Lecture 12 - Dementia Flashcards
Mild Neurocognitive Disorder is equal to….
mild cognitive impairment
Doesn’t interfere with independent living
What is major Neurocogntivie disorder….
Dementia, can be mild/moderate/severe
** substantial impairment that interferes with independent living**
characteristics of Alzheimers Dementia
Insidious onset
Gradual progression
Memory
Plaques and tangles
APOE*4, Presenilin
Age
Characteristics of Vascular Dementia
abrupt onset
Stepwise deterioration
Executive dysfunction
Gait changes
Strokes or bleeding
Characteristics of Lewy Body Dementia
Related to PD
Sleep disorders
Hallucinations
Motor Symptoms
Alpha-synuclein in cortex
EPS sensitive
Characteristics of Frontotemporal Dementia
Age 45-60
Personality changes
Behavior n Language Sx
Atrophied neurons
Spongy cortex
Alzheimers Risk Factors Early Onset (<1%)
Presenilin 1
Presenilin 2
Amyloid precursor protein
Down syndrome
Alzheimers Risk Factors Late onset
Age
FH
APO-e4
Modifiable Risk Factors Alzheimers
CVD Risk = Smoking, cholesterol/BP, diabetes, obesity (vascular)
Traumatic brain injury
Education
Social/cognitive engagement
Lab tests for Dementia
Routine: TSH, B12/Foalte, Sodium (Differential), Renal
Diagnostic Testing for Dementia
used by ruling out other stuff
Delirium testing is…
Confusion Assessment Method (CAM)
Cognition Screening tests
Montreal Cognitive Assessment (MoCA)
Mini-Cog
refer for further testing if positive
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
MMSE Cut-offs
MCI = N/a
Mild = 20-23
Moderate = 11-19
Severe = < 10
Txm goals of Alz
Maintain quality of life
maximize function
enhance cognition
treat mood and behavior problems
ease caregiver burden
2 types of pharm treatments for Dementia
Acetylcholinesterase inhibitors
NMDA receptor antagonists
Cholinesterase inhibitors
Donepezil (Aricpet) mild-severe
Galantamine (Razadyne) mild-moderate
Rivastigmine (Exelon) mild-mdoerate
Can Galantamine n Rivastigmine be used for severe dementia?
yes
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
