Lecture 12 - Dementia Flashcards by Patryk Lasiuk

Mild Neurocognitive Disorder is equal to….

mild cognitive impairment

Doesn’t interfere with independent living

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What is major Neurocogntivie disorder….

Dementia, can be mild/moderate/severe

** substantial impairment that interferes with independent living**

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characteristics of Alzheimers Dementia

Insidious onset
Gradual progression
Memory
Plaques and tangles
APOE*4, Presenilin
Age

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Characteristics of Vascular Dementia

abrupt onset
Stepwise deterioration
Executive dysfunction
Gait changes
Strokes or bleeding

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Characteristics of Lewy Body Dementia

Related to PD
Sleep disorders
Hallucinations
Motor Symptoms
Alpha-synuclein in cortex
EPS sensitive

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Characteristics of Frontotemporal Dementia

Age 45-60
Personality changes
Behavior n Language Sx
Atrophied neurons
Spongy cortex

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Alzheimers Risk Factors Early Onset (<1%)

Presenilin 1
Presenilin 2
Amyloid precursor protein
Down syndrome

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Alzheimers Risk Factors Late onset

Age
FH
APO-e4

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Modifiable Risk Factors Alzheimers

CVD Risk = Smoking, cholesterol/BP, diabetes, obesity (vascular)
Traumatic brain injury
Education
Social/cognitive engagement

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Lab tests for Dementia

Routine: TSH, B12/Foalte, Sodium (Differential), Renal

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Diagnostic Testing for Dementia

used by ruling out other stuff

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Delirium testing is…

Confusion Assessment Method (CAM)

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Cognition Screening tests

Montreal Cognitive Assessment (MoCA)
Mini-Cog

refer for further testing if positive

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Cognition Staging tests

Mini mental State Exam (MMSE)
Gold standard but have to pay $$ due to copyright so not used everywhere

helpful to use variety cause they have different pro/cons

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MMSE Cut-offs

MCI = N/a
Mild = 20-23
Moderate = 11-19
Severe = < 10

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Txm goals of Alz

Maintain quality of life
maximize function
enhance cognition
treat mood and behavior problems
ease caregiver burden

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2 types of pharm treatments for Dementia

Acetylcholinesterase inhibitors
NMDA receptor antagonists

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Cholinesterase inhibitors

Donepezil (Aricpet) mild-severe
Galantamine (Razadyne) mild-moderate
Rivastigmine (Exelon) mild-mdoerate

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Can Galantamine n Rivastigmine be used for severe dementia?

yes

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NMDA receptor antagonist

Memantine (Namenda) mod-severe

done use in mild cause not really effective**

ChEI adverse effects

GI = really high and reason most people d/c
Insomnia/Nightmares another more common effect (take AM may help)
Can cause urinary incontinence**

inc risk of bleeding with anticoagulants so just watch
also watch CV stuff like Bradycardia (Low HR)

Watch for QT prolong with other QT drugs

ChEI Drug interactions

Anticholinergics
Cardiac Meds
Inc bleeding risk

ChEI dosing tips

If GI side effect then…slow titration rate, inc in smaller doses, change to patch

May need to reinitiate dosage and titration if therapy is interrupted for > 2-3 wks

If insomnia or dreams are bothersome, dose in AM

Memantine SE

Dizziness, confesion, HA, anxiety most common

Look out for HTN

Memantine Interactions

Dextromethorphan Amantadine

Donepezil Dosing

initial 5mg QHS, inc to 10mg QHS over 4-6weeks easiest to titrate no renal dosing

which ChEI has a patch

Rivastigmine use if GI side effects or poor med adherence

Memantine Dosing IR

Weekly intervals inc 5mg QD 5mg BID 5QAM/10QPM 10mg BID Max 5mg BID if CrCl < 30

Memantine Dosing ER

Weekly interval inc 7mg QD 14mg QD 21mg QD 28mg QD Max 14 BID if CrCl < 30

Namzaric

Donepezil (10mg) and memantine ER (7/14/21/28) Have to titrate Donepezil 5mg for 4-6 week before switching to combo product

Anti-Amyloid Monoclonal Antibodies (MAB)

Aducanumab (Aduhelm) Lecanemab (Leqembi)

Anti-Amyloid Monoclonal Antibodies (MAB)

Aducanumab (Aduhelm) Lecanemab (Leqembi)

MAB indications

Mild cognitive impairment = MCI Mild dementia Must confirm presence of beta amyloid pathology prior to initiating treatment

Aducanumab ADE

Headache Falls Diarrhea Confusion, delirium concerning side effects = ARIA-edema or hemorrhage

Aducanumab Dosing

IV infusion over 60min every 4 weeks titration based on weight over 6 months to maintenance dose 10mg/kg

Lecanemab ADE

higher rate of infusion = can premeditate A.fib ARIA- edema/hemorrhage Headache Diarrhea

Lecanemab Dosing

actual body weight 10mg/kg every 2 weeks IV infusion over 60min

Txm for Mild Dementia

Anti-amyloid MAB ChEI

Txm for Moderate Dementia

ChEI Memantine ChEI + Memantine

Txm for Severe Dementia

Memantine ChEI +/- Memantine can D/c therapy if get to this stage

Which drugs want to be avoided for Behavioral and psychological symptoms of Dementia

Benzos symptoms include: psychosis, anxiety, aggression, agitation, depression, apathy

only FDA approved treatment for BPSD?

Suvorexant for insomnia in mild/moderate dementia

Anti-psych boxed warning

pts with dementia related behavioral disorders treated with antipsychotics are at inc risk of death most deaths are cardiac related or infectious

BPSD Antipsychoitcs info

be very cautions with Lewy Body Dementia Assessment: Behavior log, NPI-Q, AIMs Monitor: Lipids, A1c, weight, EPS, QTprolong, Sedation, Gait

Overall recommendation on using Estrogen for Dementia?

Nah

Overall recommendation for anti-inflam agents for Dementia?

not rec

Vit E for dementia

inc risk of all cause mortality with higher doses some potential. can consider only if no CVD or DM risk factors 2000IU not typically recommended

Ginkgo Biloba use in dementia?

overall probs not effective bleeding risk, so careful wit antiplatelet