IC16 Dementia (Alzheimer's Disease)

Question 1

What is the DSM-5 criteria for dementia?

Answer 1

1. Evidence of significant cognitive decline from prior level of performance in one of more cognitive domains
   
   • Concern of the individual, a knowledgeable informant or the clinician there has been a significant decline in cognitive function
   • A substantial impairment in cognitive performance preferably documented by a standardised neurophysiological testing or in its absence other quantified clinical assessment
2. The cognitive deficits interfere with independence in everyday activities
3. The cognitive deficits do not occur exclusively in the context of delirium
4. The cognitive deficits are not better explained by another mental disorder

Question 2

What are the 6 areas of cognitive function?

Answer 2

1. complex attention
2. executive function
3. learning and memory
4. language
5. perceptual-motor
6. social cognition

Question 3

What screening tools can be used for AD?

Answer 3

MMSE
MoCA

Question 4

WWhat MMSE scores (out of 30) indicate mild, moderate and severe AD?

Answer 4

mild - 20-24
mod - 10-19
severe - < 10

Question 5

What are the non-modifiable risk factors for AD? (4)

Answer 5

age
female sex
ethinicity (african american and hispanic)
genetics (apolipoprotein E)

Question 6

What are the modifiable risk factors for AD? (8) (SHHOLDDD)

Answer 6

Smoking
HTN
Hearing loss
Obesity
Limited physical activity
Diabetes
Drinking (binge)
Depression

Question 7

Explain the pathophysiology behind formation of senile plaques.

Answer 7

When APP is worn out it is broken down by α- and γ- secretase to soluble peptides

When APP is broken down by α- and β- secretase, it forms insoluble β-amyloid fragments that deposit extracellularly and contribute to neurotoxicity

Plaques can form between neurons and affect signalling, therefore affecting brain functions like memory

Plaques can also cause amyloid angiopathy, increasing hemorrhage risk

Question 8

Explain the pathophysiology behind formation of neurofibrillary tangles.

Answer 8

β-amyloid plaques activate intracellular pathways that activate kinases

Phosphorylated tau proteins undergo conformational change, dissociate from the cytoskeleton and form neurofibrillary tangles

Neurons with tangles and non-functioning microtubules undergo apoptosis

Question 9

Name the AChEI drugs

Answer 9

Donepezil, rivastigmine, galantamine

Question 10

What are AChEIs MOA?

Answer 10

inhibit the AChE enzyme thereby promoting a relative increase in ACh abundance at the synaptic cleft for cholinergic neurotransmission

Question 11

How should AChEIs be titrated

Answer 11

A slow titration dosing regimen over 4-8 weeks

Question 12

What are side effects of AChEIs

Answer 12

nausea and vomiting, loss of appetite, vivid dreams and insomnia

Question 13

In which populations are AChEIs contraindicated and should be used in caution?

Answer 13

CI: bradycardia
caution: pts with seizure d/o

Question 14

What should be done if adverse effects are experienced while using AChEIs?

Answer 14

Dosage can be lowered temporarily (for a few days or weeks) before re-escalating it more slowly and monitoring for the recurrence of SE

OR the drug can be discontinued and a different AI started

Question 15

When are NMDA antagonists indicated in AD?

Answer 15

moderate to severe dementia
pts who cannot tolerate AChEIs

Question 16

What are side effects of NMDA antagonists?

Answer 16

constipation (common), headache, confusion and dizziness

Question 17

In which populations should NMDA antagonists be used in caution?

Answer 17

1. CVD
2. seizure disorders
3. severe renal and hepatic impairment

Question 18

What are some non-pharmacological measures to manage AD? (dont memorise all la..)

Answer 18

• Cognitively stimulating activities (eg. reading, games)
• Physical exercise (eg. aerobic and anaerobic)
• Social interactions with others (eg. family events)
• Healthy diet (eg. high in green leafy vegetables)
• Adequate sleep (eg. uninterrupted sleep with sufficient hours)
• Proper personal hygiene (eg. regular bathing)
• Safety, including inside the home (with kitchen appliances) and outside (driving)
• Medical and advanced care directives (eg. designation of power of attorney)
• Long-term health care planning (eg. for living arrangements in late stage dementia)
• Financial planning (eg. asset allocation)
• Effective communication (eg. for expressing needs and desires with visual aids)
• Psychological health (eg. participating in personally meaningful activities)

Question 19

What are behavioural and psychologal sx of dementia (BPSD)?

Answer 19

spectrum of non-cognitive and non-neurological symptoms of dementia like agitation, aggression, psychosis, depression and apathy

Question 20

How does agitation and aggression manifest in BPSD and how can it be managed?

Answer 20

manifests as complaining, angry statements and threats

can be managed with environmental modifications and non-specific calming methods

Question 21

How does depression manifest in BPSD and how can it be managed?

Answer 21

sadness, pessimistic thoughts and withdrawal, typically in the earlier stages of disease

can be managed with exercise, social connection and CBT

Question 22

How can anxiety in BPSD be managed?

Answer 22

most disabling BPSD

can be managed by eliminating the trigger

Question 23

How does apathy manifest in BPSD and how can it be managed?

Answer 23

aimlessness with lack of initiative, motivation

can be managed by reading to the patient, small group activities and encouraging them to ask questions

Question 24

How do psychotic symptoms manifest in BPSD and how can they be managed?

Answer 24

delusions or hallucinations

can be managed by confirming that the patient’s claims are not occurring, and memory aids can help as well

Question 25

What is wandering in BPSD and how can it be managed?

Answer 25

circular or random without diversion

can be managed with supervised walks or using a GPS watch

Question 26

How does apathy nocturnal disruptions in BPSD and how can it be managed?

Answer 26

secondary to depression, anxiety, agitation or pain

can be managed by assessing underlying cause which may include thirst and hunger, and restricting caffeine and overly stimulating activities

Question 27

When should pharmacological treatment be considered in treating BPSD?

Answer 27

Once potentially reversible causes have been excluded and NPM trialled unless there is an immediate risk to the patient or others

always used in combination with non-pharmacological interventions