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Semester 2 YEAR 3 - Lecture Notes > Week 8 - All dementias and The Treatments > Flashcards

Week 8 - All dementias and The Treatments Flashcards

1
Q

Dementia Background INFO

A

Dementia is clinical syndrome where cognitvie function is affceted leading to deterioration in ability to perform daily activities

  • Progressive, incurable disease
    - treatment only target sympotms
    - early diagnosis + management improves outcomes
  • Affects more women
  • Disease of older people (>65 yo)
  • In dementia cognitive function (memory, language, attention, descion-making, learnig) declines quicker than normal ageing
  • Expected to live 7-8 more years once diagnosed with dementia
  • Developing cognitive impairments is a risk factor for alzheimers
    - AD = most common type of dementia
  • ONLY start seeing signs of cognitive impairment approx. 10 years
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2
Q

What is the general cause of dementia

A

Loss of cholinergic neurones = less Ach is released into synpase = cognition issues

Loss of dopanergic neurones = less dopamine released = motor sympotms

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3
Q

List the types of dementia

A
  1. Alzheimer’s Dementia (AD)
  2. Vascular dementia
  3. Mixed Dementia
  4. Lewy body Dementia
  5. Fronto-temporal dementia
  6. Parkinson’s disease dementia
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4
Q

What are the CORE symptoms of dementia

A
  • Memory loss (occurs first)
  • Disorientation (i.e. lost)
  • Loss of concentration / attention
  • Impaired decision making
  • Speech issues
  • Swallowing difficulties
  • Incontinence
  • Mobility issues

NOTE: Symptoms differ amongst diff. dementias

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5
Q

What are the symptoms of Vascular Dementia (VD)

A
  • Have physical symptoms
    • slurred speech
    • dizziness
    • difficulty performing motor tasks
    • unable to recognise things
  • Memory is better
  • Emotioanl instability (depression)
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6
Q

What are the symptoms of Alzheimer’s Dementia (AD)

A
  • Memory impairment is most PROMINENT feature
    • memory loss
    • disorientation
    • misplacing things
    • confusion
  • Problems perfoming ADL (washing, dressing, eating)
  • Loss of speech / Language
  • Mood and behaviour

NOTE: main symptoms relate to cognition

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7
Q

What are the symptoms of Lewy Body Dementia (DLB)

A
  • Cognition slows (KEY feature) + fluctuates
    • confusion
    • attenion issues
    • hallucinations (visual or auditory)
    • tremors
  • Motor function declines
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8
Q

How is dementia diagnosed

Inc. 3 stages of dementia severity

A
  1. Using ICD-11
    - need to HAVE 2 CORE sympotms
    - marked cognitive impairment that interferes with personal life / daily function
    - behavioral changes
  2. Referral to SPECIALIST who perform test including cognition tests

DIAGNSOSIS:
- blood tests to rule out other cuases
- i.e. anaemia, hypothyrodism
- conduct patient + family history
- check thyroid, vit. B12, folate levels etc.
- CT and MRI scan to rule out tumours
- when diagnsoed need to inform DVLA

3 Stages:
1. Mild
- short term memory loss
- core ADL maintained
- higher level functions are impaired

  1. Moderate
    - worsening cogntion
    - core ADL affected
  2. Severe
    - long term memory loss
    - become dependat + require 24hr care

ADL = activities of daily living

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9
Q

List the 3 cognition tests used to diagnose dementia

+ factors affecting their performance / results

A
  1. Mini Mental State Examination (MMSE)
  2. 7 Minute Screen
  3. 6 Item Cognitive Impairment Test
    - most commonly used

FACTORS:
- literacy / numeracy level
- may not understand english
- can’t read, speak, write
- medication
- illnesses / mental health
- sensory impairment
- issues with hearing, seeing

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10
Q

Explain how the MMSE works

A
  • Say 3 words to patient and ask them to repeat them back
  • Do this 5 times (but only count 1st try)
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11
Q

Explain how the ‘7 Minute Screen’ works

A
  • Ask patient to state the correct day, month, year, date, time
  • Score points based of how close they are to correct answer
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12
Q

Explain how the ‘6 Item Cognitive Impairment Test’ works

MUST KNOW THIS

A

Inverse Score is used (total score = 28):
- Score 0 points if question answered correctly
- Score 2 points = 1 error
- Score 4 points = >1 error
Scores of 0–7 = normal
Scores of 8 or more = significant + may indicate cognitive impairment

6CIT = most commonly used
Consists of 6 questions inc:
- temporal orientation (time, date, day)
- remembering an address (tests short term memory)
- counting backwards from 20 (test attention)
- stating the months of the year in reverse (assess memory + cognitive flexibility)

A computerized version of the 6-CIT with automated scoring is available on some general practice computer systems.

