Week 8 - All dementias and The Treatments Flashcards
Dementia Background INFO
Dementia is clinical syndrome where cognitvie function is affceted leading to deterioration in ability to perform daily activities
- Progressive, incurable disease
- treatment only target sympotms
- early diagnosis + management improves outcomes - Affects more women
- Disease of older people (>65 yo)
- In dementia cognitive function (memory, language, attention, descion-making, learnig) declines quicker than normal ageing
- Expected to live 7-8 more years once diagnosed with dementia
- Developing cognitive impairments is a risk factor for alzheimers
- AD = most common type of dementia - ONLY start seeing signs of cognitive impairment approx. 10 years
What is the general cause of dementia
Loss of cholinergic neurones = less Ach is released into synpase = cognition issues
Loss of dopanergic neurones = less dopamine released = motor sympotms
List the types of dementia
- Alzheimer’s Dementia (AD)
- Vascular dementia
- Mixed Dementia
- Lewy body Dementia
- Fronto-temporal dementia
- Parkinson’s disease dementia
What are the CORE symptoms of dementia
- Memory loss (occurs first)
- Disorientation (i.e. lost)
- Loss of concentration / attention
- Impaired decision making
- Speech issues
- Swallowing difficulties
- Incontinence
- Mobility issues
NOTE: Symptoms differ amongst diff. dementias
What are the symptoms of Vascular Dementia (VD)
- Have physical symptoms
- slurred speech
- dizziness
- difficulty performing motor tasks
- unable to recognise things
- Memory is better
- Emotioanl instability (depression)
What are the symptoms of Alzheimer’s Dementia (AD)
- Memory impairment is most PROMINENT feature
- memory loss
- disorientation
- misplacing things
- confusion
- Problems perfoming ADL (washing, dressing, eating)
- Loss of speech / Language
- Mood and behaviour
NOTE: main symptoms relate to cognition
What are the symptoms of Lewy Body Dementia (DLB)
- Cognition slows (KEY feature) + fluctuates
- confusion
- attenion issues
- hallucinations (visual or auditory)
- tremors
- Motor function declines
How is dementia diagnosed
Inc. 3 stages of dementia severity
- Using ICD-11
- need to HAVE 2 CORE sympotms
- marked cognitive impairment that interferes with personal life / daily function
- behavioral changes - Referral to SPECIALIST who perform test including cognition tests
DIAGNSOSIS:
- blood tests to rule out other cuases
- i.e. anaemia, hypothyrodism
- conduct patient + family history
- check thyroid, vit. B12, folate levels etc.
- CT and MRI scan to rule out tumours
- when diagnsoed need to inform DVLA
3 Stages:
1. Mild
- short term memory loss
- core ADL maintained
- higher level functions are impaired
- Moderate
- worsening cogntion
- core ADL affected - Severe
- long term memory loss
- become dependat + require 24hr care
ADL = activities of daily living
List the 3 cognition tests used to diagnose dementia
+ factors affecting their performance / results
- Mini Mental State Examination (MMSE)
- 7 Minute Screen
- 6 Item Cognitive Impairment Test
- most commonly used
FACTORS:
- literacy / numeracy level
- may not understand english
- can’t read, speak, write
- medication
- illnesses / mental health
- sensory impairment
- issues with hearing, seeing
Explain how the MMSE works
- Say 3 words to patient and ask them to repeat them back
- Do this 5 times (but only count 1st try)
Explain how the ‘7 Minute Screen’ works
- Ask patient to state the correct day, month, year, date, time
- Score points based of how close they are to correct answer
Explain how the ‘6 Item Cognitive Impairment Test’ works
MUST KNOW THIS
Inverse Score is used (total score = 28):
- Score 0 points if question answered correctly
- Score 2 points = 1 error
- Score 4 points = >1 error
Scores of 0–7 = normal
Scores of 8 or more = significant + may indicate cognitive impairment
6CIT = most commonly used
Consists of 6 questions inc:
- temporal orientation (time, date, day)
- remembering an address (tests short term memory)
- counting backwards from 20 (test attention)
- stating the months of the year in reverse (assess memory + cognitive flexibility)
A computerized version of the 6-CIT with automated scoring is available on some general practice computer systems.
NOTE: based on results of this test GP will refer to memory clinic where further diagnostic tests are done
Treating dementia BASICS
- Treatment is NOT curative
- Invovle them in decisions
- Speak slowly + clearly, offer patient simple chocies (yes / no)
AIM:
- delay patient going into care home
- improve independance
- ease carer burden
What drugs should be avoided in dementia
- Anticholinergics (antimuscarnics)
- ↑ risk of developing dementia
- ↑ risk of cognitive impairment
- anticholinergic burden - Antidepressants
- Antipsychotics
- Opiates
- BDZs
- Sedating antihistamines
- penetrate BBB = can cause cognitive impairment, hallucinations - Alpha blockers
List the non-pharmacological treatments
- Lifestyle modification
- stop smoking / alcohol, weight loss, CV risk factors, healthy diet, social life, education
- Having routine / familiarity
- reminder charts, ‘remember rooms’
- orientation boards (know time / date)
- colours for signs = stand out
- ‘this is me’ documents = get to know patient + stimulate reminiscing convo.
