relative with AD
- Obesity in middle age (dementia in general)
- Diabetes
- Patients with APO-e4 gene
Diagnosis of AD
Multiple cognitive deficits including memory impairment and 1 or more of the following:
- Aphasia (language disturbance, naming)
- Apraxia (motor disturbance, how to use a comb)
- Agnosia (impaired recognition of familiar objects/people…)
- Executive function disturbance (attention, concentration, organizing, planning…)
List the 3 types of memory impairment in AD
*Memory impairment is usually the first symptom
3 types of episodic memory
-Immediate recall (mental rehearsal of phone #)
-Memory of recent events (prominently impaired in AD)
-Memory of distant events
List the symptoms of early dementia
- Forgetting names or appointments
- Losing things
- Difficulty performing familiar tasks (driving, cooking, household chores)
- Personality changes
- Mood swings, often with brief periods of rage
- Paranoia or suspiciousness
- Confusion, disorientation to unfamiliar surroundings
List the symptoms of intermediate dementia
- Worsening of previous symptoms with less ability to compensate
- Unable to carry out ADLs
- Disrupted sleep
- Hallucinations
- Confabulation
- Inattention, poor concentration, loss of interest in outside world
List the symptoms of severe dementia
- Continued worsening of previous symptoms
- Complete dependence on others for ADLs
- Impairment of other movements such as swallowing (higher risk for aspiration and malnutrition)
- May be unable to speak or walk
- Complete loss of short- and long-term memory (may not even recognize their own face)
What are the warning signs of AD?
- Asking the same question over and over again
- Repeating the same story, word for word, again and again
- Forgetting how to perform common tasks previously performed with ease
- Losing one’s ability to pay bills or balance the checkbook
- Getting lost in familiar surroundings or misplacing household objects
- Neglecting to bathe, wearing the same clothes over and over again while insisting they have bathed or that the clothes are clean
- Relying on someone else to make decisions or answer questions
“Inappropriate” AD behavior
Because a patient…
-forgets rules of proper behavior, he may
get undressed when he feels hot
-may masturbate or use inappropriate language whenever he has a sexual impulse
-has difficulty understanding what he sees and hears, he may misinterpret an offer of help for an attack and become combative
-has short-term memory impairment, he may repeatedly ask the same question or tell the same story
-cannot express their needs clearly, he may yell when in pain
Define AD sundowning
Symptoms usually resolve within one hour of exposure to light and return each evening within one hour of darkness
-Etiology unkown
Define AD sundowning behavior difficulties
- Restlessness
- Agitation
- Suspicious behavior
- Disorientation
- Visual and auditory hallucinations
- Less cooperation
- Increased argumentativeness
Tx of AD sundowning
- Coping (no ‘treatment’)
- Keep patient active in morning and encourage early afternoon nap
- Avoid caffeine towards late evening
- Sleep with radio or night-light
What is the diff dx for AD?
- Disease
- Infection
- Stroke
- Head injury
- Drugs
- Nutritional deficiencies
Reversible causes “DEMENTIA” mnemonic
D-drugs (any drug with cholinergic activity) E-emotional (depression) M-metabolic (hypothyroid) E-eyes and ears declining N-normal pressure hydrocephalus T-tumor or other space-occupying lesion I-infection (syphilis, AIDS) A-anemia (B12 or folate deficiency)
List the irreversible causes on your diff dx
- Alzheimer disease
- Vascular dementia
- Parkinson’s disease
- Lewy Body disease
- Huntington disease
- Creutzfeldt-Jakob disease
- Pick disease
Explain age-related memory from your diff dx
“Can’t find my glasses”
- Benign
- Slowing of mental processes
- NOT dementia
- Does not impair a person’s ability to learn new information, solve problems, or carry out ADLs
List the symptoms of Parkinson’s disease
- Asymmetric resting tremor
- Muscle rigidity
- Bradykinesia
- Postural instability (late in disease)
Pathophysiology of Parkinson’s disease
- D/t loss of dopaminergic neurons from substantia nigra
- Chronic and progressive
Etiology of Parkinson’s disease
- 40% of Parkinson’s patients develop dementia
- Usually after age 70 and 10-15 years after diagnosis
- 50% of patients are also depressed
Tx of Parkinson’s disease
carbidopa-levodopa (Sinemet)
- Helps with symptoms
- Does not inhibit disease progression
Etiology of multi-infarct dementia (vascular dementia)
- 10-15% of dementias
- Stepwise deterioration
- Can be abrupt onset
- Death usually occurs within 5 years of diagnosis
Risk factors of multi-infarct dementia (vascular dementia)
HTN, smoking, diabetes, and hyperlipidemia
Evidence of vascular disease by…
- History
- Physical exam (focal neurologic signs of TIA, CVA)
- Laboratory testing
Symptoms of multi-infarct dementia (vascular dementia)
- Prone to emotional outbursts
- Personality changes
Tx of multi-infarct dementia (vascular dementia)
Treat risk factors (HTN, DM, CAD…)
Pathophysiology of dementia with Lewy Bodies
Lewy bodies: protein deposits that destroy nerve cells throughout the cerebral cortex
- Early signs of memory loss are often absent
- Death usually occurs 6-12 years post-diagnosis
List the requirements for dementia with Lewy bodies
2 of the following are required:
- Fluctuating cognition and pronounced variations in attention and alertness
- Recurrent visual hallucinations, delusions and paranoia
- Spontaneous motor features of parkinsonism
- -Move slowly
- -Shuffle when they walk
- -Stoop over
Tx of dementia with Lewy bodies
rivastigmine (Exelon) may help
General info for Pick’s disease
AKA Frontotemporal Dementia
- 35-75 years old
- 20-40% have family history29
- Pathogenesis unclear
- Personality changes and poor insight
- Loss of appropriate social emotions, disinhibition, deficits in executive functioning and memory, perseveration
- Estimated survival is 3-6 years from time of diagnosis
Define Charles Bonnet Syndrome
- Visual hallucinations in patients with visual acuity or visual field loss
- Mean age of 70-85 years old
- Hallucinations can completely go away if vision is corrected
Why is a complete physical exam important?
