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dementia Flashcards

1
Q

non-modifiable risk factors for dementia

A

1) elderly
2) female
3) ethnicity: black, hispanic
4) genetics

  • apolipoprotein E (APOE4) gene
  • not routinely tested unless presence of family history
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2
Q

modifiable risk factors for dementia

A

1) HTN, DM
2) binge drinking, smoking
3) limited physical activities
4) obesity
5) hearing loss
6) depression

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3
Q

pathophysiology of dementia

A

1) senile plaques

  • cleavage of amyloid precursor protein (APP) by beta and gamma secretases
  • form beta-amyloid peptides that are sticky -> beta-amyloid plaque aggregates -> senile plaques -> very inflamamtory -> neuron apoptosis

2) neurofibrillary tangles

  • presence of senile plaques -> hyperphosphorylation of tau protein -> assembly of paired helical filaments (PHF)
  • Tau proteins required for microtubule stabilisation and intracellular transport
  • formation of PHF -> neuron apoptosis

3) brain atrophy and neurodegeneration

  • apoptosis involved in multiple neurotransmitter system (cholinergic, serotonergic, glutaminergic) -> neurochemical deficit and alterations -> cognitive decline and neuropsychiatric behaviours
  • apoptosis in areas critical for cognition in brain (cortex, hippocampus)
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4
Q

DSM-5 for dementia (major neurodegenerative disorder)

A

1) evidence of significant cognitive decline from prior level of performance in 1/> cognitive domains from baseline

  • complex attention, executive function, learning and memory, language, perceptual-motor or social cognition
  • concerns regarding this significant decline
  • substantial impairment in cognitive performance

2) cognitive deficit interfere with independence of everyday activities
3) cognitive deficits not due to delirium
4) cognitive deficits not better explained by another mental disorder

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5
Q

DSM-5 criteria for dementia (minor neurodegenerative disorder)

A

1) evidence of modest cognitive decline from prior level of performance in one or more cognitive domains
2) cognitive deficit interfere with independence of everyday activities
3) cognitive deficit not due to delirium
4) cognitive deficit not better explained by another mental disorder

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6
Q

clinical presentation of early stage dementia

A

1) cognitive

  • short term memory loss, word finding difficulties

2) psychological

  • apathy, depressive symptoms

3) behavioural

  • social withdrawal, disinhibition

4) sleep

  • REM behaviour disorder

5) physical

  • gait impairment
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7
Q

clinical presentation of late stage dementia

A

1) cognitive

  • memory loss, more marked expressive difficulties and eventual loss of language

2) psychological

  • delusions, anosognosia (not aware of dementia)

3) behavioural

  • aggression, hallucination, wandering

4) sleep

  • altered sleep-wake cycle

5) physical

  • reptitive purposeless movement, parkinsonism, seizure
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8
Q

diagnosis of dementia tldr

A

1) mini MSE
2) montreal cognitive assessment (MoCA)
3) clinical evalutation

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9
Q

diagnosis of dementia - mini MSE

A
  • mild 20 - 40
  • moderate 10 - 19
  • severe < 10
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10
Q

diagnosis of dementia - montreal cognitive assessment

A
  • mild 18 - 25
  • moderate 10 - 17
  • severe < 10
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11
Q

diagnosis of dementia - clinical evaluation

A
  • med history
  • cognitive examination
  • neuropsychological testing if required
  • physical examination
  • lab testing (thyroid function, Vit B12)
  • structural brain imaging w CT/MRI
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12
Q

treatment algorithm for dementia

A

1) mild - moderate

  • acetylcholinesterase inhibitor (AI) monotherapy

2) moderate and intolerant/CI to AI or severe

  • memantine monotherapy

3) already on AI

  • moderate: consider combination w memantine
  • severe: start combination w memantine
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13
Q

types of AI

A

1) donepezil
2) rivastigmine

  • oral and transdermal patch
  • shorter t1/2 than galantamine
  • metabolised by kidney

3) galantamine

  • oral tablet
  • also act on nicotinic receptor in brain -> therapeutic effect
  • metabolised in liver (CYP450)
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14
Q

MOA of AI

A

inhibit acetylcholinesterases in synpase

  • increase acetylcholine neurotransmission at synaptic cleft
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15
Q

dosing regimen for AI

A
  • slow titration regimen over 4 - 8 wks to reach target dose and minimise AE
  • what to do if encounter AE
    ** lower dose temporarily before re-escalating more slowly and monitor for AE recurrence
    ** or discontinue drug and switch to other AI
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16
Q

monitoring for AI

A
  • good response = slight improvement in day to day life
  • routine cognitive test
  • switch to memantine if intolerable/X tolerate
17
Q