- Treat co-morbidities
- e.g. depression, anxiety, sleep disorder
- Cognitive Stimulation Therapy (CST)
- group based therapy
- improves memory + thinking ability
- Sensory stimulation
List the pharmacological options for treating dementia
NOTE: drug treatment only licensed for alzheimer’s
- Acetylcholinesterase inhibitors
- Memantine
Explain the 2 pharmacological options for treating dementia
NOTE: drug treatment only licensed for alzheimer’s
- Acetylcholinesterase inhibitors
- prolong level of function + improve symptoms
- CAUTION: asthma / COPD, cardiac issues, renal / hepatic impairment, ulcer risk
- SE: GI issues, incontintence, alertness, hallucination, dizziness, bradycardia (ALL self-limiting + seen early stages of treatment)
- e.g. Rivastamine
- MoA: form covalent bond with AChE (enzyme) inactivating it for 10 hours
- e.g. donepezil, galantamine
- do NOT form covalent bonds
- Memantine
- NMDA (glutumate) antagonist
- ↓ activity of glutumate
- glutumate is dmaagining in dementia pathway
Explain the cholinergic synapse
- ACh is released into synapse
- ACh activates receptors on post-synaptic membrane
- (Acetyl)Cholinesterase (AChE ~ enzyme) breaks down ACH
- broken down ACh is taken up + recycled in pre-synaptic neurone
- When ADD AChE-I this inhbits enzyme = ACh levels in synapse remain high
- boosts cholinergic activity in synapse = helps symptoms
NICE Guidelines for treating AD
AD = alzheimer’s dementia
1st line (monotherapy):
- AChE-I for mild-moderate AD
- Memantine for severe AD
2nd line (combination)
- ADD memantine to AChE-I
- used in moderate or severe AD
OTHER:
- Memantine used in moderate AD (if contraindications to AChE-I / intolerable)
- AChE-I pick drug with cheapest cost + well tolerated by patient
REVIEW: every 6 months
NICE Guidelines for treating ‘Vascular Dementia’ and ‘Lewy body Dementia’
AD = alzheimer’s dementia
Do NOT use AChE-I or Memantine in VD (unless patient ALSO has AD)
CAN use AChE-I or Memantine in LBD
AIM: is to prevent stroke
- treat / prevent hypertension
AChE-i Treatment INFO
- Drugs are available as geenrics BUT always use same formula + brand (dementia patients like familiarity)
- some patient may not respond to one AChE-I = switch to another
- do NOT STOP AChE-I unless making disease worse, intolerable SE etc.
- do NOT give with food (absorption delayed + absortpion rate ↓)
- IMPORTANT patient takes medicine
- covert adminstration may be required
- switching formulations if unable to swallow
DOSING:
(start with low dose then titrate)
- galantamine (8mg) AND donepezil (10mg) = ↑ dose after 1 month
- memantine =↑ dose after 1 week
- rivastigmine (4mg) = ↑ dose after 2 week
What are behavioural and psychological sympotoms of dementia (BPSD)
6 Key symptoms groups
Affects 90% of people suffering with dementia
- ↓ QoL
- can last from a few weeks to longer
- usually seen in response to an activity
- more likely to be admitted to nursing home
6 Key Symptom Groups:
1. Mania
- euphoria
2. Psychosis
- hallucinations, delusions
3. Depression
4. Agitation
- restlessn, pacing, repetitive actions
5. Apathy
- lack of; interest, motivation
6. Agression
How can we treat / manage BPSD: non-pharmacological
Rule out other causes BPSD
- Use PAIN acronym
- Physical problem? (pain, infection etc.)
- Activty related? (bored, washing)
- Iatrogenic? (SE of meds)
- Noise / environemnt? (lights)
TREATMENT:
- talking them down
- distracting them
- massage
- pet therapy
- music therapy
- bright light therapy (help sleep)
- psychoeducation (for carer / family)
How can we treat / manage BPSD: pharmacological
1st line = non-pharmacological methods
ONLY use medicines if causing SEVERE distress OR theres an IMMEDIATE RISK of harm
TREATMENT:
1. Antipsychotics
- avoid use of typical in parkinson’s and lewy body
- e.g. risperidone or olanzapine
- has poor tolerability, bad SE = need to discuss benefits + harm before starting
- used for limited period at lowest dose
- treatment ONLY continued if seeing improvement
- Anti-depressants
- only used if treating pre-exisiting depression
