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3153 Psychiatry > IC16 Alzheimer's Disease > Flashcards

IC16 Alzheimer's Disease Flashcards

1
Q

What is the clinical definition of dementia according to DSM-5?

A

Dementia (Major Neurocognitive disorder)

  • Significant cognitive decline in >=1 cognitive domains
    o Domains:
     Complex attention
     Executive function
     Learning and memory
     Language
     Perceptual motor or social cognition
    o Significant decline in cognitive function
    o Substantial impairment in cognitive performance
  • Interferes with independence of everyday activities
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2
Q

What are the symptoms of dementia?

A

Symptoms:

  1. Short term memory loss
  2. Word-finding difficulty
  3. Apathy
  4. Depressive symptom
  5. Withdrawal from social engagement
  6. Disinhibition
  7. Rapid eye movement behaviour disorder
  8. Gait impairment
  9. Hallucinations
  10. Wandering
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3
Q

What are the different stages of dementia?
What number correlates with which stage?

A

Stages of Dementia (the lower the number, the more severe the dementia is):

  1. Mild (20-24)
  2. Mod (10-19)
  3. Severe (<10)
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4
Q

What are the 2 tools used for assessing dementia?
What are their uses?

A

Tools:

  1. MMSE
  2. MoCA
  • For screening and monitoring
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5
Q

How to differentiate between alzheimer’s disease and cerebrovascular disease?

A

Alzheimer’s Disease vs Cerebrovascular disease
Pathologic characteristics:

1) Brain atrophy
2) Senile Plaques
3) Neurofibrillary tangles
vs
1) Ischemia lesions

Onset:
Slow onset, gradual progression
vs
Acute vascular event –> onset within mins to days (clear event, followed by dementia)

Hx, examination and cognitive function:
Short term memory loss, and cognitive deficits
vs
Vascular risk factors etc.

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6
Q

What are the non-modifiable RF of dementia?

A

Non-modifiable RF:

  1. Age (>65y/o; worse >85y/o)
  2. Female
  3. Black, Hispanic
  4. Genetics (apolipoprotein E)
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7
Q

What are the modifiable RF of dementia?

A

Modifiable RF:

  1. HTN
  2. DM
  3. Binge drinking
  4. Smoking
  5. Limited physical activity
  6. Obesity
  7. Hearing loss
  8. Depression
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8
Q

What is the patho of AD?

A

Pathophysiology of Alzheimer’s Disease

  1. Senile Plaques – extracellular deposits of beta-amyloid protein (large insoluble and cause neurotoxicity)
  2. Neurofibrillary tangles – phosphorylated tau proteins, accumulate in cytoplasm, axon and dendrites, causing loss of cytoskeleton microtubules
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9
Q

What are the drug options for alzheimer’s disease?

A
  1. acetylcholinesterase inhibitors
  2. NMDA receptor antagonist
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10
Q

What are some examples of AI?
What are their MOA?
What are their place in therapy?
What are the advantages of each AI?

A

Acetylcholinesterase inhibitors
e.g. donepezil, rivastigmine, galantamine

  • inhibit acetylcholinesterase enzyme, ↑acetylcholine
  • not great efficacy, used at the start, symptomatic treatment

For mild-mod AD
For mild-sev AD (donepezil)

Adv:
Donepezil: familiarity, low cost
Rivastigmine: transdermal patch, can be used for pts with PD + dementia

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11
Q

How to administer AI?
If there is ADR and not tolerated, what should be done?
What or how to monitor efficacy?

A
  • slow titration over 4-8wks
  • if have ADRs, lower dose temporarily before increasing slowly again / switch to another AI

Monitor:

  1. see slight improvement in function
  2. use cognitive test to assess
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12
Q

What are the ADRs, precautions and CI of using AI?

A

ADR:

1) N&V
2) Loss of appetite
3) Vivid dreams
4) insomnia
5) skin irritation (rivastigmine patch)
6) Diarrhea

Precautions:

1) seizure
2) peptic ulcer

CI:

1) bradycardia

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13
Q

What are the considerations when reviewing medications for patients with AD?

A

Other considerations:

  1. ↓polypharmacy
  2. ↓meds that cause cognitive impairment e.g. anticholinergics, antihistamines
  3. Assist caregivers with medications
  4. Evaluate risk/benefit for existing meds e.g. anticoagulants
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14
Q

What are the possible non-pharm for AD patients? List at least 3.

A

Non-pharm:

  1. Cognitive stimulating activities e.g. reading, games
  2. Physical exercises e.g. aerobic and anaerobic
  3. Social interactions e.g. family events
  4. Healthy diet e.g. Mediterranean diet high in green leafy vegetables
  5. Enough sleep
  6. Proper personal hygiene
  7. Safety inside and outside homes e.g. knifes, driving
  8. Medical and advanced care directives e.g. power of attorney
  9. Long term health care planning e.g. living arrangements in late stage of dementia
  10. Financial planning e.g. allocation of assets
  11. Effective communications e.g. expressing need and desires, visual aids
  12. Psychological health e.g. participating in personally meaningful activities like playing music
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15
Q

What is BPSD?
What is the goal in managing BPSD?

