Lecture 45 - Pharmacotherapy of Neurocognitive Disorders: Dementia Flashcards
DSM-5: Neurocognitive Disorders
The DSM-5 changed the nomenclature for the diagnostic criteria of what has previously been known as “dementia”.
New diagnostic criteria have defined dementia, delirium, amnestic, and other cognitive disorders under “Neurocognitive Disorders” (NCDs)
These can be “major” or “mild” and include etiological subtypes
NCDs describe disorders in which the primary deficit is in cognitive
function and are acquired rather than developmental
Must represent a decline from previously attained level of functioning
Neurocognitive domains
The basis for diagnostic criteria; each domain defines expectations for major and mild NCDs
Complex attention
Sustained/divided attention, processing speed
focused on delirium, short term and reversible
Learning and memory
Immediate/recent memory, very-long-term memory
Perceptual/motor
Visual perception/praxis
Executive function
Planning, decision-making, working memory, flexibility
Language
Expressive and receptive language (naming, word finding)
Social Cognition
Recognition of emotions, range of behavior
DSM-5 – Mild Neurocognitive Disorders
Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains
o Concern of the individual, informant, or clinician that there is a mild decline in cognitive function
o Modest impairment in documented cognitive performance
Does NOT interfere with independence
Not attributed to a delirium episode (acute, temporary, cognitive decline)
Not better explained by another mental or medical disorder
DSM-5 –
Major Neurocognitive disorder
Evidence of significant cognitive decline from a previous level of performance in one or more domains
o Concern of the individual, informant, or clinician of significant decline
o Substantial impairment in documented cognitive performance
Cognitive deficits interfere with independence
Not attributed to a delirium episode (acute, temporary, cognitive decline)
Not better explained by another mental or medical disorder
Etiological subtypes
May be used in either major or mild NCDs
Alzheimer’s disease
Vascular dementia
Lewy body disease
*May be considered unspecified if doesn’t fit any of the above
*Can specify with or without behavioral disturbances
Evaluation
◦ Family history of dementia ◦ Head injuries/falls
◦ Alcohol/substance use
◦ Depression
◦ Acute illness
◦ Medication review
◦ Language impairment
◦ Extrapyramidal symptoms ◦ Focal weakness, gait
Differential diagnosis
◦ CV disease/vascular dementia
◦ Lewy body dementia
◦ Parkinson’s disease
◦ Normal pressure hydrocephalus
◦ Mixed dementia
◦ Pick’s disease (frontotemporal)
◦ Huntington’s disease
◦ Reversible causes
Reversible cognitive decline
Also known as “reversible labs”
◦ B12 or folate deficiency
◦ Hypothyroidism
◦ CBC
◦ Electrolytes
◦ Liver function tests
◦ Infection (especially UTI)
◦ Depression – pseudodementia
◦ RPR/VDRL – syphilis
some or all of these labs should be evaluated
Rarely explains symptoms
Infection may cause delirium presentation with or without underlying dementia
Drug-induced cognitive impairment
- Skeletal Muscle Relaxants
- Tricyclic Antidepressants
- Bladder antispasmodics
- Antihistamines
- OTC allergy/cough cold
- Rx anti-emetics
Rating scales
MMSE
Alzheimer’s Disease Assessment Scale (ADAS)
Montreal Cognitive Assessment (MoCA)
Saint Louis University Mental Status (SLUMS) Exam
MMSE
◦ Used to assess cognitive functioning
◦ Evaluates orientation, memory, attention, naming, comprehension, spatial orientation
◦ Change in 3-4 points over a 1 year period indicates significant decline
◦ Maximum score = 30 points
◦ Mild: 26 – 18; Moderate: 17 – 10; Severe: 9 – 0
◦ Test performance is influenced by age and educational level
◦ Clinically used to follow scores over time, but large clinical variation
ADAS
◦ Evaluates severity of dysfunction in cognitive and non-cognitive behaviors over time
◦ 11 cognitive items, 10 non-cognitive behavioral items
◦ Cognitive subscale used by FDA in evaluating clinical trials as a primary outcome measure (ADAS-cog)
◦ Range of scores 0-70, higher scores indicate worse cognitive performance
◦ Average cognitive decline in an untreated person with severe Alzheimer’s disease is a 6 – 11 point decrease per year
MoCA
◦ Better differentiates mild cognitive impairment
◦ Visuospatial/executive, naming (animals), memory (remember 3 objects)
◦ Attention – repeating numbers forward/backward
◦ Language/fluency
◦ Abstraction – how do 3 objects relate to
each other
◦ Orientation
◦ 30 point total score
SLUMS
◦ Orientation – day/year/state
◦ Remember 5 objects
◦ Making change
◦ Naming animals in one minute
◦ Numbers forward/backward
◦ Clock face drawing
◦ Spatial orientation
◦ Listening to a story and relating details back
◦ 30 point total scale
Treatment Goals
Currently, the goal of treatment is to slow the symptoms of cognitive decline and preserve functioning for as long as possible
Newest remove pathology, but impact on long-term progression, disease course continues to be studied
Treatment of psychiatric and behavioral problems may maintain ability to live in one’s own home as long as possible.
no disease modifying agent
Options for treatment
cholinesterase inhibitors
NMDA receptor antagonist
Cholinesterase inhibitors
◦ Recommended as first-line treatment with no preference as to agent
◦ All are FDA-approved for mild to moderate dementia
◦ Donepezil is FDA-approved for severe dementia
◦ Donepezil usually chosen first due to ease of dose titration and once-daily dosing
◦ Donepezil (Aricept)
◦ Rivastigmine (Exelon)
◦ Galantamine (Razadyne)
NMDA Receptor Antagonist
◦ Does not slow or prevent neurodegeneration
◦ FDA-approved in moderate to severe dementia only
◦ NOT useful in mild cognitive impairments
◦ Marginal benefit usually realized in Alzheimer’s disease
◦ Memantine (Namenda)
◦ Donepezil/Memantine (Namzaric)
