Lec 13-Dementia I

Question 1

What is dementia

Answer 1

• Chronic or persistent disorder behaviour and higher intellectual function due to organic brain disease
• Memory disorders, changes personality, deterioration in personal care, impaired reasoning ability and disorientation
• Lose cognition

Question 2

Demographics

Answer 2

• Dementia primarily disease of old age
• Avoid stereotypes
  
  • Most older people live independently
  • Look after themselves
  • Contribute to society rather the burden
  • All need similar service
• Average life expectancy- Female (77.7); Male (71.9)
• Projected population- 1995-2025
  
  • 80+= increase by half
  • 90+ likely to double

Question 3

Prevalence dementia US/Europe

Answer 3

• USA today about 4 million with Alzheimers disease
• USA 2050: greater than 14 million AD
• US primary care review 66% cases dementia undetected
• UK today: 0.75 million dementia
• UK 2050: greater 1.5 million dementia

Question 4

The financial cost

Answer 4

• USA= £100 billion annually
• UK= £10 billion annually

Question 5

Baby Boomers

Answer 5

• Next stage global epidemic dementia “baby boomers” reach old age
  
  • Post war 1945-64
  • Bill clinto, G Bush, Tony Blair
• US new schools were built
• 60s generation discovered sex also generation discover dementia

Question 6

Symptoms- general

Answer 6

• Memory loss
  
  • General forgetfulness- diagnosis difficult
  • Forget recent events
  • Forget people, personal care
• Difficulties learning and retaining new information
  
  • Misplace objects (e.g. car keys or spectacles)
• Difficulty complex tasks- cooking, driving financial matters
• Reduced ability reason and problem solving
• Impairment of spatial and visuospatial awareness
  
  • Bumping into objects, getting lost in a familiar place
  • Maintain same environment- avoid hospital admission
• Language problems- inability find words, follow the conversation
• Behavioural changes- irritability suspiciousness, withdraw, delusions and hallucinations
• Apart from early stages- patients lack insight

Question 7

Assessment of symptoms

Answer 7

• Various rating scales- NPI; ADAS-cog, ADL scale
• Mini mental state examinations (MMSE) measure cognition
• Total score = 30
• Mild= 21-26
• Moderate= 10-20
• Severe= <10
• Cognition assessed in 5 domains- Orientation; registration; attention; recall; language
• Patients and carers practical thrings more important- e.g. ability to dress, feed or undertake activities

Question 8

Symptoms and illness phase

Question 9

Dementia types and symptoms

Answer 9

• Over-classification- diagnosis only confirmed PM
• Alzheimer’s disease- classic form 70% of cases
• Vascular dementia- vascular component
  
  • Symptoms- insight and personality retained longer
  • Control risk factors e.g. hypertension, diabetes, smoking
• PD dementia- associated PD
• Dementia with Lewy bodies (DLB)- Psychotic symptoms, extrapyramidal symptoms; rigidity; bradykinesia; tremor
• DLB/PDD- consider effect treatments on movement- PDD and DLB may be related

Question 10

Pathology AD

Answer 10

• Brain atrophy- Wasting away normally developed organ or tissue due to degeneration of cells
• Amyloid plaques- pathological hallmarks of AD- Neurofibrillary tangles and amyloid plaques occur more frequently in with dementia
• Neurofibrillary tangles

Question 11

Medication and treatment

Answer 11

• 1st review for medication worsen cognition
• Cognitive enhancers
  
  • Cholinesterase inhibitor
  • Memantine
  • NICE guidelines
• Treatment for behavioural symptoms
  
  • Non-medication
  • Medication

Question 12

Review medication impair cognition

Answer 12

• Sedative compounds- BZs; H2 antagonist; Anti-psychotics
• Medication anti-cholinergic activity
  
  • Anti-psychotics, Anti-depressants
  • Anti-cholinergics e.g. procyclidine, benztropine
  • H2 antagonists e.g. ranitidine, cimetidine
    
    • Odds ratio- cognitive impairment
• Physical drugs e.g. furosemide, digoxin, warfarin, prednisolone

Question 13

Acetylcholinesterase inhibitors

Answer 13

• ACh inhibitors licensed symptomatic treatment mild- moderate AD
  
  • Tacrine never licensed- hepatic toxicity

Question 14

Major cholinergic changes AD

Answer 14

• Significant Ach deficit- 40-90% depletion acetyl choline moderative/severe disease
• Decrease Ach correlates decline memory and cognitive
• Ach metabolized acetylcholinesterase (AchE)
• Meds such donepezil inhibits enzyme AchE
  
