ic16 dementia

Question 1

what is the DSM-5 criteria for diagnosis of major neurocognitive disorder (dementia)

Answer 1

(A) significant cognitive decline from prior level of performance in one or more cognitive domains (complex attention, learning and memory, language, executive function, perceptual-motor, social cognition)
i) concern of significant decline in cognitive func
ii) substantial impairment preferably documented by a standardised neuropsychological testing or in its absence another quantified clinical assessment

(B) the cognitive deficits interfere with independence in everyday activities

(C) the cognitive deficits do not occur exclusively in the context of delirium

(D) cannot be better explained by another mental disorder

Question 2

what is the DSM-5 criteria for minor neurocognitive disorder (MCI)

Answer 2

(A) evidence of modest cognitive decline from prior level of performance in one or more cognitive domains (complex attention, learning and memory, executive function, perceptual-motor, social cognition, language)
i) concern about mild decline in cognitive function
ii) modest impairment in cognitive performance preferably documented by standardised neuropsychological testing or in its absence another quantified clinical assessment

(B) the cognitive deficits interfere with independence of everyday activities

(C) the cognitive deficits do not occur exclusively in the context of delirium

(D) not better explained by another mental condition

Question 3

what are the various manifestations of dementia

Answer 3

i) cognitive: short term memory loss, word finding difficulties

ii) psychological: apathy, depressive sx

iii) behavioural: withdrawal from social engagement, disinhibition (inability to withhold an inappropriate or unwanted behaviour)

iv) sleep: rapid eye movement behaviour disorder

v) physical: gait impairment

Question 4

what are the types of dementia

Answer 4

i) AD
ii) vascular dementia
iii) lewy body dementia
iv) frontotemporal dementia
v) mixed type

Question 5

what type of testing is used to classify the stages of AD

Answer 5

mini mental state exam can determine the level of cognitive deficits (total score out of 30)

mild AD: 20-24
moderate AD: 10-19
severe AD: <10

Question 6

compare between AD and vascular dementia (pathologic characteristics, onset and course, early stage features)

Answer 6

pathologic characteristics: [AD] brain atrophy esp of mesial temporal lobe and histological hallmarks of senile plaques and neurofibrillary tangles [vascular dementia] visible infarcts and white matter lesions

onset and course: [AD] slow onset and gradual progression [vascular dementia] acute vascular event -> onset of cognitive impairment within mins/ days

early stage features: [AD] presenting sx typically short term memory loss [vascular dementia] evidence of cerebrovascular disease on MRI (neuroimaging), vascular risk factors, prior stroke or vascular events, focal neurologic deficits consistent with stroke

Question 7

what are the risk factors of dementia (non modifiable and modifiable)

Answer 7

non modifiable: age (5-10% for >65, 50% for >85), females, ethnicity (black, hispanic), genetics (apolipoprotein E APOE4 gene)
*gene not routinely tested

modifiable: HTN, DM, binge drinking, smoking, limited physical activity, obesity, depression, hearing loss

Question 8

what are the components for the clinical evaluation of dementia

Answer 8

1. medical hx
2. outpatient or bedside cognitive examination
3. neuropsychological testing if needed
4. etiology determined based on: medical hx (neurologic, general medical, family), physical examination (neurological signs eg. cognitive impairment, focal signs, parkinsonism; pertinent systemic signs eg. for vascular and metabolic diseases), neuropsychological testing
5. lab testing (thyroid func and vitB12, other testings as indicated such as for metabolic, infectious, autoimmune and other etiologies)
6. structural brain imaging using CT or MRI (for AD there is generalised or focal cortical atrophy usually asymmetric and is hippocampal atrophy; vascular contributions like infarcts or white matter lesions; frontal lobe or anterior temporal lobe atrophy for frontotemporal dementia; other abnormalities like brain mass eg. tumor and hydrocephalus)

Question 9

what are eg. of brief cognitive screening tools and what are their scorings like

Answer 9

1. mini mental state exam (MMSE)
   mild AD if 20-24/30
   moderate AD if 10-19
   severe AD if <10
2. montreal cognitive assessment (MoCA)
   mild cognitive impairment if 18-25
   moderate if 10-17
   severe if <10

Question 10

what is the dosing regimen like for AChEIs (titration and monitoring)

Answer 10

i) slow titration over 4-8w to reach target dose and minimise s/e
ii) if s/e encountered, lower dose temporarily (days/weeks) before reescalating more slowly and monitor for recurrence of s/e
iii) if not discontinue and choose a diff AChEI
iv) monitoring involves caregiver feedback (slight improvements in day-to-day life) and routine cognitive tests (MMSE, MoCA)

