-
What is delirium?
- an acute or subacute change in cognition and attention or confusion; abnormal mental state
- NOT A DISEASE
-
What is mild cognitive impairment?
- a transitional state b/w the cognition of normal aging and mild dementia without functional impairmentNot a dementia
-
What is dementia?
- acquired deterioration in cognition that impairs activities of daily living that results from various central neurodegenerative and ischemic processes
- may affect memory, language, visuospatial ability, calculation, judgement, and/or problem solving
- neuropsychiatric and social deficits may be present: depression, withdrawal, hallucinations, agitation, insomnia, and disinhibition
-
When can dementia not be diagnosed?
when delirium is present
-
What are the modifiable risk factors for delirium?
- hearing or vision impairment
- immobilization
- meds
- concurrent illness (infection, dehydration)
- electrolyte abnormalities
- surgery
- environment (ICU, noise, people)
- pain
- emotional distress
- sleep deprivation
- acute neurological disorder (stroke)
-
What are the non-modifiable risk factors for delirium?
- dementia or cognitive impairment
- age >65yo
- comorbidities
- male gender
- renal or hepatic disease
- hx of delirium
- hx of CVA/neurological disease
- hx of falls or gait disorder
-
What are the nonpharmacological tx for delirium?
- minimize sensory impairment
- reorient the pt - play cards or something to keep them thinking
- correct dehydration
- early mobilization
- avoid use of physical restraints and urinary catheters when possible
- environmental interventions:
- limit room and staff changes
- keep room quiet
- low level lighting at night
- minimize night-time interruptions
-
When do we use meds to tx delirium?
when symptoms compromise safety or interfere with medical care
-
What drugs are used to treat delirium?
- neuroleptics (lowest dose for shortest duration)
- e.g. Haldol <3mg/d
-
What is the first sx of Alzheimer's dementia (AD)?
memory loss
-
What ist he first sx of frontotemporal dementia?
- apathy
- poor judgement/insight/speech/language
- hyperorality
-
What is the first sx of dementia of Lewy Bodies?
- visual hallucinations
- REM sleep disorder
- delirium
- Capgras' syndrome
- parkinsonism
-
What is the first sx of vascular dementia?
- often, but not always, sudden
- variable
- apathy
- falls
- focal weakness
-
What effect does Alzheimer's dementia (AD) have on mental status?
episodic memory loss
-
What effect does frontotemporal dementia have on mental satus?
- frontal/executive
- language
- spares drawing
-
What effect does dementia of the Lewy Bodies have on mental status?
- drawing and frontal/executive
- spares memory
- delirium prone
-
What effect does vascular dementia have on mental status?
- frontal/executive
- cognitive slowing
- can spare memory
-
What effect does Alzheimer's dementia (AD) have on neuropsychiatry?
initially normal
-
What effect does frontotemporal dementia have on neuropsychiatry?
- apathy
- disinhibition
- hyperorality
- euphoria
- depression
-
What effect does dementia of the Lewy Bodies have on neuropsychiatry?
- visual hallucinations
- depression
- sleep disorder
- delusions
-
What effect does vascular dementia have on neuropsychiatry?
-
What effect does Alzheimer's dementia (AD) have on neurology?
initally normal
-
What effect does frontotemporal dementia have on neurology?
- d/t PSP/CBD overlap
- vertical gaze palsy
- axial rigidity
- dystonia
- alien hand
-
What effect does dementia of the Lewy Bodies have on neurology?
parkinsonism
-
What effect does vascular dementia have on neurology?
- usually motor slowing
- spasticity
- can be normal
-
What are the risk factors for Alzheimer's dementia (AD)?
- family hx
- age >65 (affects 20-40% over 85yo)
- few years of formal education
- late-onset depression
- mutations on chromosomes 1, 14, 21
- Down Syndrome
- Apo E4 presense on chromosome 19
- vascular disease risk factors (diabetes increases risk x 3)
- head injury
- decreased brain reserve capacity
-
What is correlated with early onset AD?
- genetic mutations on chromosomes 1, 14, 21
- chromosome 1 produces presenilin 2
- chromosome 14 produces presenilin 1
- (these encode for proteins involved in amyloid precursor protein - APP)
- Chromosome 21 encodes for APP = production of B-amyloid protein
-
What is the average survival for AD?
