Clinical CNS Dementia Flashcards
(130 cards)
1
Q
Name the clinical features of dementia:
A
Impaired memory and poor cognitive function
Impaired thinking
Disturbed behaviour
Lack of insight
Lack of spontaneity
Poverty of speech- alogia
Low mood
2
Q
Describe impaired memory and poor cognitive function as a clinical feature of dementia:
A
Forgetfulness
Poor attention
Disorientation in time and place
Agnosia (recognition of objects, people, self)
Dysphasia (name of things)
Dyspraxia (understanding commands)
3
Q
Describe impaired thinking as a clinical feature of dementia:
A
Slow
Impoverished
Incoherent- use words with no meaning
Rigid- inflexible way
4
Q
Describe disturbed behaviour as a clinical feature of dementia:
A
Disorganised
Inappropriate
Distracted
Restlessness
Antisocial
5
Q
What is the prevalence of dementia?
A
Around more than 850,000 people currently diagnosed with dementia in the UK
By 2051 over 2 million
Prevalence increased with age
6
Q
Describe the age prevalence of dementia:
A
1 in 1400 of age 40-64
1 in 100 of age 65-69
1 in 25 of age 70-79
1 in 6 of age 80+
7
Q
Describe some dementia statistics:
A
2/3 of people living with dementia do so in the community
2/3 of care home residents have a diagnosis of dementia
1/4 of acute hospital beds are occupied by someone with dementia
8
Q
What are the risk factors for developing dementia?
A
Older age
Poor cognitive performance
Low BMI/overweight
Slow physical performance- modest exercise decreases decline
Not eating veg
Alcohol consumption
Diabetes- poor glucose control worse cognitive function and decline
Depression/ bipolar
ApoE4 increase risk gene
MRI showing white matter disease
Ventricular enlargement
Carotid artery thickening
History of bypass surgery
9
Q
What are the specific types populations affected by dementia?
A
Learning disabilities- have a higher risk of suffering from dementia due to premature aging. Down’s syndrome increases genetic risk
Parkinsons
BME (Black Minority Ethnic)- greater risk of early onset
Caucasians ApoE2 gene varient so decrease risk of AD but not true in BME
10
Q
What is the mortality like in dementia?
A
Survival rate from diagnosis is around 5-8 years
In 2017 deaths from dementia were around 903 deaths per 100,000
11
Q
Name and state the prevalence of the different types of dementia:
A
There are over 400 types, 4 most common:
-Alzheimer’s disease- 50-60% of cases
-Vascular disease- 20-25% of cases
-Lewy body disease- 15-20% of cases
-Frontotemporal Lobar Degeneration/Frontotemporal dementia- 7% of cases
Mixed dementia= more than 1 type
12
Q
Name other classifications of dementia:
A
Traumatic brain injury
Substance/medication induced
HIV infection
Prion disease
Parkinon’s
Huntington’s disease
Mixed aetiology
Unspecified
13
Q
What is Alzheimer’s disease (AD)?
A
Memory impairment with gradual onset and continual decline
14
Q
Name and describe other clinical but core features of AD:
A
Aphasia- difficulty in language/speech, reading, listening, typing, writing
Apraxia- difficulty performing a command, moving, speaking
Agnosia- can’t recognise faces, locations
Disturbance of executive functioning- struggle planning, problem solving, organisation, time management
15
Q
Name other clinical features of AD:
A
Depression
Psychosis
Behavioural
16
Q
When is early stage AD?
A
1-3 years
17
Q
Describe the features of early stage AD:
A
Language difficulties-hard to communicate
Depression- screen all pts for depression with dementia diagnosis
Losing direction when out and about
Recent memory impairment and forgetting names
Increase nº accidents while driving
Impaired ADLs
18
Q
When is the mid stage of AD?
A
2-7 years
19
Q
Describe the features of mid stage AD:
A
Aphasia
Amnesia- form of memory loss, problem forming new memories
Inability to bathe, eat, toilet or dress without assistance
Inability to calculate solutions and problem solve
Behavioural and psychiatric changes (BPSD)
20
Q
When is the late stage of AD?