AI SE

A
  • cholinergic hyperactivation -> activation of parasympathetic nervous system
    ** N/V, D, increased bowel movement
  • less common
    ** muscle cramp, bradycardia, loss of appetite, increased gastric juice secretion
18
Q

AI caution

A
  • starting donepezil w pre-existing bradycardia or meds that cause bradycardia
19
Q

NMDA receptor antagonist for dementia - types

A

memantine

20
Q

NMDA receptor antagonist for dementia - MOA

A

block NMDA receptor -> reduce excitotoxicity

21
Q

NMDA receptor antagonist for dementia - SE

A

hallucination, confusion, dizziness, headache

22
Q

lecanemab for dementia

A
  • only coming to SG end 2024
  • need to go through genotyping and phenotyping before initiation
  • a lot of exclusion criteria to go through
  • patient need IV infusion every few weeks
  • AE: vasogenic oedema, small haemorrhage
23
Q

non pharmaco for dementia

A

1) cognitive stimulating activities
2) physical exercise
3) social interactions with others
4) health diet, adequate sleep
5) proper personal hygiene
6) safety inside and outside home
7) medical and advanced care directives (designation of power of attorney)
8) long term health care planning
9) financial planning
10) effective communications
11) psychological health (participate in personally meaningful activities)

24
Q

what is BPSD?

A
  • spectrum of non-cognitive and non-neurological symptoms of dementia
    ** agitation, aggression, psychosis, depression, apathy
  • often an attempt of patient to communicate, need to understand why behaviour is occurring
25
Q

contributing factors to BPSD

A

1) medical

  • depression, anxiety, delirium
  • untreated pain (uncommunicated, want to get attention)
  • infection, constipation, urinary retention
  • hearing/visual impairment

2) pharmacological

  • medication w anticholinergic effect
  • anticonvulsant
  • systemic corticosteroids (esp high dose)
  • med w sedative actions
  • anti PD meds

3) environmental/social

  • unfamiliar environment
  • lack of privacy, space, security
26
Q

framework for approaching BPSD first step

A

determine if BPSD or delirium

27
Q

framework for approaching BPSD - what to do if it is BPSD

A

1) examine and treat any causative problems
2) review if behavioural problems returned

28
Q

framework for approaching BPSD - confirmed BPSD - causative problems

A

1) physical problems (infection, pain, constipation)
2) activity related problems
3) intrinsic to dementia (wandering)
4) depression

  • consider SSRI/mirtazapine
  • monitor for hyponatremia and any initial increase in agitation

5) anxiety

  • consider SSRI
  • monitor for hyponatremia and any initial increase in agitation
  • if severe case and SSRI not useful -> benzodiazepine

6) insomnia

  • sleep hygiene
  • 2-3 wk trial short acting melatonin or hypnotic if melatonin CMI
29
Q

framework for approaching BPSD - confirmed BPSD - problems not returning after initial treatment

A

X further treatment required, X antipsychotic use

30
Q

framework for approaching BPSD - confirmed BPSD, problems return after initial treatment

A

1) non pharm 1st line
2) pharm

  • only when symptoms severe and pose risk to individual/others or when reversible causes excluded and non pharm trialed
  • short term and kept under close review
  • monitoring
    ** every 3 month, slowly taper dose after 3 month of improved BPSD, if recurrence then restart lowest effective dose
    ** SE and worsening cognitive function
31
Q

framework for approaching BPSD - confirmed BPSD, problems return after initial treatment - non pharm

A

1) full understanding of patient for patient centred approach
2) remove triggers of BPSD symptoms, provide calming environment
3) go back to patient pre-morbid routine and make small changes for patient to articulate their wishes
4) make dosage form/frequency simpler for caregivers
5) sundowning: make sure room well lit and free from shadows

32
Q

framework for approaching BPSD - confirmed BPSD, problems return after initial treatment - pharm treatment

A

1) AI/memantine if not already prescribed
2) SSRI

  • for depression and anxiety
  • citalopram reduce agitation and improve other symptoms like delusion

3) AVOID TCA
4) antipsychotics

  • help aggression, agitation, psychotic symptoms that are causing severe distress or an immediate risk of harm to patient or others
  • not helpful for BPSD (wandering, calling out, social withdrawal, inappropriate sexualised behaviour, challenges due to environmental triggers
  • X routinely used cuz of AE
33
Q

framework for approaching BPSD - confirmed delirium

A
  • delirium symptoms
    ** short history of confusion, hallucination, delusion w fluctuating cognition
  • treat underlying acute medical conditions causing behavioural problems (UTI, drug SE, alc/drug withdrawal)
  • review if behavioural problems returned
    ** if X recurrence then X further treatment, X antipsychotic use
    ** if recurrence then non pharm approaches
34
Q

framework for approaching BPSD - neither delirium or BPSD

A
  • check if patient treated for other neuropsychiatric problems
    ** if yes then follow guidelines for those problems

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