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what is the MMSE
screening tool for cognitive impairment; NOT intended to diagnose AD/dementia
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MMSE scoring
- normal 24-30
- mild 17-23
- moderate 10-16
- severe < 10
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what is the Blessed Dementia Scale
clinical rating scale with 22 items that measure changes in performance of every day activities
based on info from relatives or friends
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Evaluation tools of dementia
- cognition (MMSE, ADAS)
- depression (depression scale)
- function (ADLs and IADLs)
- Others (CIBIC, NPI, SIB)
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ADLs
- activites of daily living which measures self care tasks such as;
- personal hygiene and grooming
- dressing and undressing
- self feeding
- functional transfers
- bowel and bladder management
- ambulation
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IADLs
- instrumental activities of daily living;
- housework
- taking medications as prescribed
- money mgmt
- use of technology
- shopping for groceries
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what is dementia
a syndrome that exhibits impaired short and long term memory as its most prominent feature
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four major anatomical changes that causes dementia
- cortical atrophy
- degeneration of cholinergic and other neurons
- neurofibrillary tangles
- neuritic plaques
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clinical presentation of dementia
- cognitive deficits occurring PROGRESSIVELY
- -4 to 6 point drop in MMSE over 1 yr
- symptoms;
- cognition (memory loss, apraxia, agnosia
- non-cog (depression, psychotic symptoms
- functional behavior (IADLs and ADLs)
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medications that cause differential diagnosis
- anticonvulsants
- anticholinergic
- anxiolytics
-
donepezil brand name/dosing
- aricept
- initial dosing 5-10 (mild to moderate)
- -adjust q 4-6 wks
- 10-23mg for severe
- -adj q >=3mths
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how should donepezil be administered
HS w or w/out meals
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Rivastigmine brand name/dosing
- exelon
- PO; initial 1.5 BID adjust every 4wks
- -max dosing (6mg BID)
- patch; 4.6mg daily
- 9.5mg daily (max)
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rivastigmine administration
take with meals; patch-upper or lower back
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galantamine brand name/dosing
- razadyne
- initial dosing; IR-4mg BID increase q 4wks
- ER-8mg daily increase q 4wks
- -max dosing 24mg daily
-
razadyne max dosing for renal or hepatic impairment
16mg/day
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investigational agents used for AD
- estrogen
- NSAIDS
- MAOI
- gingko biloba
- vitamin E
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how to select pharmacotherapy
- dementia severity
- history of prior response
- AE profile
- Co-morbidities
- concomitant medications (DDI)
- ease of adherence (QD vs BID; dose form)
- Cost
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which dementia drug has the least amt of adverse effects
rivastigmine due to its metabolic pathway
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monitoring paramaters
- behavior
- mood
- bowel function
- cognitive function
- general function
- adverse effects
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when will small improvements in cognition and function be observable
at 4-6 wks
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when do you switch to another AChEI
after 12-24 wks if no improvement is seen (no need to try a third agent)
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what do you do if AChEI therapy is interrupted for more than a few days
re-titrate from the starting dose
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how can donepezil be administered if pt is having insomnia and vivid dreams/nightmares
AM dosing
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risk factors for VaD
- advanced age
- DM
- small vessel cerebrovascular disease
- HTN
- hyperlipidemia
- cigarette smoke
- alcohol use
- males>females
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clinical presentation of VaD
- -decline in cognitive impairment
- -personality and mood changes
- -early presence of gait disturbance, unsteadiness, unprovoked falls
- -urinary frequency, urgency, incontinence
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which drug is has shown clinical significance for treating VaD
aricept and namenda
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secondary prevention of VaD
- bloop pressure (CCB)
- Cholesterol
- DM
- antiplatelet therapy
- smoking cessation
- decrease or D/C alcohol use
- lifestyle modifications
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how to treat a pt with excessive worrying, sleep disturbances, rumination
- anxiety; trazodone, buspirone (if no insomnia)
- or short acting BZD, SSRI
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how to treat a pt with withdrawal, loss of appetite, irritability, restleness, sleep disturbances
Depression; trazodone, SSRI
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how to treat a pt with repeat questions, wandering, pacing
often unresponsive to medications; redirect pt activity
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how to treat a pt with delusions (often is of theft), hallucinations, misperceptions
psychotic behaviors; AAP (if w/ paranoid features), SSRI
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how to treat a pt with physical or verbal aggressivenes toward others, exvessive yelling and screaming
aggresive behaviors; anticonvulsant, such as divalproex or carbamazepine with AAP
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what is the CATIE-AD trial
pts w/ dementia and psychosis or agitated behavior should be treated with AAP
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what must you treat in pts with lewy body dementia
- cognition/memory: AChEI
- Parkinsonism: Levodopa/Carbidopa
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medications that cause pseudodementia
- psychotropics
- analgesics
- anti-hypertensives
- corticosteroids
- cimetidine
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things that cause pseudodementia depression
- self neglect
- insomnia
- anhedonia
- lack of effort on mmse
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