Mental Health: Dementia Flashcards
What is dementia?
umbrella term for several diseases affecting memory, other cognitive abilities and behaviour that interfere significantly with a person’s ability to maintain their activities of daily living.
dementia is referred to as a X due to disease of the brain?
syndrome
two words to describe the nature of the disease?
chronic and progressive
list some of the higher cortical functions that are disturbed?
memory, thinking, orientation, comprehension, calculation
is conciousness impaired in patients with this disease?
no
what might impairments of cognitive function commonly be accompanied or occasionally preceeded by?
deterioration in emotional control, social behaviour or motivation
What are the symptoms of dementia?
- memory loss
- disorientation of time
- difficulty with daily tasks (shopping, cooking)
- confusion
- difficulty speaking/writing
- repetitive questioning
- decreased social interaction and withdrawal
- hallucinations and paranoia
What conditions comprise dementia? (the different types of dementia)
- Alzheimer’s disease
- vascular dementia
- dementia with Lewy bodies
- mixed dementia
- frontotemporal dementia
- others (alcohol, HIV, Creutzfeldt-Jakob, Huntington’s)
What is the most common cause of dementia?
Alzheimer’s disease: amyloid plaques and tau tangles
alzheimers disease is the most common cause of dementia. what is the pathophysiology behind this?
amyloid plaques and tau tangles, abnormal build up of proteins in and around the brain -> loss of NTs sending messages between cells
over time patients with alzheimers experience their brain shrinking, which areas are usually affected first?
memory
what neurotransmitter is particularly affected and by alzheimers and -> loss of communication between nerve cells, esp hippocampus in brain
Acetylcholine ACh
What is the 2nd most common cause of dementia?
vascular dementia
How does vascular dementia occur?
- blood vessels in brain are damaged reducing blood flow to brain and hence function
- linked to stroke/TIA
why is vascular dementia linked to stroke and TIA which also explains why atherosclerosis is an important risk factor to consider?
blood vessels in brain are damanged and reduce blood flow to the brain thus affecting function
why are is it important that the aim of treatment for vascular dementia is to tackle the underlying cause?
reduce the speed at which further brain cells are lost
important consideration for VD?
Risk factors for atherosclerosis: HTN, diabetes, lifestyle: smoking, overweight
what is the cause of the 3rd most common type of dementia: dementia with lewys bodies?
small round clumps of protein that build up inside nerve cells in the brain
lewy bodies are formed of clumps of clumps of what protein?
alpha synuclein
what are lewys bodies also responsible for in patients with parkinsons ?
damage that causes movement problems
fronto temporal dementia is an uncommon type and mainly affects the front and sides of the brain. What problems does it cause and what is the usual age range of diagnosis?
behaviour and language problems and 45-65
What is done to diagnose dementia?
rule out other causes for memory changes e.g. delirium due to infection
&
timescale of symptoms (full history)
- relation to other conditions
- MRI/CT head
- cognitive assessments
What is the aim of current dementia treatment?
- promote independence
- maintain function
- manage symptoms
What are the main principles when initiating dementia drugs?
- symptom treating rather than disease modifying
- licensed for Alzheimer’s
- off-license for other/mixed dementias
- specialist initiation
what 3 things to remember with Pharmacological Management?
- Options are limited!!!!
- The type of dementia is important
- Symptom treating rather than disease modifying
What are the 2 main categories of dementia drugs?
- AChE inhibitors
- NMDA receptor antagonists
what drug class do the following drugs belong to:
donepezil, rivastigmine and galantamine
(used for mild-mod dmeentia)
ache inhibitors
what is the drug class of memantine?
(used for mod-advanced dementia)
NMDA antagonist
What is the rationale for using AChE inhibitors in Alzheimer’s?
block breakdown of ACh allowing for communication between neurones
What is the rationale for using NMDA receptor antagonists like Memantine in dementia?
- NMDA receptor for glutamate
- glutamate released when cells damaged
- overstimulates receptor causing neuronal cell death
- antagonist block effects of excess glutamate
role in more advanced stages of dementia
what tells you how severe thus what treatment to use: AChE inhibitors or NMDA?
Severity of dementia classification based on specific symptoms done by mini mental exam
How do we treat vascular dementia?
(brain damage cant be reversed, may be possible to slow disease progression by…)
- Treating the underlying conditions and other factors that impact atheroslecrosis are being treated with antiplatelets and statins
- Adopting a healthier lifestyle
- Rehab support: OT, speech therapy, physio
What are examples of modifiable risk factors that can cause vascular dementia?
- alcohol
- smoking
- hypertension
- obesity
- lack of exercise
- raised cholesterol
- poorly controlled diabetes
- vit B12 or folate deficiency
What are BPSD?