NOTE: based on results of this test GP will refer to memory clinic where further diagnostic tests are done

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13
Q

Treating dementia BASICS

A
  • Treatment is NOT curative
  • Invovle them in decisions
  • Speak slowly + clearly, offer patient simple chocies (yes / no)

AIM:
- delay patient going into care home
- improve independance
- ease carer burden

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14
Q

What drugs should be avoided in dementia

A
  1. Anticholinergics (antimuscarnics)
    - ↑ risk of developing dementia
    - ↑ risk of cognitive impairment
    - anticholinergic burden
  2. Antidepressants
  3. Antipsychotics
  4. Opiates
  5. BDZs
  6. Sedating antihistamines
    - penetrate BBB = can cause cognitive impairment, hallucinations
  7. Alpha blockers
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15
Q

List the non-pharmacological treatments

A
  1. Lifestyle modification
    • stop smoking / alcohol, weight loss, CV risk factors, healthy diet, social life, education
  2. Having routine / familiarity
    • reminder charts, ‘remember rooms’
    • orientation boards (know time / date)
    • colours for signs = stand out
    • ‘this is me’ documents = get to know patient + stimulate reminiscing convo.
  3. Treat co-morbidities
    • e.g. depression, anxiety, sleep disorder
  4. Cognitive Stimulation Therapy (CST)
    • group based therapy
    • improves memory + thinking ability
  5. Sensory stimulation
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16
Q

List the pharmacological options for treating dementia

NOTE: drug treatment only licensed for alzheimer’s

A
  1. Acetylcholinesterase inhibitors
  2. Memantine
17
Q

Explain the 2 pharmacological options for treating dementia

NOTE: drug treatment only licensed for alzheimer’s

A
  1. Acetylcholinesterase inhibitors
    • prolong level of function + improve symptoms
    • CAUTION: asthma / COPD, cardiac issues, renal / hepatic impairment, ulcer risk
    • SE: GI issues, incontintence, alertness, hallucination, dizziness, bradycardia (ALL self-limiting + seen early stages of treatment)
    • e.g. Rivastamine
      • MoA: form covalent bond with AChE (enzyme) inactivating it for 10 hours
    • e.g. donepezil, galantamine
      • do NOT form covalent bonds
  2. Memantine
    • NMDA (glutumate) antagonist
    • ↓ activity of glutumate
    • glutumate is dmaagining in dementia pathway
18
Q

Explain the cholinergic synapse

A
  1. ACh is released into synapse
  2. ACh activates receptors on post-synaptic membrane
  3. (Acetyl)Cholinesterase (AChE ~ enzyme) breaks down ACH
    • broken down ACh is taken up + recycled in pre-synaptic neurone
  4. When ADD AChE-I this inhbits enzyme = ACh levels in synapse remain high
    • boosts cholinergic activity in synapse = helps symptoms
19
Q

NICE Guidelines for treating AD

AD = alzheimer’s dementia

A

1st line (monotherapy):
- AChE-I for mild-moderate AD
- Memantine for severe AD

2nd line (combination)
- ADD memantine to AChE-I
- used in moderate or severe AD

OTHER:
- Memantine used in moderate AD (if contraindications to AChE-I / intolerable)
- AChE-I pick drug with cheapest cost + well tolerated by patient

REVIEW: every 6 months

20
Q

NICE Guidelines for treating ‘Vascular Dementia’ and ‘Lewy body Dementia’

AD = alzheimer’s dementia

A

Do NOT use AChE-I or Memantine in VD (unless patient ALSO has AD)
CAN use AChE-I or Memantine in LBD

AIM: is to prevent stroke
- treat / prevent hypertension

21
Q

AChE-i Treatment INFO

A
  • Drugs are available as geenrics BUT always use same formula + brand (dementia patients like familiarity)
  • some patient may not respond to one AChE-I = switch to another
  • do NOT STOP AChE-I unless making disease worse, intolerable SE etc.
  • do NOT give with food (absorption delayed + absortpion rate ↓)
  • IMPORTANT patient takes medicine
    - covert adminstration may be required
    - switching formulations if unable to swallow

DOSING:
(start with low dose then titrate)
- galantamine (8mg) AND donepezil (10mg) = ↑ dose after 1 month
- memantine =↑ dose after 1 week
- rivastigmine (4mg) = ↑ dose after 2 week

22
Q

What are behavioural and psychological sympotoms of dementia (BPSD)

6 Key symptoms groups

A

Affects 90% of people suffering with dementia
- ↓ QoL
- can last from a few weeks to longer
- usually seen in response to an activity
- more likely to be admitted to nursing home

6 Key Symptom Groups:
1. Mania
- euphoria
2. Psychosis
- hallucinations, delusions
3. Depression
4. Agitation
- restlessn, pacing, repetitive actions
5. Apathy
- lack of; interest, motivation
6. Agression

23
Q

How can we treat / manage BPSD: non-pharmacological

A

Rule out other causes BPSD
- Use PAIN acronym
- Physical problem? (pain, infection etc.)
- Activty related? (bored, washing)
- Iatrogenic? (SE of meds)
- Noise / environemnt? (lights)

TREATMENT:
- talking them down
- distracting them
- massage
- pet therapy
- music therapy
- bright light therapy (help sleep)
- psychoeducation (for carer / family)

24
Q

How can we treat / manage BPSD: pharmacological

A

1st line = non-pharmacological methods

ONLY use medicines if causing SEVERE distress OR theres an IMMEDIATE RISK of harm

TREATMENT:
1. Antipsychotics
- avoid use of typical in parkinson’s and lewy body
- e.g. risperidone or olanzapine
- has poor tolerability, bad SE = need to discuss benefits + harm before starting
- used for limited period at lowest dose
- treatment ONLY continued if seeing improvement

  1. Anti-depressants
    - only used if treating pre-exisiting depression

Semester 2 YEAR 3 - Lecture Notes (22 decks)

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