A
7+ years
21
Q
Describe the features of late stage AD:
A
Seizures
Short term and long term memory loss
Double incontinence
Mutism or non sensical speech
Complete dependence on others
Rigid posture
22
Q
What are the demographic aetiology factors of AD?
A
Increased age
Family history
Down’s syndrome
23
Q
What are the genetic aetiology factors of AD?
A
Down’s syndrome
ApoE4
24
Q
What are the environmental and medical aetiology risk factors of AD?
A
Low IQ
Previous head injury
CVD
Depression
DM
Obesity
25
What is vascular dementia (VaD)?
Sudden onset followed by a step wise progressive decline
26
Describe VaD:
Onset is usually around late 60-70s
Caused by an infarct, general if there is a history of HTN, stroke and TIAs
Around 10% of patients develop VaD after a first stroke and more than 1/3 after recurrent strokes
27
What is the main treatment of VaD?
Prevention is the best treatment
Good management of BP, diabetes, heart disease, cholesterol, smoking
28
What are the clinical features of VaD?
Emergent emotional or personality changes (including depression) followed by memory impairment
Apraxia
Agnosia
Dysarthria- muscle used for speech are weakened
Dizziness
29
What are the other focal neurological signs (which are not present in AD) which are present in VaD?
GAIT disturbance- in late VaD there is a shuffling gait which differentiates from Parkinson's by its broad base and preserved arm swing
Weakness of extremities
Extensor plantar response
Pseudobulbar palsy- involuntary emotional expression disorder- in face can't control muscles
Exaggeration of deep tension reflexes
30
Describe the extensor plantar response:
Sharp object is stroked up patients foot, big toe bend backwards in VaD
In healthy adults, big toe and all toes bend forwards
31
What is the risk factors of VaD?
FH
DM
Smoking
AF
Male sex
HTN
History of stroke or TIAs
Recent studies have shown similar RFs as for AD
32
What are the key clinical features of Lewy body dementia?
Progressive cognitive decline, especially in attention and visuospatial ability
A variant of Kiezmers disease, more common in men
Persistent and well formed visual hallucinations, sometimes auditory
Early gait disturbances
Parkinson's type features
Other psychotic features
33
What are the supportive features of Lewy body dementia?
Repeated falls
Syncope (fainting)
Transient loss of consciousness
Systemised delusions
Non-visual hallucinations
REM sleep behaviour disorder
Depression
Extremely sensitive to SEs of anti-psychotics
34
What is the aetiology of Lewy body dementia?
Closely related to Parkinson's disease and both are characterised as synucleinopathies
FH
No known environmental RFs
35
Describe frontotemporal dementia:
Most common form of presenile dementia
Onset between 45-70
Insidious onset, slow progression
Early loss of insight
Early signs of disinhibition
Distractibility and impulsivity
36
Describe the pathophysiology of frontotemporal dementia:
Frontal lobe pathology responsible for behavioural and personality changes
Temporal lobe patholgy responsible for language disorder
37
Describe the language features of frontotemporal dementia:
Progressive decrease in speech output
Echolalia- patients repeat words/phrases that someone has said to them and back to them
Preservation- repeat same words over and over again
38
Describe the affective features of frontotemporal dementia:
Depression
Apathy
Emotional blunting
39
What is the aetiology of frontotemporal dementia?
Primarily unknown- strong genetic link:
Mutations in progranulin (GRN)
TAU-linked to chromosome 17
TDP-43 and C90RF72 genes
40
Why is it important to get an early diagnosis in dementia?
Reversible treatable conditions such as pseudo-dementia are detected and excluded
Patient and family have time to plan for the future
Personal affairs maybe put in order while the individual still has insight
Early access to support groups
Treatment that slows down progression of disease can be more effective
41
What is the clinical diagnosis like in dementia?
