Dementia Hour 1 Flashcards Preview

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Flashcards in Dementia Hour 1 Deck (30):
1

Age associated cognitive changes:

1. Difficulty retrieving words and names
2. Slower processing speed
3. Difficulty sustaining attention when faced with competing environmental stimuli
4. Learning something new takes a bigger effort
5. No functional impairment

2

Mild Cognitive Impairment: Definition

1. Memory complaint corroborated by an informant
2. Objective memory impairment for age and education
3. Preserved general cognition
4. Normal activities of daily living
5. Not demented

3

Amnestic MCI:

1. Memory loss not meeting criteria for dementia
2. Could be earliest phase of AD
3. Clinical diagnosis: no "MCI test"

4

Dementia (neurocognitive disorder and specified as mild or major)

1. Memory decline/impairment and at least one of the following: aphasia, impaired executive function, apraxia, agnosia; DSM 5 says decline in memory, complex attention, exec function, learning/memory, language, perceptual/motor, social cognition
2. Cognitive deficits must impact social and occupational function (Major not capable of independent living, minor does not)
3. Diagnosis must be made in the presence of a clear sensorium (ie not out of surgery)

5

Early-onset AD:

1. occurs b/w ages 30-60
2. Rare
3. Familial in most cases
4. Abnormal presenilin 2 (1), presinilin 1 (14), abnormal APP (21)

6

Late-onset AD:

1. most common form
2. develops after age 60
3. combo of factors usually responsible like diabetes, increased cholesterol, hyperlipidemia, but think apo E4 gene on chromosome 19

7

AD risk factors

1. increasing age
2. females
3. FH of dementia
4. Fewer years of education
5. Lower occupational status
6. Depression, other emo illnesses
7. Head injury
8. Low folate, B12
9. Elevated plasma homocysteine levels
10. Presence of apo E4 allele
11. Postop delirium
12. Alcohol abuse

8

Early symptoms of AD:

1. Early cognitive symptoms (trouble keeping appointments, difficulty finding words, misplacing objects)
2. Early functional symptoms (difficulty driving, difficulty selecting clothes, missing appointments, problems at work)
3. Early behavioral symptoms could include (subtle changes in personality, social withdrawal, depression)

9

Depression vs. Dementia:

Patients with primary depression:
1. Demonstrate less motivation during cognitive testing
2. Express cognitive complaints that exceed measured deficits
3. Maintain language and motor skills

10

Brain imaging, when would you consider?

Not routinely indicated when suspecting Alzheimer's
1. focal findings on exam
2. rapid onset/decline
3. falls, head trauma by history;
nonspecific findings in AD and vasc D: lacunar infarcts, small vessel and white matter disease

11

Frontotemporal dementia (Pick's Disease) vs. Alzheimer's:

1. Insidious onset, gradual progression
2. early decline in social interpersonal conduct
3. early impairment in regulation of personal conduct with loss of insight
4. Early emotional blunting
5. Characterized by behavioral abnormalities
6. Memory loss occurs later

12

Frontotemporal dementia: Rx

1. No role for cholinesterase inhibitors
2. Careful use of atypical antipsychotics (pines and dones, since these could make person worse)
3. Divalproex for behavior control
4. SSRIs for irritability, depression, impulsive behaviors

13

Durgs for treating neuropsychiatric disturbances in AD patients:

1. Antipsychotics (risperidone, haloperidol): use this at lowest possible dose for a short period of time
2. antidepressants (sertraline, venlafaxine): depression could precede or follow AD
3. Anxiolytics (buspirone, lorazepam): reduce any confusion or depression among a patient

14

Vascular dementia facts; how to control it

1. Most common dementia after Alzheimer's
2. Step-wise progression (can be abrupt after CVA)
3. Usually seen with cardiovascular risk factors
4. "Mixed" dementia with AD or Lewy Body NOT unusual
5. Emotional lability

1. Max BP control
2. Statins (but need enough fats and lipids to myelinate)
3. Stop smoking
4. Control blood sugar
5. Diet
6. Exercise: cognitive or physical
Situation in DC is a MESS!!!!

