ic17 dementia Flashcards
DSM5 criteria for major neurocognitive disorder dementia?
1) significant cognitive decline from prior level of performance in ≥1 area: complex attention (control/shift/divide attention),
executive function,
learning & memory,
language,
perceptual-motor (plan decisions),
social cognition
2) interfere with independence in everyday activities
3) do not occur exclusively in the context of delirium… or explained by another mental disorder
what are the different types of dementia
1) alzheimer’s disease
* associated with brain atrophy + senile plaques + neurofibrillary tangles
**2) vascular dementia **
* associated with infarcts, atherosclerosis…
* PMH vascular risk facotrs or prior stroke/vascular events
3) lewy body dementia
* brain atrophy with lewy body inclusions containing alpha-synuclein
**4) frontotemporal dementia **
* focal brain atrophy affecting frontal and anterior temporal lobes,
5) mixed type
modifiable risk factors for dementia
HTN
DM
alcoholism
smoking
limited physical activities
obesity
hearing loss
depression
clinical evaluation of suspected dementia?
1) lab testing:
- vit b12 and thyroid levles
- other metabolic, infectious, autoimmune tests to rule out other etiologies
2) brain imaging w CT/MRI
- AD: generalised/focal cortical atrophy, often asymmetric (hippocampal atrophy)
- vascular dementia: brain infarcts/white matter lesions
- frontotemporal: frontal lobe/anterior temporal lobe atrophy
other abnormalities: brain mass (tumor) and hydrocephalus (fluid buildup in ventricles)
how to use AChEIs + (indication)
slow titration 4-8 weeks to target dose
if adr = lower dose temporarily before reescalating OR chagne to another drug
used for MILD-MODERATE
alternative treatments to AChEIs + (indication)
consider use of non-competitve NMDA antagonist = MEMANTINE
for patients who
1) cannot tolerate AI or
2) first line in new diagnosis of MODERATE-SEVERE dementia
3) adjunct to AChEI in MODERATE-SEVERE dementia
how to monitor for improvement in phx tx?
monitor for slight improvements to day to day life OR routine cognitive tests (moCA)
side effects of AChEIs
n/v
loss of appetite
increased freq of bowel movements
vivid dreams
insomnia
C/I AChEIs
bradycardia
check if anyone beta blockers
caution AChEIs
pUD
repsiratory disease
seizure
urinary tract obstruction
side effects of memantine
confusion.
hallucinations.
dizziness.
headache.
constipation.
caution for memantine
in cardiovascular disease, seizure disorder,
severe HEPATIC and RENAL impariment
non phx approaches to AD
1) cognitively stimulating activities (reading, games)
2) physical exercise
3) social interactions
4) healthy diets eg mediterranean diet (high in green leafy vegetables)
5) adequate sleep
6) proper personal hygiene
7) safety in homes
8) medical/advanced care directives *designation of power of attorney
9) long term health and financial planning
10) effective communication
what is BPSD + examples
behavioural and psychological symptoms of dementia
eg agitation, aggression, psychosis, depression, apathy
BPSD management algorithm
if YES = examine and treat any causative/underlying problems
eg physical problems (infection, pain, discomfort), activity-related (washing/dressing)…
- if delirium, treat any underlying chest infections, alcohol/drug withdrawal…
consider non phx interventions: day structure, psychological/ physiological/ environmental interventions
- understand the patient’s background to gain insight into potential causes/solutions
only consider phx if the symptoms are severe/ pose a risk to the individual or others (and resistant to above tx)
- to review every three months and routinely withdrawn slowly
phx management of BPSD :
if restless/agitated
- consider trazodone 50-150mg OD
if depressive sx or anxiety
- SSRI (low dose sertraline or mirtazapine)
- citalopram for agitation
if severe acute distress (cautious)
- lorazepam 0.5-2mg in divided doses
if psychosis (ONLY if aggression/agitation is causing severe distress or immediate risk of harm)
(effectiveness varies)
(not beneficial for wandering/calling out/social withdrawal/hyper sexuality.
- [1st line] risperidone 0.25-2mg.day for short term treatment
- [2nd line] olanzapine 2.5mg-10mg/day
if psychosis WITH PD/Lewy body dementia r both
- use either quetiapine 12.5-300mg/day or aripiprazole 5-15mg.day
last choice: amisulpride 25-50mg/day
risk of antipsychotics + dementia
stroke, CV events, strokes
new treatment options for ad
lecanemab
anti amyloid monoclonal antibody
used for early AD = reduction in amyloid load and reduced (modest) cognitive decline)
SE of lecanemab
amyloid-related imaging abnormalities
EDEMA (vasogenic) = headache, confusion, visual changes, dizziness, nausea, gait difficult
HAEMORRHAGE
initiation of SSRI in dementia, what to look out for?
monitor for any increase in agitation
monitor NA+ LEVELS (ANY hyponatremia associated with SIADH)