Complete history, including medical, physical and mental state examinations
Review any medicines being taken as those with anticholinergic and sedative SEs can impact adversity on congnition
Diagnostic criteria from either DSM or ICD have been met
Psychometric tests have been performed
Neuroimaging had been performed if possible e.g MRI and CAT scans
42
Name the investigations used in primary care for establishing the cause of dementia and differential diagnosis:
FBC
U&Es
LFTs
CRP
Calcium and phosphate
TFTs
Vit b12 and folate
Urine dipstick
BG
Temperature
43
Name the investigations used in secondary care for establishing the cause of dementia and differential diagnosis:
MRI and CAT scan
Urinalysis
HIV status
Neuropsychological assessment
ECG
44
Name the clinical screening tools used to help diagnose dementia:
Mini-mental state examination- MMSE
Abbreviated mental test score- AMTS
Alzheimer's Disease Assessment scale- cognitive sub scale- ADAS-cog
Addenbrooke's cognitive examination 3- ACE3 or mini ACE- easier and more readily available- cheaper
45
Describe the AMTS:
Determine extent of cognitive decline
Quick, under 4 minutes
0-10 score
7 or less= impairment
46
Describe the MMSE test:
Assess cognitive function and decline
MMSE tests memory, attention calculation, orientation, language, ability to follow command and praxis (ability to name common objects and repeat words)
Primarily used to aid diagnosis in AD and recommend by NICE to assess severity of AD and response to pharmacological treatment
8Qs (10-15 mins)
Score 0-30
47
What are the strengths and limitations of MMSE test?
Less sensitive in early stages, more difficult in late stages
Levels of prior intelectual inability/education
English isn't first language
Socioeconomic background
However is sensitive to effects of cholinesterase inhibitors
48
Name and describe the MMSE score:
27-30 Normal
25-27 Mild cognitive impairment
21-26 Mild AD (5%)- treatment commence
10-20 Moderate AD (32.1%)
10-14 Moderately severe AD
<10 Severe AD (12.5%)
49
What are the purposes of dementia medication?
To prevent dementia
At the onset of dementia
During the later stages of dementia
50
Name the different classes and give examples of different types of dementia medication:
AchEi e.g donepezil, rivastigmine, galantamine
NMDA antagonists e.g memantine
Antioxidants e.g ginkgo
Anit-inflammatories e.g ibuprofen
Neurotrophic factors e.g oestrogen
Antiamyloid agents e.g tramiprosate
51
Is it useful to take AchEi before a diagnosis of dementia?
No
52
Is it useful to take NSAIDs to prevent dementia?
Mixed opinions
53
Is it useful to take antihypertensives to prevent dementia?
Yes
ACEi and diuretics
54
Is it useful to drink beer to prevent dementia?
Yes- but a small consumption
Silicone decreases the bioavailability of aluminium in the brain
55
Is it useful to have oestrogen to prevent dementia?
Yes
Potent chemical factor preventing vascular brain disease
Preservation and control of neurons
56
Is it useful to take oestrogen based HRT to prevent dementia?
No
57
Is it useful to eat fish to prevent dementia?
Yes 60% decrease if eaten once a week
58
Is it useful to take omega-3 to prevent dementia?
No
59
Is it useful to take lithium to prevent dementia?
Mixed
Those with bipolar have 2 or more risks but decreases risk
60
Is it useful to take statins and vitamins (B,C,E,folic) to prevent dementia?
Mixed
High levels of homocysteine increases risk of AD but vit D decreases homocysteine
61
Is it useful to take ginkgo when you have dementia?
No
62
Is it useful to take ginseng when you have dementia?
Yes
63
Is it useful to take vitamin E when you have dementia?
No
64
Is it useful to take folic acid when you have dementia?
Mixed- not enough evidence
65
Is it useful to take multivitamins when you have dementia?
No
66
Is it useful to take omega 3 when you have dementia?
Mixed
67
Is it useful to take anti-amyloid when you have dementia?
