IC16 Dementia (Alzheimer's Disease) Flashcards
What is the DSM-5 criteria for dementia?
- 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
- The cognitive deficits interfere with independence in everyday activities
- The cognitive deficits do not occur exclusively in the context of delirium
- The cognitive deficits are not better explained by another mental disorder
What are the 6 areas of cognitive function?
- complex attention
- executive function
- learning and memory
- language
- perceptual-motor
- social cognition
What screening tools can be used for AD?
MMSE
MoCA
WWhat MMSE scores (out of 30) indicate mild, moderate and severe AD?
mild - 20-24
mod - 10-19
severe - < 10
What are the non-modifiable risk factors for AD? (4)
age
female sex
ethinicity (african american and hispanic)
genetics (apolipoprotein E)
What are the modifiable risk factors for AD? (8) (SHHOLDDD)
Smoking
HTN
Hearing loss
Obesity
Limited physical activity
Diabetes
Drinking (binge)
Depression
Explain the pathophysiology behind formation of senile plaques.
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
Explain the pathophysiology behind formation of neurofibrillary tangles.
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
Name the AChEI drugs
Donepezil, rivastigmine, galantamine
What are AChEIs MOA?
inhibit the AChE enzyme thereby promoting a relative increase in ACh abundance at the synaptic cleft for cholinergic neurotransmission
How should AChEIs be titrated
A slow titration dosing regimen over 4-8 weeks
What are side effects of AChEIs
nausea and vomiting, loss of appetite, vivid dreams and insomnia
In which populations are AChEIs contraindicated and should be used in caution?
CI: bradycardia
caution: pts with seizure d/o
What should be done if adverse effects are experienced while using AChEIs?
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
When are NMDA antagonists indicated in AD?
moderate to severe dementia
pts who cannot tolerate AChEIs
What are side effects of NMDA antagonists?
constipation (common), headache, confusion and dizziness
In which populations should NMDA antagonists be used in caution?
- CVD
- seizure disorders
- severe renal and hepatic impairment
What are some non-pharmacological measures to manage AD? (dont memorise all la..)
- 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)
What are behavioural and psychologal sx of dementia (BPSD)?
spectrum of non-cognitive and non-neurological symptoms of dementia like agitation, aggression, psychosis, depression and apathy
How does agitation and aggression manifest in BPSD and how can it be managed?
manifests as complaining, angry statements and threats
can be managed with environmental modifications and non-specific calming methods
How does depression manifest in BPSD and how can it be managed?
sadness, pessimistic thoughts and withdrawal, typically in the earlier stages of disease
can be managed with exercise, social connection and CBT
How can anxiety in BPSD be managed?
most disabling BPSD
can be managed by eliminating the trigger
How does apathy manifest in BPSD and how can it be managed?
aimlessness with lack of initiative, motivation
can be managed by reading to the patient, small group activities and encouraging them to ask questions
How do psychotic symptoms manifest in BPSD and how can they be managed?
delusions or hallucinations
can be managed by confirming that the patient’s claims are not occurring, and memory aids can help as well
What is wandering in BPSD and how can it be managed?
circular or random without diversion
can be managed with supervised walks or using a GPS watch
How does apathy nocturnal disruptions in BPSD and how can it be managed?
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
When should pharmacological treatment be considered in treating BPSD?
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
