Dementia

Question 1

Dementia definition

Answer 1

• Clinical syndrome
• insidious onset and gradual progression
• impairment of at least 2:
  
  • memory
  • executive function
  • visuospatial ability
  • language
  • personality/behaviour
• must interfere with social or occupational function
• cannot be accounted for by other psych conditions

Question 2

Screening for dementia

Answer 2

• MOCA
• MMSE

Question 3

Alzheimer’s disease

Answer 3

• most common 60-80%
• slowly progressive memory loss
• amyloid plaques accumulate in hippocampus and entorhinal cortex
• intracellular neurofibrillary tangles
• loss of neurons

Question 4

Vascular dementia

Answer 4

• second most common
• ischemic or hemorrhagic CVD
• hypoxic brain lesions
• lacunar infarcts or multiple cortical infarcts

Question 5

Dementia with Lewy Bodies

Answer 5

• abnormal lewy bodies (alpha-synuclein clumps)
• progressive cognitive decline
• hallucinations
• parkinsonism
• fluctuating cognition
• VERY SENSITIVE TO NEUROLEPTICS
  
  • Exacerbation of parksinism
  • neuroleptic malignant syndrome!

Question 6

Frontotemporal dementia

Answer 6

• focal degeneration of frontal and temporal lobes
• younger onset (50-60)
• progressive personality changes
• behavioural disinhibition
• apathy
• loss of social awareness
• executive function deficits but memory spared
• eventually progresses to global dementia

Question 7

Natural history of dementia

Answer 7

• may present at mild cognitive impairment
• memory loss but no functional impairment
• increased need for ADL help
• advanced:
  
  • lose ability to ambulate, communicate, feed and toilet
• rapidly progression = delirium
• Clinical Dementia Rating
• Global deterioration scale
• FAST (Functional Assessment Staging)

Question 8

Prognosis in dementia

Answer 8

• median survival after diagnosis of Alzheimer’s 4-6 years
• poor short term prognosis:
  
  • aspiration
  • UTI
  • sepsis
  • pressure sores
  • fever
  • weight loss
• terminal illness
• can survive for long periods with severe functional and cognitive decline

Question 9

Symptoms in dementia : pain

Answer 9

• report less pain due to poor recall and poor communication
• assessment:
  
  • patient report
  • caregiver report
  • observation of distress
• use faces pain scale, pain thermometres instead of verbal
• Pain Assessment in Advanced Dementia (PAINAD)
• Acetaminophen first line
• Avoid NSAIDS (bleeding, PUD, RF, cardiovascular complications, fluid retention)
• Opioids ATC and long acting
• undertreatment of pain greater risk factor for delirium than use of opioids

Question 10

Neuropsychiatric symptoms

Answer 10

• depression, psychosis or agitation
• identify and treat underlying cause
  
  • uti, delirium constipation, pain
• consider empirically treating with acetaminophen
• evaluation of unmet needs:
  
  • thirst, hunger, sleep, sensory deprivation

Non pharmacological first

• music therapy
• massage
• physical activity

Pharmacologic therapy

• used if agitated but no long term benefit
• use only if severe agitation and non pharm failure
• little difference between firs gen and second gen
• DO NOT USE IN DLB (lewy body)
• mood stabilizers not effective

Question 11

Lewy Body Dementia and Neuroleptics

Answer 11

• worsens Parkinsonism
• Neuroleptic Malignant Syndrome
• DO NOT USE

Question 12

Depression

Answer 12

• common 50%
• difficult to diagnose
• can manifest as behavioural symptoms of aggression, refusal to eat
• SSRI, SNRI, or NRI first line

Question 13

Cognitive decline

Answer 13

• decreased production of choline acetyl transferase
• reduced acetylcholine synthesis
• impaired cholingeric function

CHOLINESTERASE INHIBITORS

• donepezil, galantamine

NMDA ANTAGONIST

• memantine
• Improve congitive, functional and behavioural outcomes
• modest clinical significance
• may also work in non alzeimer’s dementia
• avoid or discontinue in advanced dementia or short prognosis

Adverse effects:

• nausea, vomiting, diarrhea
• syncope, bradycardia, pacemaker insertion, hip fracture

Question 14

Eating and swallowing problems

Answer 14

• feeding tubes do not :
  
  • improve survival
  • prevent aspiration pna
  • decrease pressure ulcers
  • improve comfort
• tube related complications
  
  • replacement
  • hospitalization
  • restraints to prevent dislodgement
• treat modifiable factors:
  
  • xerostomia
  • depression
  • oral health
• hand feeding, proper oral care is recommended

Question 15

Palliative Care Interventions

Answer 15

• Advanced care planning
• Avoidance of burdensome treatment
  
  • hospitalization is a significant event heraldign short term mortality and morbidity
• Caregiver support