Behavioural and Psychological Symptoms of Dementia
What are the 3 categories of BPSD?
- psychosis
- agitation
- mood disorder
What are examples of psychosis symptoms of BPSD?
- delusions
- hallucinations
What are examples of agitation symptoms of BPSD?
- aggression
- wandering
- abnormal vocalisation
- disinhbition
What are examples of mood disorder symptoms of BPSD?
- depression
- anxiety
- apathy
- hypomania
How is BPSD treated?
- non-pharmacologically
- pharmacologically w antipsychotics (risperidone/off-license)
what is the only antipsychotic drug that has a UK lincense for BPSD?
risperidone
When are antipsychotics used in dementia patients?
only if at risk of harming themselves or others, or experiencing psychosis that cause severe distress
Why don’t we prescribe antipsychotics to dementia patients as much anymore?
in the Banerjee report 2009, only 20% received benefit and the mortality risk increases the longer you take them
what effect does long term use of antipsychotics have on mortality risk?
increases
What are the principles for prescribing an antipsychotic?
- note licensing
- ensure clear need
- review regularly (6 weeks)
- lowest dose for as short as possible
- side-effect profile e.g. Parkinson’s
- risk vs benefit decision
how often should antipsychotics be reviewed?
every 6 weeks
Alzheimers WS: Geoffrey
What do cognitive tests aim to measure?
Tests aim to measure:
- Orientation to time and space
- Short term memory recall
- Attention + ability to solve problems
- Language
- Comprehension +motor skills
give 5 example cognitive assessment tools used
- Mini Cog
- Abbreviated mental test score
- 6CIT
- MIS
- MMSE
name of cognitive tool thats a 30 point questionnaire used in clinical practise as ESTIMATE of cog impairment?
and can be useful for assessing severity + progression of disease?
MMSE
mini mental state exam
Geoffrey scores 21 on an MMSE. Does this confirm the diagnosis of Alzheimer’s disease?
Making a diagnosis
FULL history (including cognitive, behavioural and psychological symptoms)
Person AND family member/ friend
Physical exam and bloods to rule out REVERSIBLE causes of cognitive decline )delirium, depression, poor eyesight, poor hearing, medication
For Alzheimers include a test of verbal episodic memory: information about recent or past events and experiences (rather than factual knowledge , habits or skills)
(MMSE of 21-26: mild Alzheimer’s disease )
Donepezil and Oxybutynin: moderate DDI. May cause what?
cognitive impairment
Antimuscarinic medications are a group of anticholinergic agents, specifically known for blocking the activity of muscarinic receptors. These receptors play an important role in mediating the functions of the parasympathetic nervous system, which controls many involuntary functions to conserve energy, including the contraction of smooth muscle, dilation of blood vessels, increased bodily secretions, gastrointestinal activity, and heart rate.
Anticholinergic burden -Anticholinergics block Ach, name some SEs
o Dry eyes
o Urinary retention
o Dizziness
o Cognitive impairment
o Falls
Effect increases with polypharmacy
ACB calculates cumulative effect on an individual of taking one or more meds with anticholinergic activity
ACB score of 3 or more increases risk of ?
cognitive impairment, functional impairment, falls and mortality in older adults.
Increased doses and long duration of use are associated with increased risk of dementia
Dementia WS: Pauline
Pauline has struggled to settle in and is often found ‘wandering’ around looking lost; staff are kind and lead her back to the day room where the TV is always on but it doesn’t take long before she wanders off again. She seems agitated and frustrated and often snaps at both the staff and other residents.
how to alleviate her symptoms?
BPSD >90% px
3 distinct BPSD symptoms:
- Psychosis: delusion and hallucinations
- Agitation: aggression, wandering, abnormal vocalisation, disinhibition
- Mood disorder: depression, anxiety, apathy hypomania
Treating BPSD
Non-pharmacological therapy
Antipsychotics:
- Only Risperisone has a UK license for BPSD
- Others used off license
Antipsychotics should ONLY be used in px with dementia if theyre either:
- at risk of harming themselves or others
- experiencing agitation, hallucinations, or delusions that are causing severe distress.
What is person centred care? What are the benefits of person centred care and how can it help a person with dementia?
personalised
coordinated
enabling
Suggest a person centred care approach to facilitate the management of Pauline.
Get family to visit, conversations to bring back memories
Was a music teacher, give her instruments to play
Target personalised care
Feels bored and is roaming for something/ someone familiar
Try and fix before considering pharmacological treatment: agitation and restlessness, harm to self/ others.
Risk of low BP on standing
Low water %
Consider SE
May impact on her in terms of health and falls