Question 11

when is memantine considered and what is its moa and monitoring

Answer 11

memantine considered for moderate to severe AD or if pt cannot tolerate AChEIs

monitoring: caregiver feedback and routine cognitive tests

Question 12

what are the c/i for AChEIs

Answer 12

c/i in bradycardia

Question 13

what are the nonpharmacotx for dementia

Answer 13

i) cognitively stimulating activities
ii) physical exercise
iii) social interaction with others
iv) healthy diet eg. mediterranean diet (high in green leafy vege)
v) adequate sleep (uninterrupted and sufficient hrs)
vi) proper personal hygiene
vii) safety incl inside home and outside
viii) medical and advanced care directives
ix) long term healthcare planning eg. living arrangements
x) financial planning
xi) effective communication eg. visual aids to communicate needs
xii) psychological health (by participating in personally meaningful activities)

Question 14

what is “BPSD” and its key characteristics

Answer 14

behavioural and psychological sx of dementia (BPSD)

spectrum of non cognitive and non neurological sx of dementia such as agitation, aggression, psychosis, depression and apathy

often an attempt by the pt to communicate

experienced by at least 80% of dementia pts

can be extremely stressful for pt and caregivers

appropriate tx of BPSD can significantly improve QoL of pt and caregiver

Question 15

what is the first line tx for BPSD and what is the first step in starting tx

Answer 15

non pharmacotx

must identify target behavior (agitation and aggression, depression, anxiety, apathy, psychotic sx, wandering, nocturnal disruptions)

Question 16

what is the non pharmacotx for BPSD

Answer 16

1. agitation and aggression: underlying causes (depression, unmet needs, boredom, discomfort, perceived threat), environmental or management modifications, non specific calming and positive experience interventions like music or touch therapy
2. depression: CBT, exercise, social connection and engaging activities; if more severe then need clinician input
3. apathy: activities that are enriching and stimulating
4. anxiety: identifying and eliminate trigger, maintain structure and routine and reduce the need for stressful decision making, music and CBT has the greatest amount of evidence in showing benefit
5. psychotic sx: identify excessive sensory stimulation or lack of it, use memory aids or distractions
6. wandering: consider how to make wandering safe eg. supervised walks, secured space to roam, exercise equipment, GPS; identify purpose to the wandering (bc can have benefits like pt recognises still has autonomy)
7. nocturnal disruptions: assess for underlying cause incl thirst or hunger, restrict caffeine in the evening, limit fluid intake hrs before bed, establish night time routine, minimise noise and light intrusion, ensure adequate stimulating activities during daytime

Question 17

how to differentiate apathy from depression

Answer 17

apathy can be distinguished from depression by the absence of sadness and other signs of psychological distress

Question 18

what are the factors that may be contributing to BPSD (medical, pharmacological, environmental or social)

Answer 18

i) medical: depression, anxiety, delirium (may be due to infection, metabolic disturbances, drug toxicity, substance withdrawal), untreated pain, infection, dehydration or hypoNa, constipation or urinary retention, fatigue, hearing or visual impairment

ii) pharmacological: drugs w anticholinergic effect (TCAs), ASM, systemic corticosteroids esp high doses, drugs w sedative effect (benzo, opioids, antihistamines), anti-parkinsonian meds

iii) environmental or social: unfamiliar environment, separation from family, noise, crowding, lack of privacy, difficulty finding facilities, difficulty accessing outdoors, lack of space to move around, perceived lack of security, lighting, under or overstimulation, withdrawal from alcohol or drug, loneliness, difficult relationship with carer

Question 19

what are the pharmacotx for dementia and what are the indications to start/ restart and monitoring

Answer 19

not first line

should be prescribed for target sx or behaviours

only considered once potentially reversible causes have been excluded and non pharmacotx have been trialled unless there is an immediate risk to the pt or others or pt is very severely distressed

if used, always in combi w non pharmacotx

initiated as a trial and not prescribed indefinitely without need

review response to tx, dose and s/e at least q3m

routinely withdrawn, slowly, after 3m of improved sx unless severe or due to comorb psychiatric disorder like MDD or bipolar

restarted at lowest effective dose if sx return following a withdrawal and schedule further trial withdrawal in 3-6m

Question 20

what are the options for pharmacotx for BPSD (list the eg. for each drug class)

Answer 20

1. SSRIs: effective for depression and anxiety (eg. citalopram shown to reduce agitation and may improve other sx like delusions)
2. TCAs: generally not prescribed bc anticholinergic effects may further disrupt cognition
3. antipsychotics: only if aggression, agitation or psychotic sx causing severe distress or immediate harm to pt or others or if has preexisting comorb mental illness where antipsychotics indicated (only modestly effective in managing BPSD and high efficacy variability between pts; unlikely beneficial for wandering, social withdrawal, and sx closely related to clear environmental triggers)

Question 21

what are the main concerns with giving antipsychotics to tx BPSD

Answer 21

in elderly, all antipsychotics assoc w incr risk of stroke, CV events and excess mortality over a relatively short time frame

Question 22

what are the various care coordination community resources for dementia