No
68
Name anti-amyloid antibodies used in early AD:
Aducanumab
Lecanemab
69
Describe aducanumab as a drug used in early AD:
Designed to target amyloid plaques in early stages of AD
The phase III trials aimed to evaluate the safety of aducanumab and the effect it had on memory, thinking and day to day activities in people with confirmed diagnosis of mild cognitive impairment or mild AD
70
Describe Lecanemab as a drug used in early AD:
Brand name Leqembi
Admin as an IV infusion in early AD
Lecanemab decreases markers of amyloid in early AD and resulted in moderately less decline on measures of cognitive function than placebo at 18 months
It is associated with adverse effects such as fluid formation in the brain
71
Describe the use of disease modifying treatment in dementia:
Will only work if taken early enough, maybe decades before diagnosis
Disease modifying treatments is expected to yield more dramatic benefits then treatment of established dementia
72
Describe the dosing of donepezil as a drug in dementia:
Aricept
Start at 5mg OD ON then increase to 10mg OD ON
4 week interval between dose increase
Taken at night as some patients may feel dizzy/ cause bradycardia
orodisperisble available
73
Describe the features of donepezil:
Selective reversible AchEi
License: mild to moderate dementia in AD
T1/2: 70 hrs
Protein binding 96%
74
Describe the dosing of galantamine as a drug in dementia:
Reminyl Galysa
4-12mg BD
8mg MR OD- 24mg MR OD
Liquid and MR available
75
Describe the features of galantamine:
Selective reversible AchEi enhances response of nAchR to Ach
License: mild to moderate dementia in AD
T1/2: 7-8 hrs
Protein binding 18%
76
Describe the dosing of rivastigmine as a drug in dementia:
Exelon
1.5-6mg BD
Liquid (2 wk gap between dose increase)
Patch available (4 wk gap between dose increase):
9.5mg in 24 hr patch
77
Describe the features of rivastigmine:
Non-selective reversible AchEi (non-competitive)
License: mild to moderate dementia in AD and PD (capsule)
78
What are the outcomes of AchEi for dementia progression?
Improvement 1/3 lasts 6-12 months up to 2 years, before decline
Non-decline 1/3 steady for 6-12 months
No response 1/3 continue to decline- if treatment switched, 1/2 will improve or non decline
79
What would be the outcomes if the AchEi works for the dementia patient?
The progressive decline in functioning that would otherwise have occurred can be delayed by several months/ years
This decreases carer burden
This delays the need for transfer to a dementia care home
80
What would be the outcomes if the AchEi doesn't work for the dementia patient?
Failure to benefit from one AchEi doesn't necessarily mean that they won't respond to another
Also poor tolerance to one AchEi doesn't rule out good tolerance to another
81
What is the tolerance of AchEi?
To ensure max benefits
Decrease unwanted effects
Slow titration is recommended
Rivastigmine patches are better tolerated than capsules
Rivastigmine is best choice for pts taking multiple meds, and also licensed for PD
82
Describe the NICE 2018 guidelines for dementia treatment:
Use the least expensive one first- donepezil 70-80% of patients first line
Alternative AchEi could be prescribed if it is considered appropriate when taking into account adverse event profile, expectations about adherence, medical co-morbidity, possibility of drug interactions
83
What are the adverse effects of AchEi?
When they start to work, they can cause cholinergic stimulation (procholinergic effect) of the body to:
Common SEs: N&V, diarrhoea, loss of appetite, sleep disturbance, abnormal dreams, incontinence, headache, fatigue
84
What are the dangerous SEs of AchEi?
Bradycardia
Dangerous in certain heart diseases or if taking heart slowing drugs e.g digoxin, BBs, CCBs
85
Name drugs that are associated with an increase in anticholingeric burden and therefore cognitive impariement:
Antihistamines
Tricyclic antidepressants
Antipsychotics e.g quetiapine
Drugs used in urinary incontinence e.g solfenacin
Hyoscine
Pain killers e.g morphine
Some asthma and COPD meds
86
How would you optimise taking donepezil?
It can cause sleep disturbances/ nightmares so give dose in the morning
It has a long half life do doesn't matter as much if missed a dose
87
How would you optimise taking Rivastigmine?
Patches can cause rash
If mild then use an emollient cream
If severe then prescriber should be informed, rotation at the application site helps
It has a short half life so may need dose titration if doses missed
88
How would you optimise general AchEi?
Nausea is a common SE
This may be minimised by taking doses after food
Transient SE, normally goes away in a few weeks, if not then switch to another AchEi or alternative
Bradycardia may also occur so check pulse every few months and seek advice if less than 50bpm
89
Describe the dosing of Memantine as a drug used in the later stages of dementia:
Ebixa
Usually started at 5mg OD for 1 week then increase by 5mg per week until 20mg OD is reached
Also in liquid formulation
90
Describe the features of memantine:
NMDAr antagonist that may be neuroprotective and thus disease modifying
License: moderate to severe dementia in AD
Monotherapy is recommended for managing moderate AD who are intolerant of or have CI to AchEi or severe AD
91
What are the SEs of memantine?