A

Behavioural and Psychological Symptoms of Dementia/Alzheimer’s Disease (BPSD)

  • An attempt to express themselves / communicate
  • Extremely stressful
  • Want to ↑QOL
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16
Q

What are examples of BPSD?

A

Examples of BPSD:

  1. Agitation/ aggression
  2. Depression
  3. Anxiety
  4. Psychosis
  5. Apathy
  6. Wandering
17
Q

What is 1st line in managing BPSD?

A

*Non-pharmacological + identifying root cause is 1st line for BPSD

18
Q

How to manage agitation and aggression in patients with BPSD?

A

1) identify underlying cause e.g. depression, discomfort, boredom, feel threatened
2) make environmental/management modifications
3) Calm and positive experience interventions e.g. music, massage, fake pet, twiddle muff

19
Q

How to manage depression in BPSD patients?

A

1) exercise
2) social connection
3) Engaging activities
4) CBT

20
Q

What could anxiety be possibly due to?
How to manage anxiety in patients with BPSD?

A

Possibly due to family separation, different setting, ↓capacity to make sense of the environment

1) identify & remove triggers
2) maintain structure & routine
3) ↓need for stressful decision-making
4) music
5) CBT

21
Q

How to manage apathy in BPSD patients? (Lack of motivation, drive, emotional response)

A

1) Reading
2) encourage them to ask qns
3) Small group & individual activities e.g. puzzles, games, music, pets therapy

Generate positive behaviour

22
Q

How to manage psychotic sx in patients with BPSD? (hallucinations, delusions)

A

1) Modify the reversible causes e.g. overstimulation, delirium, new med, substance misuse
2) confirm the pts’ claims are not occurring
3) Use memory aids e.g. pictures
4) Distraction

23
Q

How to manage wandering in patients with BPSD? (Possibly related to agitation)

A

1) exercise
2) make wandering safe
3) supervised walks
4) secured space to roam
5) exercise equipment
6) GPS watch
7) determine if there is a purpose to the wandering e.g. to return home, looking for someone

24
Q

How to manage nocturnal disruptions in BPSD patients? (Sundowning (↑agitation in afternoons))

A

1) identify underlying cause e.g. thirst, hunger
2) restrict caffeine intake in the evening, limit fluid intake near bedtime
3) establish a night-time routine
4) ↓light and noise intrusion

25
Q

What are some factors contributing to BPSD? List at least 3.

A

Factors contributing to BPSD:
(medical)

  1. Delirium
  2. Untreated pain
  3. Fatigue
  4. Hearing/visual impairment

(drugs)

  1. Anticholinergics
  2. Anticonvulsants
  3. Opioids, BZDs, zopiclone (sedation)

(social/environment)

  1. Unfamiliar environment
26
Q

What is the role of pharmacological treatment in managing BPSD?
What are some considerations before starting patient on medications for BPSD?

A
  • Play a limited role in managing BPSD
  • Only prescribe when there is an indication + target symptoms/behaviours
  • Should NOT be used if just to sedate patients who are difficult to manage
  • Considerations (situations to use medications):
  1. Only use after all reversible causes have been managed
  2. Non-pharm management has been done
  3. Immediate risk to patients or others
  4. Patients are severely distress
27
Q

How long should pharmacological treatment be used to manage BPSD?
If symptoms return after stopping, what should be done?

A
  • Use for 3 months, then taper down slowly
  • If symptoms return after stopping, restart at the lowest dose and then review/trial withdrawal in 3-6months
28
Q

What are the possible pharm treatment for depression and anxiety in BPSD patients?
How does it help?
What are the ADRs of SSRIs?

A

SSRIs e.g. citalopram
Citalopram

  • ↓Agitation
  • Improve some BPSD e.g. delusions

ADRs:

1) QTc prolongation
2) Worsen cognition
Both are dose-dependent

29
Q

What medications are used for agitation, aggression and distress for BPSD patients?
When should they be used?
What are the concerns/risks to look out for when giving this med to BPSD patients?
How long should they be used?

A

Antipsychotics
- *Only given if agitation, aggression or psychotic sx are causing severe distress or an immediate risk of harm to patient /others
- unlikely beneficial for wandering, social withdrawal, challenging behaviour due to a clear environmental trigger
- Monitor every 6 weeks, stop when no longer needed

Significant concerns in elderly patients with dementia:

1) stroke
2) cardiovascular events
3) death
4) pneumonia (due to sedative properties of antipsychotics)–> aspiration

3153 Psychiatry (10 decks)

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