neurocognitive disorders

Question 1

Reversible reasons for cognitive decline

Answer 1

B12 or folate deficiency; hypothyroidism, electrolytes, LFTs, UTI, depression, syphilis

Question 2

alzheimers

Answer 2

• gradual onset and slow progression
• Early effects on cognition -> late effects on motor, behavioral, and sensory
• Final Stage: patient is often totally dependent on others for care

Question 3

rating scales

Answer 3

• MMSE: used to asses cognitive functioning; not developed to assess over time
• ADAS: evaluates severity of dysfunction in cognition and non-cognitive behaviors over time
• MoCA: used to assess mild cognitive impairment
• SLUMS

Question 4

treatment approaches

Answer 4

• Goal: slow the symptoms of cognitive decline and preserve functioning for as long as possible
• **Treatment of psychiatric and behavioral problems that may occur will maintain placement in the home for as long as possible
• Current treatments have now been shown to reverse the disease process, prolong life, or cure

Question 5

choleresterase inhibitors

Answer 5

donepezil, galantamine, rivastigmine

• Recommended as first-line treatment with no preference as to agent
• All FDA approved for mild-moderate dementia (donepezil approved for severe)
• Side Effects: GI bleeding, N/V/D, weight loss
• Rivastigmine available as patch

Question 6

NMDA receptor antagonist

Answer 6

memantine

• Does not slow/prevent neurodegeneration
• FDA approved for moderate-severe dementia
• NOT useful in mild cognitive impairment
• Use in caution in patients with seizure disorder

Question 7

combination products

Answer 7

• Cholinesterase inhibitor + NMDA antagonist

- Clinical trials do not show efficacy for this; can show significant increase in side effects and lack of tolerability

Question 8

treatment of psychosis

Answer 8

• Antipsychotics: for psychosis or severe behavioral problems (combativeness): *Not useful for repetitive behaviors (yelling, wandering), Atypicals: quetiapine, risperidone
• Antidepressants: Lack of treatment will likely worsen cognitive symptoms, Will take up to 3 months to see effect of antidepressant, SSRIs are first line, avoid paroxetine

Question 9

other considerations

Answer 9

• Cholinesterase inhibitors have been demonstrated to be helpful for behavioral disturbances
• Benzodiazepines may be useful for short-term: Increased risk of fall, Concern as a cause of dementia; condition must be monitored
• Trazodone: first agent for agitation and insomnia
• Anticonvulsants such as valproic acid

Question 10

nonpharm treatment

Answer 10

• Avoid confrontation
• Maintain consistent and structured environment with appropriate stimulation
• Monitor for sudden declines in cognition and functioning

Question 11

helpful ideas

Answer 11

• Eliminate conflict and frustration* – ensure activities are appropriate for functioning
• Establish regular sleep habits*
• Make sure the environment is safe, calm, and predictable*
• Watch caregiver for signs/symptoms of depression

Question 12

agitation interventions

Answer 12

• Recognize triggers
• Intervene early, recognize behavior
• Maintain calmness in interactions, avoid arguing

Question 13

sleep disturbance interventions

Answer 13

• Avoid glare for window/ mirrors**
• Consistent bedtime
• Minimize daytime napping