Dementia

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Author:
timothy.pdlt
ID:
212352
Filename:
Dementia
Updated:
2013-04-09 04:07:41
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dementia
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Description:
therapeutics, side-effects, drug interactions
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  1. GoT of dementia Tx
    • alter disease progression
    • treat s/s
    • alleviate caregiver burden
    • minimize ADRs
  2. Epidemiology of dementia
    • incidence: 7/1000 (65-69y/o), doubles q5years, then 120/1000 (85-89y/o)
    • prevalence: 8% in elderly
    • cost: 1.5x more
  3. Etiology of dementia
    • Alzheimer's disease
    • vascular dementia
    • frontotemporal lob
    • dementia with Lewy bodies
    • PD
  4. Treatable factors of dementia
    • vitamin B12 deficiency
    • hypothyrodism
    • depression
  5. Drug-induced dementia
    • polypharmacy
    • anticholinergics
    • antipsychotics
    • sedative/hypnotics
    • narcotics
    • PHT
    • CC
    • NSAIDs
    • digitalis
  6. DSM-IV-TR diagnostic criteria for dementia
    • 1. memory impairment
    • 2. >1 of the following: aphasia (language disturbance), apraxia (impaired motor despite intact motor function), agnosia (impaired recognition despite intact sensation), disturbed executive functioning (planning, organizing)
    • 3. cognitive deficit impairs social or occupational function
    • 4. gradual onset and progressive cognitive decline
    • 5. no s/s during delirium
  7. Clinical features of dementia
    • 1. ADLs: self-care vs. instrumental
    • 2. behavior: agitation, apathy, anxiety, depression, irritability, delusions, hallucinations
    • 3. cognition: memory, word finding, repetitiveness, executive function
  8. Diagnostic scores for dementia
  9. Pharmacotherapy options for dementia
    • 1. cholinesterase inhibitors: donepezil (I= mild-severe), rivastigmine (I= mild-mod), galantamine (I=mild-mod)
    • 2. NMDA R antagonist: memantine (I= mod-severe)
    • 3. gingko biloba: questionable efficacy
    • 4. estrogens: epidemiological data but disappointing trials
    • 5. NSAIDs: epidemiological data but disappointing trials
    • 6. vitamin E 1000IU BID: one study showed delayed AD progression
  10. Tx options for AD dementia
    • all cholinesterase inhibitors are modestly efficacious with mild-mod
    • memantine has small benefit on cognition, function, and behavior in mod-severe AD
    • ChEI+memantine is rational esp. in mod-severe
    • results of Tx of severe AD (MMSE<10m, GDS=6-7) is totally variable
    • *switching from donepezil to rivastigmine patch= wait 5-7days
  11. What is vascular dementia (VaD)?
    • due to cerebrovascular hemorrhage or ischemia
    • etiology: HTN, DM, increased lipids, embolism
    • Hachinski ischemic scale is used to differentiate VaD from AD (<4= AD, >7= VaD)
  12. Characteristics of vascular dementia
    • abrupt onset
    • plateaus of stable function
    • change in gait
    • seizures
    • patchy cognitive deficits
    • urinary incontinence
  13. Tx options for VaD
    Tx may be modestly beneficial

    • efficacy for global function @24weeks
    • 1. donepezil: NNT=11
    • 2. galantamine: NNT=7
    • 3. rivastigmine: insufficient evidence
    • 4. memantine: NSS NNT=13
  14. Characteristics of dementia with Lewy bodies (DLB)
    • fluctuating cognitive impairment
    • recurrent visual hallucination
    • Parkinsonism
    • dementia occurs <1year after Parkinsonian s/s onset
  15. Tx optiond for DLB
    • ChEIs provide benefit for cognition and behavior but increase the risk of Parkinsonism
    • 1. rivastigmine: improved behavior with no change in Parkinsonism with mild-mod DLB
    • 2. galantamine: improved behavior and global function with mild-mod DLB
  16. Tx options for PD dementia
    • ChEIs= increase risk of Parkinsonian s/s
    • 1. rivastigmine improves cognition nad global function but significantly more N/V/tremor
  17. Characteristics of frontotemporal dementia (FTD)
    • 1. behavioral changes: verbal and social disinhibition, emotional blunting
    • 2. language impairment: progressive aphasia
    • 3. relative memory sparing
  18. Tx options for frontotemporal dementia (FTB)
    • ChEIs are not effective for behavioral s/s
    • 1. donepezil: worsen FTB behavior
    • 2. rivastigmine: improve behavior but data from open-label study
    • 3. galantamine: ND
  19. Duration of dementia Tx
    ChEIs can slow cognitive decline over 4-5years

    • if d/c, then taper x2weeks
    • monitor upon d/s and consider reinstating withing 2-6weeks if breakthrough s/s (decrease in cognition/function, behavioral changes)
  20. CI and precautions of ChEIs
    • epilepsy (dementia+ChEIs= lower seizure threshold)
    • history of seizure/DI
    • hepatic/renal disease
    • significant bradycardia
    • significant bronchospastic disease
    • PUD
    • obstructive urinary disease
  21. S/E of ChEIs
  22. Management of ChEIs S/E
    • d/c if disabling or dangerous
    • decrease dose if minor s/e and can retry dose after 2-4weeks
    • antiemetics may have anticholinergic effects
  23. CI and precautions of memantine
    • seizure history
    • cardiovascular disorder
  24. S/E of memantine
    • 1. CNS (6%): dizziness, confusion, HA
    • 2. GI: N/V (3%), constipation (5%)
  25. DI of memantine
    urinary alkalizers (carbonic anhydrase inhibitors)= decrease memantine clearance
  26. Dementia Tx dosing regimen
  27. Behavioral and psychological S/S of dementia (BPSD)
    personality change, depression, agitation, misidentification= common
  28. BPSD that are medication responsive
    • anxiety
    • restlessness
    • sadness
    • insomnia
    • feeling withdrawn
    • verbal/physical aggression
    • delusions and hallucinations
    • sexually inappropriate behavior
  29. BPSD that are unlikely to be medication-responsive
    • wandering
    • inappropriate dressing
    • repetitivenss
    • hiding/hoarding
    • eating inedibles
    • inappropriate isolation
    • removal of restraints
  30. Progression of BPSD
    • 1. MMSE 25: depression, apathy, withdrawal
    • 2. MMSE 15: depression, delusions, agitation, wandering, insomnia
    • 3. MMSE 5: agitation, insomnia
  31. Drug Tx for BPSD
  32. Harms of antipsychotic Tx in dementia patients
    • EPS
    • impaired cognition
    • increased hospitalizations
    • death (HR= 1.54)

    *avoid QTP in DLB due to increased Parkinsonian s/s)
  33. Alzheimer's Drug Therapy Initiative (ADTI)
    • coverage only if:
    • 1. MMSE 10-26
    • 2. GDS 4-6
    • 3. have ability or social support to properly take medication
    • 4. no CI

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