Exam 3 lecture 7 Flashcards
What are the neurocognitive domains and how can they be used
Neurocognitive domains are diagnostic criteria. Each domain defines exoectation for major or mild NCD
- Complex attention- sustained/divided attention, processing speed
- Learning and memory- immediate/recent memory, very long term memory
- perceptual/motor- visual perception/praxis
- executive function- planning decision making, working memory, flexibility
- language- expressive and receptive language
- social cognition- recognition of emotion, range of behavior
difference between dementia and delirium
Dementias- are deficits in learning and memory (long term and irreversible)
delirium is focused on attention (short term and reversible)
define mild neurocognitive disorders
Evidence of modest cognitive decline from a previous level of performance in 1 or more cognitive domains
does not interfere with independence
not attributed to delirium episode
not explained by mental/medical disorder
Define major neurocognitive disorder
Evidence of significant cognitive decline from a previous level or performance
interfere with independence
not attributed to delirium episode
not explained by mental/medical disorder
types of NCD
alzheimers
vascular dementia
lewy body disease
What are the reversible labs that lead to reversible cognitive decline
B12 or folate deficiency
hypothyroidism
CBC
electrolytes
LFT
infection
Depression
Most frequently seen drugs that cause cognitive impairement
Skeletal Muscle Relaxants
* Tricyclic Antidepressants
* Bladder antispasmodics
* Antihistamines
* OTC allergy/cough cold
* Rx anti-emetics
describe alzheimers, vascular dementia and lewy bodies if they were on a graph
Lewy bodies- up and down. Looks like it is getting better but gets worse
Vascular dementia- looks like a downward stair case. Has periods where there is no decline and periods where there is.
Alzheimers- constant decline
options for treatment for NCDs
Cholinesterase inhibitors
NMDA receptor antagonists
cholinesterase inhibitor FDAapproved for? what line of treatment? drugs?
FDA approved for mild to moderate and severe dementia
1st line and donepezil usually chosen 1st
Donepezil (Aricept)
◦ Rivastigmine (Exelon)
◦ Galantamine (Razadyne)
NMDA receptor antagonists used for? FDA approved for? drugs?
Does not slow/prevent neurodegeneration
FDA approved in moderate to severe dementia only
not useful in mild-cognitive impairement
Drugs Memantine (Namenda)
◦ Donepezil/Memantine
(Namzaric)
tx causes 6-12 months in delay of alzheiners
dosing of donepezil? side effects?
Dosing of galantamine? side effects?
dosing of rivastigimine? side effects?
dosing of memantine? side effects?
dosing of memantine/donepezil? side effectrs?
donepezil
initiate- 5 mg QD at bedtime
increase to 10 mg QD at bedtime after 4-6 wks
side effects- GI bleeding (caution with NSAIDs) N/V/D, bradycardia, syncope, weightloss
CYP 2D6 3A3/4 substrate
galantamine-
IR- 4 mg BID for 4 wks with breakfast and dinner
>16 mg/day not recommended for moderate renal/hepatic impairement
side effects- GI bleeding, weightloss, N,V,D, bradycardia, syncope, insomnia
rivastigamine
- dosing- initiate 1.5 mg BID. Take with meals to minmize GI side effects
toxicity- due to not removing previous patch everyday N/V/D (significant)
memantine
Dose adjustment required in severe renal impairment (CrCl= 5 – 29 ml/min) = Initiate 5mg once daily x 1 week, if tolerated, target dose = 5mg twice daily
side effects- Use with caution in patients with seizure disorder Dizziness, headache, hallucinations, insomnia, confusion, constipation Use with caution with carbonic anhydrase inhibitors and sodium bicarbonate – clearance of memantine is reduced by 80% if urine is alkalinized No P450 interactions
memantine/donepezil
On donepezil 10 mg only: start Namzaric 7/10 daily and increase by 7 mg increments as tolerated to 28/10 target dose once daily If on memantine 10 mg twice daily or ER 28 mg once daily, switch to Namzaric 28/10 with evening meal once daily Warning for vagotonic effects like bradycardia and heart block; increased risk of GI ulceration; diarrhea, nausea, vomiting; bladder outflow obstructions;
Is combination tx more efficacious? What should we educate the pt about regarding drug tx of NCDs, how to titrate dose? Key concepts with regard to taking drugs?
Combination tx- more efficacious,
educate that there is expected progression of disease.
Titrate to highest dose based on side effects
key concepts- adverse effects are dose dependent
do not suddenly stop and start
what are some antibody drugs that are used in dementia? eligibility to get these drugs?
Adenacumab and lecanemab
eligibility- require presence of amyloid beta pathology prior to unitiating
non pcol interventions for dementia
Consider vision, hearing, and other sensory impairments
Cognitive stimulation (puzzles, problem solving, Sudoku) can have short-term benefits on cognition an QOL
Maintain a consistent, structured environment with appropriate stimulation
Provide frequent reminders and orientation cues
Reduce choices, keep requests simple, avoid complex tasks that lead to frustration
Monitor for sudden changes in cognition and functioning
◦ Could be delirium due to reversible cause (dehydration or urinary tract infection/pneumonia)
behavioral interventions for dementia
Increase enjoyable activities – listen to music, light exercise, pet therapy
Redirect and refocus – reminiscence therapy
Increase social activities – keep them busy
Encourage activities that are appropriate to the individual patient’s functional level
Establish regular sleep habits
Make sure the environment is safe, calm, and predictable
Watch caregiver for signs/symptoms of depression
agitation interventions
Recognize triggers – pain, fecal impaction, medical illness, boredom, depression, stressors Intervene early, recognize behavior
Outdoor activities more efficacious than antipsychotics for managing agitation and aggression (Watt, et al. Ann Intern Med 2019)
Maintain calmness in interactions, avoid arguing or trying to reason.
Avoid confrontation – meet the patient where they are and avoid forcing them into your reality – live in theirs unless is causes distress to them or others Introduce distraction techniques, turn attention to something pleasant
Minimize audio and visual stressors from the environment