15

Dementia with Lewy Bodies:

1. Sporadic (usually late onset)
2. Memory frequently less affected compared to AD
3. Motor symptoms VARIABLY present, since you're worried more about issues with frontal and subcortical areas
4. Frontal and subcortical features: deficits in attention and alertness
5. Neuropsychiatric symptoms: vivid visual hallucinations, delusions

16

Lewy Body Dementia:

1. Short term memory loss, gradual onset
2. VISUAL HALLUCINATIONS
3. Cognitive fluctuations
4. REM sleep disorder common (lose paralysis)
5. Frequent falls
6. Autonomic dysfunction

17

Lewy Body Dementia Rx

1. Cholinesterase inhibitors could provide symptomatic support (rivastigmine)
2. Trial of carbidopa/levodopa for severe movement symptoms
3. AVOID ANTIPSYCHOTIC DRUGS because of increased sens
4. For REM sleep disorder: clonazepam

18

MMSE:

1. screening: not a diagnostic tool
2. Not specific for dementia type and could actually be impacted by AGE, EDUCATION, ETHNICITY
2. normal (30-27), mild (30-20), moderate (20-10), severe (10 or lower)

19

ADLs: IADLs

ADL: 1. dressing 2. eating 3. ambulating 4. toileting 5. hygiene;
IADL: 1. shopping 2. housekeeping 3. accounting 4. food preparation 5. transportation

20

Importance of early diagnosis of Alzheimer's:

1. rule out reversible causes (maybe B9, B12, thyroid, BP, diabetes; maybe they're on anticholinergics)
2. Initiate appropriate therapy
3. Enrollment for clinical trials
4. Advance directives and planning

21

Donepezil:

Mech: inhibits AChE
Doses per day: 1 (don't need food)
Metabolism: Cyt P450
Adverse reactions: N/V, sleep problems; worse SE's are bizarre dreams and syncope at higher doses

22

Rivastigmine:

Mech: inhibits AChE and BuChE
Doses/day: 2
Metabolism: hydrolysis by cholinesterase
Adverse rxns: see donepezil

23

Galantamine

Mech: inhibits AChE; allosteric modulator of nicotinic receptors
Doses per day: 2 or 1
Metabolism: Cyt P450
Adverse rxns: see donepezil and rivastigmine

24

Memantine:

Mech: partial antagonist of NMDA receptor
Doses/day: 2
Metabolism: most excreted unchanged in urine
Adverse rxns: dizziness, confusion, headache, constipation (went from a defensive coordinator to head coach)

25

Infarcts associated with hypertensive small vessel disease and progressive cognitive impairment

Think LACUNAR INFARCTS: also maybe arteriosclerosis of small arteries and arterioles supplying deep grey and white matter

26

In context of dementia with LB's, what LB's can be found?

1. Cortical-type LB's in frontal, temporal, insular cortex (also limbic areas)
2. Nigral LBs
3. Lewy neurites (hippocampus and striatum)
4. Look for plaques and tangles, and then there's dual diagnosis of DLB and AD

27

MoCA stands for; some characteristics?

Normal >26, Mild 18-26, Moderate 10-17, Severe <10;
focus on the fact that executive function is tested better!!

28

Adult homes:

1. room and meals provided
2. add on assistance with daily activities
3. No complex medical problems
4. Not always licensed or monitored by local authorities
5. CASH only

29

Assisted living facilities:

1. assist with INSTRUMENTAL activities of daily living
2. Add some basic activities of daily living for extra fees (help with taking meds, taking bath, walking to dining hall)
3. No med or nursing care onsite
4. Cash only: NOT COVERED by Medicaid or Medicare

30

Skilled nursing facilities:

1. Daily skilled nursing care; onsite med care
2. Dependent in ALL basic activities of daily living (DEATH)
3. Most patients with ADVANCED DEMENTIA
4. Cash until money is depleted; most residence on Medicaid!!!