Geriatrics Flashcards
DSM 5 criteria for Major Neurocognitive d/o
A. Significant cognitive decline in 1 or more of:
complex attention
executive function
learning and memory
language (aphasia)
perceptual-motor (apraxia, agnosia)
social cognition
Decline based on concern of informant or clinician, and on objective testing (> 2 SD below normal)
B. Decline in independence in every day activities (IADLs)
C. Not delerium
C. Not another mental disorder
DSM5 NCD specifiers
Alzheimer's disease Frontotemporal lobar degeneration Lewy body disease Vascular disease Traumatic brain injury Substance/medication induced HIV infection Prion disease Parkinson's disease Huntington's disease Another medical condition Multiple etiologies Unspecified
“Reversible” Causes of Dementia symptoms
- head injury
- metabolic/nutritional: B12/folate, thiamine, thyroid, hepatic, renal
- medication
- alcohol/toxins
- infectious- HIV, syphilis, meningitis
- normal pressure hydrocephalus
- neoplasms
- autoimmune
- depression
Cortical Dementia
-Normal psychomotor spead
-language affected
-memory: impaired recall and recognition
-less impaired executive function
-less common depression
-late motor symptoms
eg Alzheimer’s
Subcortical Dementia
- slowed psychomotor speed
- normal language
- memory: impaired recall, spared recognition
- impaired executive function
- depression more common
- early motor symptoms
- eg Huntington’s disease, Parkinson’s dementia, HIV dementia
Dementia work up
Can guidelines (CMAJ 2008): CBC, Lytes, fasting glucose, TSH, B12, Ca
Others: BUN, Cr, Mg LFTs,, folate, UA, fasting lipids
as indicated: VDRL, HIV
imaging: CT (adequate for most cases), MRI (atypical cases– better at atrophy, small vessel disease), SPECT
Cognitive tests: MoCA, Behavioural neurology assessment, 3MS (2008 guidelines)
NCD Imaging indications
CT for:
-age < 60 yo
-rapid unexplained decline in cognition/function
-“short” duration of dementia
-unusual or atypical presentation
-rule in vascular disease
-rule out NPH
-rule out metastases
-recent and significant head trauma
-use of anticoagulatnts or hx of bleeding disorder
-unexplained neurological symptoms or new localizing sign
MRI preferred for high suspicion of vascular disease, or rapid and atypical presentation
Indications for Cholinesterase Inhibitors
For people with mild to severe Alzheimer's D -standard for mild-moderate AD AD with cerebrovascular disease Lewy body dementia Parkinson's disease dementia Insufficient evidence for Vascular dementia Not used for mild cognitive impairment (only treats symptoms- not cure) --assess after 3-6 month trial
Cholinesterase Inhibitor Clinical/Safety Issues
Before use, assess medical and psychosocial factors
Side effects lower with slower titration
Common: nausea, vomiting, dyspepsia, anorexia, diarrhea, insomnia, vivid dreams, fatigue, increased urination, muscle cramps
Uncommon: syncope, bradycardia, confusion, depression, agitation
Caution with liver/gastric disease, COPD, bradycardia (< 50 bpm), sick sinus, inadequate supervision
Benefits of cognitive enhancers
Cholinesterase inhibitors: modest benefits in cognition, ADLs, caregiver burden, but questionable benefit to non-cognitive behavioural symptoms
NMDA receptor antagonists: modest benefit in cognition, ADLs, caregiver burden, and possible mild benefit for non-cognitive behavioural symptoms
Memantine
NMDA R antagonist (non-competitive), and 5HT3A antagonist– decreases excessive neuronal activity (ie neurotoxicity) without inhibiting normal synaptic activity
- most useful when added to cholinesterase inhibitors for slowing cognitive/functional decline in mod-severe AD
- safe with few side effects or drug drug interactions
- may improve neuropsychiatric function (agitation/aggression, delusions, hallucinations)
- side effects- HA, constipation,
- caution with renal impairment
Non-cognitive behavioural symptoms in Dementia
mood: early, depression, mania
thinking: early/later- SI, delusions, hallucinations
Activity: early and late, agitation, wandering, aggression, sexually inappropriate behaviour, sleep/activity cycle disruption
Treatment of depression in NCD
25% of older adults with dementia have co-morbid depression1
Vascular dementia and DLB > Alzheimer’s
Depression should be considered when:
pervasive low mood and loss of pleasure
self deprecating remarks or expressions of a wish to die
personal or family history of depression prior to onset of dementia
significant behavioral change
First line choice for antidepressants include citalopram, escitalopram (not on formulary), sertraline, moclobemide, venlafaxine, bupropion and mirtazapine2
People with major depressive disorder who receive remission of symptoms following treatment with an antidepressant should be treated for a minimum of 1 year (and up to 2 years) with their full therapeutic dose2
Agitation/Psychosis in Patients with dementia (APA practice guideline 2016)
Key recommendations are for pre-treatment thorough assessment, individualized treatment plan, nonpharmacologic approaches first (in non-emergency), measurement based treatment (e.g. using NPI), avoid haloperidol and long-acting injectables, try taper after 4 months even in responders without contraindications to discontinuationKey recommendations are for pre-treatment thorough assessment, individualized treatment plan, nonpharmacologic approaches first (in non-emergency), measurement based treatment (e.g. using NPI), avoid haloperidol and long-acting injectables, try taper after 4 months even in responders without contraindications to discontinuation
Antipsychotics for behavioural symptoms in dementia
Document use of behavioral and environmental interventions
Document antipsychotic’s target symptoms
Educate health care representative about benefits, risks
Coordinate care with that of other involved clinicians
Establish time frame for assessment of results
Frequently assess (and document) benefits and AEs
Use lowest doses necessary for the shortest time period
Evidence does not support greater safety of typicals.