  • Slow down metabolism and increase Ach

Question 15

Efficacy

Answer 15

• Not cure, but relieve symptoms
• Arrest decline cognition over 24 weeks
• No evidence agents slow down underlying disease process or prolong life
• 25% patients definite response & 40-50% some benefit over clinical prevalence
• Patients fail to respond to one agent, no evidence second agent effective
• Help some people, some of the time- overall limited efficacy

Question 16

Adverse events

Answer 16

• Dose related cholinergic adverse events- start low and go slow- improve tolerability
• GI adverse events e.g. nausea, vomittin, diarrhoea, ab pain
  
  • May dissapea, but some cases need discontinued
• Other adverse events: muscle cramps, fatigue, insomnia, dizziness, falls syncope
• Serious events include convulsion, bradycardia
  
  • Caution sick sinus syndrome & supraventricular cardiac conduction disorders

Question 17

Drug interaction

Answer 17

• Donepezil & Galantamine
  
  • Metabolised by CYP3A4 & CYP2D6
  • Inhibitors (e.g. erythromycin) increase levels- breakthrough cholinergic adverse events
  • Inducers (e.g. phenytoin) decrease levels- reduce the efficacy
  • Dosage adjustments considered
• Rivastigmine- renally excreted- drug interactions unlikely

Question 18

Memantine

Answer 18

• NMDA (N-methyl-D-aspartate) receptor antagonist
• Licensed moderatley severe to severe AD
  
  • Memantine binds NMDA receptors block glutamate-controlled receptor channels
  • Efficacy
  • Adverse events

Question 19

Efficacy and adverse events

Answer 19

• Licensed severe to moderately severe AD
• Possible agitation associated dementia
• No evidence
  
  • Combination memantine and cholinesterase inhibitor
  • Use in the early stages of dementia
• Side effects- hallucinations (5% v 2.1% placebo); confusion (1.3% v 0.3%); dizziness (5% v 2.8%); headache (5% v 3.1%)

Question 20

Treatment behavioural problems

Answer 20

• Occur in 90% patient dementia
• Symptoms include aggression, hyperactivity, agitation
• Strong predictor for caregiver burden & stress, placement institutional setting
• Anti-psychotics used but associated 1,800 excess deaths due use

Question 21

Treatment BPSD

Answer 21

• Assessment and diagnosis
• Patient-centred care
  
  • Identify causality
  • Optimise and individualise clinical care
• Treatments
  
  • Complementary & alternative treatments
  • Pharmacological interventions

Question 22

Diagnosis and assessment

Answer 22

• First step accurate diagnosis & assessment extent of problem
• Identify underlying possible treatable causes- clinical & non-clinical
• Direct observation, interviewing family, caregivers, patient
• Assessment past episode BPSD, warning signs, background information including cultural issues
• Full documentation including severity grading

Question 23

Clinical causes

Answer 23

• Medical conditions e.g. arthritis, diabetes, de-hydration, untreated pain, depression
• Common caus- delirium or acute confusional state
• Medication cuase delirium and BPSD
  
  • Sedatives => confusion
  • Sympathomimetics, anti-psychotics, anti-depressants ==> anxiety/ Akathisia
  • Anti-cholinergics impair cognition => delirium/ confusion

Question 24

Non-clincal issues

Answer 24

• Changes environment => distress lose familiar items
  
  • Assess environmental factors causing BPSD
• Non-clinical factors
  
  • Environment- room temp, noise, TV programmes
  • Thirst, food
  • Issues with care- lack exercise, communication difficulties, boredom, cared by a member of opposite sex

Question 25

Individualise care

Answer 25

• Calm & consistent care environment
  
  • specific procedures & treatment agreed- all team members & visitors act consistently
• Constant re-assurance
• Communication- eye contact and touch
• Support for carers
  
  • Charitable sector, religious organisations
• Reduce boredom
• Exercise for Wanderers

Question 26

Treatments

Answer 26

• Non-medication interventions
  
  • Psychoeducational- training care staff
  • Sensory enhancement- music or light therapy
  • Complementary and alternative therapies- lavander etc
• Only treat danger patient or others
  
  • Flexible approach harmless behaviour e.g. occasional shouting
• Pharmacological intervention- anti-psychotics

Question 27

General guidance anti-psychotics

Answer 27

• Only severe distress: immediate risk harm patient or others
  
  • Best interests patients
• Other measures tried
• Start low dose: titrate response and regularly review
• Dose minimum and attempt withdraw ASAP
• Use licensed product- risperidone
• Avoid substituting BZs

Question 28

Summary