8-10 years after onset of symptoms (up to 20)
-
What problems does AD predispose pts to?
-
What is a normal scale progression for untreated AD?
- increase in ADAS-COG:
- 4pts over 6 mos
- 7pts over 1 yr
- decline in MMSE:
- 2-4pts per yr
-
What pt factors is the MMSE score subject to?
- cognitive level
- ability to see
- ability to hear
-
What are the stages of the MMSE?
- 27-30 = mild cognitive impairment
- 18-16 = mild AD
- 10-17 = moderate AD (2-8y from sx onset)
- 0-9 = severe AD (6-12y from sx onset)
-
What is the MMSE?
- 19 items
- 30pts
- low score means high impairment
-
What is the ADAS-cog?
- 11 items
- 70pts
- high score means high impairment
-
What is the mini-cog?
- 2 items
- 5pts
- high score means high impairment
-
When should you expect to see benefit from tx of AD?
3-6 mos
-
What classifies benefit from tx in AD?
- < 2pt decline on MMSE
- 4pt increase on ADAS-cog
-
What are the tx goals for Alzheimer's dementia (AD)?
- treat cognitive difficulties and preserve pt fx as long as possible
- tx psychiatric and behavioral consequences of disease
- When slowing cognitive decline is no longer a goal, d/c tx with cholinesterase inhibitors (CI) - taper off
-
What are the nonpharmacological tx for AD?
- educate pt and family on course of illness and prognosis, available tx, legal issues, end-of-life issues
- minimize environmental triggers and redirect pt attention (noise, background distraction, personal discomfort)
- use memory aids (lists, calendars, labels)
- short-term tasks - avoid complex tasks
- exercise helps with anxiety and agitation
-
What meds can increase sx of AD?
- anticholinergics
- BZD
- sleep aids
- APs
- narcotic analgesics
- muscle relaxants
- ADs
- antiHTN
- antiemetics
- urinary antispasmodics
- corticosteroids
- hypoglycemic agents
-
What cholinesterase inhibitors (CI) are used for AD?
- tacrine (Cognex)
- donepezil (Aricept)
- rivastigmine (Exelon)
- galantamine (Razadyne)
-
Which CI is approved for all 3 forms of AD (mild, moderate, and severe)?
donepezil (Aricept)
-
What are the SE of CI?
- NVD (may improve after a few wks)
- dizziness
- urinary incontinence (no help for this)
- bradycardia/syncope
- salivation
- sweating
-
What conditions should be watched closely when treating AD with CI?
- bradycardia
- sick sinus syndrome
- supraventricular cardiac conduction abnormalities
- PUD
- bladder obstruction
-
Which CI has the easiest dosing schedule?
donepezil (Aricept)
-
What should be done to minimize SE from CI?
- titrate slowly
- take with food
-
What should be done if >7 doses of CI are missed?
retitrate the drug
-
How long must you be on donepezil (Aricept) 10mg before titrating to 23mg?
at least 3mos
-
What added MOA does rivastigmine (Exelon) have that the other CIs don't?
inhibits butyrylcholinesterase as well as ACh-ase
-
Which CI has the most GI SE?
rivastigmine (Exelon) - titrate over 4-6 wks
-
What added SE does rivastigmine (Exelon) have that the other CIs don't?
dose-dependent wt loss
-
Which CI has a patch formulation?
rivastigmine (Exelon)
-
What added MOA does galantamine (Razadyne) have that the other CIs don't?
enhances the action of ACh on nicotinic receptors as well as reversible ACh-ase inhibition
-
What N-Methyl-d-Aspartic acid (NMDA) antagonists are used to tx AD?
memantine (Namenda)
-
What is the MOA of memantine (Namenda)?
blocks glutamatergic neurotransmission by non-competetively blocking NMDA receptors
-
What levels of AD is memantine (Namenda) approved for?
moderate to severe
-
Which drugs are approved to treat severe AD?