Common: headache, constipation, dizziness, HTN, dyspnoea
Caution in using it with pts with history of epilepsy/ seizures
92
What is the unlicensed use of dementia medications in Lewy body dementia?
Offer donepezil or rivastigmine to patients with mild to moderate dementia
Only consider galantamine for patients with mild to moderate dementia with LB if donepezil and rivastigmine are not tolerated
Consider donepezil or rivastigmine for people with severe dementia with LB
93
What is the unlicensed use of dementia medications in vascular dementia?
Only consider AchEi or memantine for patients with VaD if they have suspected co-morbidities with ADs, PD dementia or dementia with LB
94
What is the unlicensed use of dementia medications in frontotemporal dementia?
Do not offer AchEi or memantine to these patients
95
What is the evidence for AchEi and memantine use in dementia?
17 new RCTs and 4 systematic reviews
Increase in evidence for clinical effectiveness
New studies strengthened evidence for cognitive outcomes
Memantine improved cognition at 12 weeks and function at 24 weeks
96
What are the limitations for the evidence for AchEi and memantine use in dementia?
Quality of these trials disappointing
Observed cases instead of intention to treat analysis
Inadequate reporting of randomisation and location
Small study size (donepezil in particular)
97
What are the evidence outcomes from the key trials for AchEi and memantine use?
Decrease carer burden with galantamine
Adverse drug reactions more frequent with rivastigmine
No sig difference in cognitive function between AchEi
Sig delay in worsening symptoms with memantine (compared to placebo)
No sig benefit from NICE with use of memantine in combo with AchEi-but in some cases are used together but needs to be monitored closely, stop if no benefit
98
What are the behaviour symptoms in dementia?
From observation:
-physical aggression
-screaming
-wandering
-culturally inappropriate behaviour
-sexual disinhibition
-swearing
99
What are the psychological symptoms in dementia?
From interviews:
-anxiety
-depression
-hallucinations (seeing/hearing/feeling/tasting things that are not there)
-delusions (false beliefs)
100
What does BPSD stand for?
Behavioural and Psychological Symptoms of Dementia
101
How many people suffer from BPSD?
80-90%
102
What are the BPSD symptoms in mild dementia?
Anxiety/ depression
103
What are the BPSD symptoms in moderate dementia?
Physical aggression
Wandering, sexual inhibition- disappear in the severe stages
Screaming
Swearing
Delusions
Hallucinations
104
What are the BPSD symptoms in severe dementia?
Depression
Screaming
Suspiciousness
Paranoia
Delusions
105
When diagnosing someone with dementia, what is an important factor to include with BPSD symptoms?
Many BPSD symptoms also have non-dementia cause
Screaming+swearing= stress, hunger, anger, pain
Wandering= stress, anxiety, pain, hunger, thirst
Hallucinations= medications, infection, hypoxia, visual agnosia, contrast sensitivity, hearing impairment
106
How can physical aggression be caused by non-dementia?
Anger
Physical discomfort e.g nausea
Pain
Infection
Withdrawing from alcohol
Embarrassed/ loss of dignity
Being rushed
Felling too hot/cold
Dislike other people
Anxiety/ depression
107
What is the first line treatment for BPSD?
Non-drug intervention
Modification of the carer may:
-decrease the occurrence of BPSD
-remove the need to treat the BPSD
Many symptoms naturally resolve themselves within 4-6 weeks
Other non-pharmacological depending on preference e.g music therapy
108
What are the principles of non-drug treatment for BPSD?
Identify the symptom(s) that cause most concern
Describe each symptom in detail
The ABC approach
-Antecedence (what happens before behaviour)
-Behaviour (what was the behaviour)
-Consequence (what happened after)
109
Describe pain in BPSD:
Under-reported by patient in both frequency and intensity but are still in pain
Can use diagram of different facial expressions
Best practice- 'Abbey pain scale'- when the patient can't communicate e.g facial expressions, groaning, crying
If pain is well managed then BPSD symptoms decrease
110
What are the principles of psychiatric drug treatment for BPSD?