Findings may suggest etiology: vascular disease may have focal neurologic findings
List the areas of assessment of cognitive functions
- Speech (aphasia)
- Motor memory (apraxia)
- Sensory recognition (agnosia)
- Complex behavior sequencing (executive functioning)
Explain speech (aphasia) for assessment of cognitive function
- Ask patient to name objects
- Frequent use of ‘things’ and ‘it’ signify difficulty in naming
Explain motor memory (apraxia) for assessment of cognitive function
Ask patient to pantomime the use of a common object (toothbrush)
Explain sensory recognition (agnosia) for assessment of cognitive function
Identify object placed in the patient’s hand
Explain complex behavior sequencing (executive functioning) for assessment of cognitive function
Ask patient to perform a series of simple tasks (fold paper in half and place on floor)
Mini-Mental Status Exam
Review on slide :)
Mini-Mental Status Examination Scoring
- Score range: 0-30
- 28-30 normal
- 25-27 possible mild cognitive impairment
- 19-26 mild dementia
- 10-18 moderate dementia
- 0-9 severe dementia
Can help document changes over time (medication efficacy)
Limitations of mini-mental status exam
- Depends on education level of patient
- Not appropriate for visual- or hearing-impaired patients
- Does NOT test judgment and insight
- Ask other questions for this: “What would you do if you were in a building and smelled smoke?”
Explain the clock drawing test
- Very quick, about 1-4 minutes
- MMSE more accurate
Ask patient to:
- Put the numbers in the face of a clock
- Then, make the clock say 10 minutes past 11
Scoring is 1 point each for:
- Clock circle
- Numbers being in the proper order
- Numbers in the proper place on clock face
- Two hands of clock
- Proper time
Normal score is 4 or 5
List the lab tests to evaluate for dementia
- Urinalysis
- CBC
- CMP (blood sugar, kidney and liver function, electrolytes)
- Thyroid tests
- Serum vitamin B12
- Syphilis serology
What additional tests should you consider?
- Electroencephalography (EEG)—if seizures
- Lumbar puncture—if 6 month or less onset of symptoms or rapidly progressive
- Heavy metal screen, HIV, lyme disease titer—if history of exposure
- CT or MRI (depending on presentation)
What are the brain differences in those with AD vs. normal brain?
- Diffuse atrophy and loss of neurons, neuronal processes and synapses in the cerebral cortex and certain subcortical regions.
- This results in gross atrophy of the affected areas and enlargement of the lateral ventricles.
What are the meds for AD?
Cholinesterase inhibitors:
- Aricept (donepezil)
- Razadyne (galantamine)
- Exelon (rivastigmine)
NMDA receptor antagonist:
-Namenda
**Do not change course of disease, instead temporarily mitigate some of the symptoms
General info for cholinesterase inhibitors
- May temporarily improve mental function, but do not stop progression
- Start as soon as diagnosis is made
- All have a titration period
- All are equally efficacious15
ADRs and contraindications of cholinesterase inhibotors
- ADRs: n/v/d (usually better with slow titration and time)
- Avoid co-administration of anticholinergic drugs (benadryl, detrol…)
General info for Namenda (memantine)
- NMDA antagonist
- Approved for moderate-severe dementia
- Can use in conjunction with cholinesterase inhibitors
- Side effects: somnolence, dizziness, h/a, constipation
List the additional medications for behavioral symptoms
- Antidepressants (especially SSRI)
- Atypical antipsychotics for psychosis, agitation and aggression
- Carbamazepine for agitation and aggression
- Benzodiazepines
List the supportive measures for demented patients
- Patients do much better in familiar environments
- Follow a daily routine
- Keep patients oriented
- Windows (time of day)
- Large daily calendar
- Clock with large numbers
- Hide car keys to prevent accidents
- Door detectors can help prevent wandering
- ID bracelet helpful, especially if patient wanders
- Increased physical activity
AD prognosis
- Death often results from an infection (such as aspiration pneumonia)
- AD patients usually live 7 years after diagnosis
AD end-of-life issues
- Discuss early in disease
- Advance directives
- -What is wanted or not wanted in specific health situations
- -Living will
- -Treatments that the patient would want if they were seriously or terminally ill
- -DNR/DNI
- -Do not resuscitate/ do not intubate
- Durable power of attorney (health care proxy)
- Assigns one person legally authorized to make treatment decisions on the patient’s behalf
List considerations for caregivers
- Don’t forget those providing care to the demented patient
- Need education about disease progression and what to expect
- Incidence of depression in caregivers is up to 47%17
- Need relief sometimes (‘respite care’)
- Day-care programs
- Home nursing
- Part-time or full-time housekeeping
- Live-in assistance
- Psychotherapy
- Need to take care of themselves, too!