- donepezil (Aricept)
- memantine (Namenda)
-
What may be as effective as adding memantine (Namenda) to donepezil (Aricept) 10mg tx for AD?
donepezil (Aricept) 23mg
-
What are the SE of memantine (Namenda)?
- constipation
- confusion
- dizziness
- HA
- hallucinations
- HTN
- cough
-
What issues should be watched closel when instituting memantine (Namenda) tx in AD?
- severe renal impairment
- severe hepatic impairment
- dietary or medical changes that alkalinize the urine - decreases renal excretion of memantine (Namenda)
-
Which Alzheimer's drug is in the form of an oral disintegrating tablet?
donepezil (Aricept)
-
What added SE does donepezil (Aricept) have that other CIs don't?
- musculoskeletal SE
- insomnia
-
When should the pt be evaluated for SE when being tx for AD?
after 2-4 wks
-
When should the pt be evaluated for effectiveness when being treated for AD?
q 6 mo
-
What is the treatment for mild cognitive impairment?
none are approved yet
-
What is typical for vascular dementia pts to have in their med hx?
-
What is the tx for vascular dementia?
- focused on underlying cause (HTN, atherosclerosis, DM)
- CIs are being studied (off-label)
- memantine (Namenda) (off-label)
-
What is a major differentiating sx of Lewy Body dementia?
fluctuating cognitive fx (good and bad days)
-
What is the onset of vascular dementia?
- abrupt onset
- stepwise progression
-
What is the onset of Lewy Body dementia?
- insidious onset
- rapid progression
-
What is less common in Lewy Body dementia?
neurofibrillary tangles
-
What are the tx of Lewy Body dementia?
- rivastigmine (Exelon) - best evidence and safety
- donepezil (Aricept) - off-label
- levodopa/carbidopa (Sinemet) may be used
-
Which dementia is characterized by moderate progression?
frontotemporal dementia
-
What are the tx for frontotemporal dementia?
-
How is Parkinson's disease associated with dementia?
cognitive impairment in late stages
-
What are the tx for dementia sx of Parkinson's?
- SSRIs
- donepezil (Aricept)
- rivastigmine (Exelon) - best safety and efficacy, but still only modest benefit
- clonazepam for REM sleep disturbance
-
What should not be used to tx dementia in Parkinson's?
- Olanzapine (Zyprexa) may exacerbate Parkinson's
- memantine (Namenda) may exacerbate psychiatric sx or cognition
-
What is the effect of estrogen on dementia?
- associated with development of dementia and mild cognitive impairment
- may increase sx
-
Which drugs have studies that show a possible protective effect against dementia?
- NSAIDs
- HMG-CoA reductase inhibitors
-
What is first line tx for behavioral sx associated with dementia?
nonpharmacologic tx - identify the triggers and adapt the environment
-
Which are the most common behavioral sx associated with dementia?
- psychotic sx
- inappropriate or disruptive behavior
-
When are pharmacologic tx indicated for behavioral sx associated with dementia?
- when sx are distressing to pt or caregiver
- interfere w/ functioning or delivery of care
- poses a danger to self or others
-
Which is the only drug which shows significant improvement in dementia-related psychosis?
risperidone (Risperdal)
-
Which drugs show improvement for neuropsychiatric sx of dementia?
- risperidone (Risperdal)
- aripiprazole (Abilify)
-
What are the doses of FGAs used to tx psychosis of dementia?
haloperidol (Haldol) 0.25mg/d
-
What are the doses of AAPs used to tx psychosis of dementia?
- risperidone (Risperdal) 0.5mg/d
- olanzapine (Zyprexa) 2.5mg/d
- quetiapine (Seroquel) 25mg/d
- aripiprazole (Abilify) 10mg/d
-
What are the doses of SSRIs used to tx anxiety and depression of dementia?
- citalopram (Celexa) 10mg/d
- escitalopram (Lexapro) 5mg/d
- sertraline (Zoloft) 25mg/d
-
What are the SE of APs in elderly pts with dementia?
-
What tx are in development for dementia/Alzheimer's?
- vaccines targeting B-amyloid peptide
- monoclonal antibodies for passive
- amyloid modulators
- immunization:
- bapineuzumab - phase III trials
- solanezumab
|
|