Discuss risks and benefits of treatment
Check that the symptoms have:
-no physical cause e.g infection
-no iatrogenic cause e.g medications
-no environmental cause e.g temp of room
-no response (or not treatable by) non-drug interventions
111
When introducing psychiatric medications, what must the prescriber first do?
Involve an assessment of:
-patient capacity
-informed consent
-slow and cautious dose titrations
-judicious dosages
112
What are the monitoring steps in psychiatric medications?
Review all psychotropics at least every 3 months
Review all antipsychotics at least every 6 weeks
Time-limit Rx when possible
Review symptoms and behaviour
Review SEs
Decrease drug dosages
Discontinue when possible
113
Describe the use of combination medications in BPSD:
Use medicines that address several different symptoms to avoid unnecessary polyprescribing
e.g sedating antidepressants for:
-agitation
-depression
-sleep disturbance
114
Describe the management of mild anxiety using psychiatric medicines:
Greater at moderate then decreases in severe
16% of dementia and 4% of non-dementia patients
Treat with antidepressants
115
Describe the management of depression using psychiatric medicines:
50% of dementia patients have depression
Treat with antidepressants
116
What are the key diagnostic symptoms of depression?
Apathy
Weight loss
Sleep disturbance
Agitation
117
Describe the use of non-antipsychotic medications for BPSD:
With AchEi, 50% of patients decrease apathy but this is unlicensed
Limited evidence but may be worth a trial:
-AchEi -Memantine
118
When would management with antipsychotics be appropriate in BPSD?
Persistent aggression
Moderate-severe AD
Unresponsive non-drug approaches
Risk of harm to self or others
119
When would management with antipsychotics not be appropriate in BPSD?
Other non-dementia causes previously
120
Describe hallucinations in BPSD:
50%
Moderate is the greatest intensity
Less in mild/severe
121
What is the challenge for hallucinations in BPSD?
Visual misperceptions are not hallucinations
Visual agnosia- difficulty recognising faces/ objects
Essential to examine both auditory and visual function
122
What are the 5 typical delusions in BPSD?
People are stealing things
Spouse or other caregiver is imposter
Abandonment
Misidentification
Infidelity- convinced their spouse is unfaithful
123
Describe the 4 main types of misidentifications in delusions:
Presence of persons in the patients own home (the 'phantom boarder' syndrome)
Can't identify own self in the mirror
Can't identify othets
Television/ photos are seen as 'real'
124
Describe the trend with antipsychotics prescribed in dementia:
180 000 people with dementia in UK (25%) are prescribed antipsychotics
Antipsychotics double the risk of death
1800 stroke
1600 die as a consequence of taking these
125
What are the major adverse outcomes when taking all antipsychotics?
Oversedation and dehydration leads to infection and 3x stroke risk
Leads to falls and fractures 2x risk
126
What are the major adverse SEs of antipsychotics?
Sedation
Parkinsonism
Gait disturbance
Dehydration
Falls
Chest infection
Confusion
Movement problems: tremor, rigidity, agitation, restlessness, akathisia
Dry mouth, blurred vision, consitpation
127
Describe the use of Risperidone for BPSD:
Short term treatment of up to 6 weeks for persistent aggression on moderate to severe AD unresponsive to psychosis in dementia and risk to themselves and others
128
Which antipsychotics would you not use in BPSD and why?
Others are ineffective or have harmful SEs
Greater cognitive decline with quetiapine when compared to placebo- as has anti-cholinergic effect
Benzodiazepines can increase the risk of falls/ fractures by 8 fold
Haloperidol
129
What is dosing of Risperidone for BPSD?
0.25mg BD
Adjust by 0.25mg BD not more frequently than every other day, if needed optimum dose is 0.5mg BD for most patients
Some patients need 1mg BD
Max 6 weeks, evaluate frequently and regularly
130
Describe the discontinuation of Risperidone (antipsychotics) in BPSD:
Many patients can stop anti-psychotics for BPSD safetly without worsening of symptoms
Continue antipsychotic if patient relapses
Do NOT stop antipsychotic if it is treatment for schizophrenia (typical dose is 2mg daily)
