CLINICAL- ELDERLY Flashcards
How do we tell the difference between Alzeihmers, vascular dementia and Lewy Body dementia??
Alzheimer’s presents as memory loss especially short term memory, constant slow deterioration
Vascular dementia also memory loss but it’s a stepwise deterioration, symptoms are constant them suddenly worsen after a TIA/ other vascular event.
Lewy body dementia symptoms are problems with alertness/ attention, slow movements, mask-like face, shuffling gait, tremor
Why Not recommended in Elderly: phenothiazines (eg. Chlorpromazine) for dizziness due to postural hypotension?
Will make dizziness worse
Treat the postural hypotension: is there a cause of this why is BP so low??
Why Not recommended in Elderly: benzodiazepines for insomnia due to depression
Risk of falls, sedation and confusion
Treat the depression not the insomnia
Why Not recommended in Elderly: Levodopa for non-Parkinsonism tremor or drug-induced Parkinsonism?
The Parkinson’s in this case is not caused by dopamine deficiency so no evidence that levodopa will be effective!!
Get rid of the drug causing Parkinson’s rather than treat the side effect: avoid poly pharmacy!!
Why Not recommended in Elderly: loop diuretics for dependent oedema?
We want to get the fluid back into the circulation with dependent (gravitational) oedema
Use compression stockings and elevation
Why not use benzodiazepines, especially with long half lives, in the elderly?
Risk of falls from impaired balance Sedation Confusion Cognitive impairment Addiction
Why avoid long acting hypoglycaemic drugs e.g. Metformin in the elderly?
Can cause prolonged Hypoglycaemia so there is risk of overnight hypos: elderly not great at recognising hypos
Why try and avoid anticholiergics for Parkinson’s in the elderly??
Impaired cognition: can unmask Alzheimer’s
Confusion
Antimuscarinc side effects: e.g. Constipation and urinary problems
No evidence base
Why not use muscle relaxants for spasticity in the elderly??
Overall muscle tone is reduced as they are non specific therefore there is increased risk of falls
What four things are part of the Dementia Strategy 2009??
Improve early diagnosis
Improve support services for patients and carers
Reduce admissions to long term car (care homes)
Improve cost effectiveness of services
Where should people be referred to if they are suspected to have dementia??
Memory assessment services
Only 1/3 of people receive diagnosis of dementia of any input from specialist services!!
In a MMSE, what does a score indicates mild dementia? What treatment can be initiated??
Mild dementia is 21-25
Can instigate treatment with donepezil, rivastigmine or gelantamine
In a MMSE, what does a score of 10-20 indicate?
Moderate dementia
Can instigate treatment with donepezil, rivastigmine or galantamine
In MMSE, what score indicates severe dementia? What treatment can be considered?
Severe dementia 0-9
Can consider Memantine in severe dementia
Donepezil may also work
If we have a patient who’s got suspected dementia, it’s worth testing and retesting to confirm it. When should we review it to confirm if it’s still there?
6 months
What is mild cognitive impairment??
A syndrome defined as a cognitive decline greater than that expected for the individuals age and education level but doesn’t notably interfere with their activities of daily life.
10% of people with mild cognitive impairment develop Alzheimer’s per year!!
Apart from the more obvious types of dementia (Alzheimer’s, vascular etc) what else can NON reversible dementia result from?
Parkinsons Alcohol (Wernickes encephalopathy) Huntingtons disease HIV CJD (creutzfeldt Jakob disease of the brain)
Can you think of any of the reversible types of dementia? I.e. It’s not actual dementia they just cause symptoms of dementia?
Depression Hypothyroidism Hypoglyceamia Low sodium- causes confusion Brain tumour Subdural haemorrhage Vitamin B12 and folate deficiency
OTHER DRUGS!!
Oxybutinin (for urinary incontinence)
Antipsychotics such as Chlorpromazine
Benzodiazepines (Diazepam etc)
What can all these cause???
Can cause cognitive impairment and present dementia type symptoms
What’s the deal with antidepressants TCAs and SSRIs and dementia??
Can present with dementia type symptoms so can worsen dementia
What are the three cholinesterase inhibitors we can use to treat Alzheimer’s??
Donepezil
Rivastigmine
Galantamine
These work because there is low levels of acetylcholine in Alzheimer’s so they stop cholinesterase enzyme breaking down what’s left of acetylcholine.
They should only be continued if they are showing a worthwhile effect
What are the cholinesterase inhibitors used in Alzheimer’s disease contraindicated in??
Glaucoma
Sick sinus syndrome (abnormal heart rhythm)
Severe hepatic or renal impairment!!!!
Uncontrolled COPD
Unexplained syncope (loss of conciousness)
Which types of dementia do cholinesterase inhibitors show benefit in??
Alzheimer’s disease (prolongs the time before people need to go into care homes, slows progression)
Vascular dementia: no significant benefits of these drugs!!
Mild cognitive impairment: possibly prevention in progression to Alzheimer’s
Lewis body and parkinsons dementia: can help cognition and psychosis
What is memantines mechanism of action??
It’s an NDMA receptor antagonist:
Excess Glutamate is present in Mid to late stage Alzheimer’s which interferes with neurotransmission and contributes to neurone loss.
Memantine blocks the action of glutamate.
When should memantine be used??
Severe Alzheimer’s disease
It can be considered in moderate disease if the person is intolerant to or there’s a contraindication with the cholinesterase inhibitors (e.g. Severe hepatic or renal impairment or glaucoma)
What’s the leading cause of death in people over 75 in the UK?
Injuries as a result of Falls
What kind of things are being looked at as the FUTURE for Alzheimer’s disease treatment??
Vaccines
Monoclonal antibodies against beta amyloid (contributes to formation of plaques)
Vitamin E
Identifying biomarkers in the CSF and in the genome to see who will respond to amyloid lowering drugs at an early stage
What is GAIT and what does it pose a risk to??
Large gaps between peoples feet when they walk (aka ATAXIC)
Present when there is problems in the cerebellar
Poses a risk of FALLS
Whys it important to do vitamin D level testing in the elderly??
If people are severely deficient in vitamin D they are more at risk of falls
People with lots of vitamin D seem to have better balance
Vitamin D also very important in osteoporosis
We can give people calceos or adcal D3 forte containing calcium and vitamin D.
If very low we can give people high doses of vitamin D such as cholecalciferol 50,000 units
