geri Flashcards
Cholinesterase inhibitor (i.e donepezil)
Concept: Cholinesterase inhibitors increases acetylcholine by preventing breakdown by acetylcholinesterase.
Cholinesterase inhibitor = More acetylcholine = increased parasympathetic effect which promotes a “rest and digest” response.
Cholinesterase inhibitor effect includes:
– bronchoconstriction.
– heart rate reduction
– pupil constriction
– stimulates salivary gland secretion-drooling
– stimulates GI tract – diarrhea, nausea
– stimulates peristalsis.
– loss of appetite resulting in weight loss
– increased urinary frequency.
Notes on cholinesterase inhibitors:
modest improvement in cognitive function and global clinical effect for mild to moderate Alzheimer’s dementia.
symptomatic improvement only.
also helpful in non-cognitive improvement such as apathy and psychosis.
Donepezil should also be continued for patients with moderate to severe dementia, as demonstrated in the DOMINO Study published in NEJM 2012.
Anti-cholinergic
anti-cholinergics = less acetylcholine = mimics the sympathetic effect and promotes a “fight or flight” response.
Anti-cholinergic effect includes: – reduce salivary secretion-dry mouth – constipation – pupil dilatation- blurred vision. – increases heart rate-tachycardia – weight gain. – contricts urinary sphincter-urinary retention
frailty
clinical syndrome in which three or more of the following criteria were present:
1) unintentional weight loss (10 lbs in past year)
2) self-reported exhaustion
3) weakness (grip strength)
4) slow walking speed
5) low physical activity
ethics
Autonomy:
The principle of autonomy recognizes the rights of individuals to self determination. Respect for autonomy is the basis for informed consent and advance directives.
Beneficence:
The term beneficence refers to actions that promote the wellbeing of others. In the medical context, this means taking actions that serve the best interests of patients.
Non-Maleficence:
“first, do no harm,”
It is not only more important to do no harm than to do good; it is also important to know how likely it is that your treatment will harm a patient. So a physician should go further than not prescribing medications they know to be harmful – he or she should not prescribe medications (or otherwise treat the patient) unless s/he knows that the treatment is unlikely to be harmful; or at the very least, that patient understands the risks and benefits, and that the likely benefits outweigh the likely risks.
incontinence Pharmacologic therapy
duloxetine for stress incontinence
anticholinergic drugs (oxybutynin, tolterodine) for urge incontinence
The Mayo criteria for mild cognitive impairment
– memory complaints – objective memory impairment. – preserved general cognitive function (NO FUNCTIONAL DEFICIT) – intact activities of daily living – not demented.
Rate of conversion from MCI to Alzheimer’s disease is 5-18% per annum
The maximum MMSE score is 30 points. A score of: 20 – 24 suggests mild dementia, 13 – 20 suggests moderate dementia, < 12 indicates severe dementia.
MRI showing hippocampal atrophy
Alzheimers disease
Dementia with Lewy bodies
1) Early appearance of Parkinsonian features
2) Visual hallucinations
3) Delusional misidentification
4) REM sleep disorder
– fluctuating cognition
– memory impairment NOT prominent in early stages
TIP: A delirium induced by L-dopa prescribed for Parkinsonian symptoms attributed to Parkinson’s disease may be an initial clue to DLB.
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
Notch 3 gene mutations
Features highly suggestive of FTD
1) Prominent behavioural change
2) Intact memory
3) Lobar atrophy on brain imaging
Clues to diagnosis of frontotemporal dementia: – impaired reasoning or handling complex tasks out of proportion to memory or visuospatial impairment. – decrease personal care – alteration in diet – loss of empathy or feelings for others – blunting – inappropriate comments – inflexibility thinking.
Neuro exam may reveal akinesia, rigidity and prim reflexes.
medication for psychosis
- Risperidone for dementia
- Haloperidol for delirium
Best response with anti-psychotics include:
Aggression
Agitation
Delusions.
Least to respond:
Wandering, social withdrawal, shouting, touching, pacing.
MMSE for Alzheimers
– Mild Alzheimer’s is usually linked to an MMSE score of 21 to 26
– Moderate Alzheimer’s is usually linked to an MMSE score of 10 to 20
– Severe Alzheimer’s is usually linked to an MMSE score of less than 10
diagnostic criteria for probable DLB
– The presence of dementia
– At least two of three core features:
- fluctuating attention and concentration,
- recurrent well-formed visual hallucinations, and
- spontaneous parkinsonian motor signs.
Suggestive clinical features include:
- Rapid eye movement (REM) sleep behavior disorder
- Severe neuroleptic sensitivity
Low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET imaging
Drugs Associated with Weight Loss
- SSRI Antidepressants
– Citalopram hydrobromide (Celexa, Forest)
– Fluoxetine (Prozac, Eli Lilly)
– Paroxetine (Paxil, GlaxoSmithKline)* - Cardiac Agents
– Bepridil (Vascor,Ortho-McNeil)*
– Digoxin (Lanoxin, GlaxoSmithKline)
– Furosemide (Lasix, Aventis) - Stimulants and Appetite Suppressants
– Amphetamine/dextroamphetamine (Adderall, Shire)
– Dextroamphetamine sulfate (Dexedrine,GlaxoSmithKline)
– Methylphenidate (Ritalin,Novartis; Concerta, Alza)
– Pemoline (Cylert, Abbott)
– Phentermine (e.g., Ionamin, Celltech)
– Sibutramine HCl monohydrate (Meridia, Abbott) - Benzodiazepines
– Clonazepam (Klonopin, Roche)
– Lorazepam (Ativan,Wyeth-Ayerst) - Miscellaneous
– Metformin (Glucophage, Bristol-Myers Squibb)
Antidepressants that causes weight loss:
Citalopram
Fluoxetine
Paroxetine
