Dementia

Question 1

What is the prevalence of Dementia?

Answer 1

6-16% >65yrs, 10 yr life expectancy

Question 2

What increases the risk of Dementia?

Answer 2

CVA/TIA, brain injury, late onset psychiatric, untreated OSA, delerium, parkinson’s

Question 3

What are the ADLs/IADLS

Answer 3

DEATH: dress/eat/ambulate/toilet/hygiene

SHAFT-M: shopping/social, Housework, Accounts, Food prep, telephone, meds

Question 4

On physical exam what would you look for?

Answer 4

parkinsonianism: resting tremor, bradykinesia, rigidity, shuffled, stooped, dim arm swing
ataxia - cerebella atrophy
ssx stroke: focal/lateralizing ssx (vascular dementia)

Question 5

What is the DSM V criteria for Dementia?

Answer 5

Decline from previous level of fxn in 1 or more domains.

domains: attention, memory/learning, language, spatial/motor, executive, social

Question 6

What are the types of Dementia (MAJOR NEUROCOGNITIVE DISORDER?)

Answer 6

MCI versus Dementia
MCI- a modest cognitive decline not impacting IADLs, 2/3 eventually progress
Alzheimer’s: most common, gradual, normal neuro, STM loss initial, amnestic
Vascular: abrupt, stepwise, CVD risks
FTD: behaviors + (disinhibition, apathy, hyperorality, preservation, inertia), loss exec fxn, social issues
Lewy Body: HALLUCINATIONS, fluctuating cognition, soon extrapyramidal sx, REM sleep disorder

Question 7

Do you screen for dementia?

What are 2 screening tests for MND (major neurocog disorder)?

Answer 7

No! only investigate symptomatically. Do not screen asymptomatic.

1. MMSE
2. MCI
   working memory (digit span and WORLD) - frontal
   episodic memory (recall date/events) - temporal/hippocampus
   visuospatial (cube, clock, pentagon) - parietal
   Executive fxn ( clock, trails B, F words) - frontal

Question 8

What safety concerns may you have for someone with dementia?

Answer 8

Driving (mod to severe no driving), report to MTO
guns
stove
money
wandering
abuse

Question 9

What lifestyle recommendations list 7 for dementia?

Answer 9

Include caregiver and burnout

1. refer to Alzh society
2. ACP discussion
3. safety- driving, moola, smoke detector, etc)
4. healthy diet- mediteranian
5. smoking cessation
6. exercise program (aerobic/resist/tai chai)
7. elim narcotics/anticholinergics/benzos
8. blister packs for compliance
9. encourage social interaction
10. Sleep and hygiene

Question 10

What 1 test would you order prior to starting pharma on a pt with dementia?

Answer 10

EKG prior

avoid AChei if LBBB, 2/3rd degree HB, SSS, bradycardia)

Question 11

Do you treat mild cognitive impairment?

Answer 11

No- lifestyle, no pharm

Question 12

What pharma options are there for MND? Give 3

Answer 12

AChei - if no benefit/SE then stop, slows decline by 2.4 pts/6m
1. Donepazil - aricep
2. Rivastigmine - Exelon ( parkinsons/cerebrovascular)
3. Galantamine - Reminyl
NMDA-
4. Mematidine

For atypical depression
citalopram
Do not use Valproic acid! for agitation/aggression

Question 13

What are the best tx for each type of depression?

Answer 13

FTD- non pharm, SSRI for compulsions, atypical antipsychotics for aggression
Alz- 3 AChei (rivastigmine, aricept, galantimine) + memantidine
Vascular - manage HTN, smoking, lipids, sedentary, AChei
Lewy body- Rivastigmine, AVOID neuroleptics (haldol/ripseridone)

Question 14

When to refer?

Answer 14

FTD, Lewy, Parkinsons, young <65, rapid progression within 12 m appearance first cognitive ssx

Question 15

What inx to order with MND?

Answer 15

cbc, TSH, Lytes, B12, Ca, Albumin, FBG, lipids
EKG prior to tx
CT non contrast head - or MRI (preferred)

Question 16

What is your differential for MND?

Answer 16

D- diabetes, drugs, delerium, depression
E- epilepsy, eyes, ears
M- Migraine, multi infarct, metabolic (FBG, Na, TSH, Ca)/Meds
E- ethanol (folate and b12) 
Neurologic def disease (Bleeds, encephalitis, abscess, meningitis
Nutrition 
TIA/tumours/trauma
infection/insulin
Abscess/alcohol