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Dementia Flashcards

Clinical tips (74 cards)

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1
Q

What is dementia?

A

A syndrome of acquired cognitive impairment that interferes with normal activities and function

Common causes include Alzheimer disease, vascular dementia, Lewy body dementia, and frontotemporal dementia.

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2
Q

Name the common causes of dementia.

A
  • Alzheimer disease (AD)
  • Vascular dementia (VD)
  • Lewy body dementia (LBD)
  • Frontotemporal dementia (FTD)

Dementia can also be a complication of Parkinson disease.

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3
Q

What does the DSM-5-TR classify dementia as?

A

Neurocognitive disorders (NCDs)

This classification includes conditions affecting cognition such as delirium and traumatic brain injury.

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4
Q

True or false: Dementias are almost always progressive.

A

TRUE

As dementia progresses, responsive behaviours may develop.

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5
Q

What are responsive behaviours in dementia?

A
  • Depression
  • Anxiety
  • Apathy
  • Agitation
  • Delusions
  • Hallucinations

These are also known as behavioural and psychological symptoms of dementia (BPSD).

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6
Q

What are the hallmark symptoms of Alzheimer disease?

A
  • Gradual onset and progressive loss of cognition and memory
  • Difficulty recalling recent events
  • Sleep disturbances
  • Apathy
  • Apraxia

Caused by the accumulation of beta-amyloid and tau proteins.

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7
Q

What characterizes vascular dementia?

A

Stepwise decline in cognition after cerebrovascular events

Cognitive deficits involve memory, executive function, language, and attention.

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8
Q

What are the symptoms of Lewy body dementia?

A
  • Early-onset visual hallucinations
  • Daytime drowsiness/napping
  • Fluctuating consciousness
  • Disorganized speech
  • Parkinsonian symptoms
  • REM behavioural sleep disorder

Aggregates of alpha synuclein proteins lead to neuronal loss.

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9
Q

What are the characteristics of frontotemporal dementia?

A
  • Disinhibition
  • Socially inappropriate behaviour
  • Compulsive behaviours
  • Apathy
  • Lack of empathy
  • Change in habits and beliefs

Specific proteins are associated with distinct molecular defects.

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10
Q

What is the FAST rating for the preclinical stage of dementia?

A

3

This stage has considerable overlap with normal aging and may or may not progress to dementia.

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11
Q

What are the goals of therapy for dementia?

A
  • Alter disease progression
  • Manage cognitive, behavioural, and psychological symptoms
  • Mitigate risk of harm
  • Minimize medication side effects
  • Alleviate caregiver burden

These goals aim to optimize function and meet patient and caregiver needs.

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12
Q

What is the Montreal Cognitive Assessment (MoCA) used for?

A

Screening for mild cognitive impairment (MCI) or early dementia

It is most useful for identifying cognitive decline.

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13
Q

What does the Mini-Mental Status Exam (MMSE) help distinguish?

A

Moderate stage dementia from normal cognition

It can be used alone or in combination with the clock drawing test.

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14
Q

What is the neuropsychiatric inventory questionnaire (NPI-Q) used for?

A

Assessing neuropsychiatric symptoms

It helps in evaluating mood and behaviour history.

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15
Q

What laboratory tests are recommended for cognitive impairment evaluation?

A
  • CBC
  • Fasting glucose
  • Electrolytes
  • Calcium
  • Renal function
  • TSH
  • B12

These tests help identify potentially reversible medical illnesses contributing to impairment.

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16
Q

What are cholinesterase inhibitors used for?

A

Treatment for cognitive and functional symptoms in dementia

They block the breakdown of acetylcholine, increasing its levels in the synaptic cleft.

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17
Q

Name the three cholinesterase inhibitors mentioned.

A
  • Donepezil
  • Rivastigmine
  • Galantamine

They are mainstays of treatment for various types of dementia.

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18
Q

What is the mainstay of frontotemporal dementia management?

A

Nonpharmacologic approach targeted at managing symptoms

Emphasis on family and caregiver support.

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19
Q

What should be addressed early in dementia care?

A

Advance care planning

This includes establishing advance health-care directives and durable powers of attorney.

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20
Q

What is the expected decline on the MMSE scale for untreated patients with mild to moderate dementia?

A

2–4 points per year

An annual decline of less than 2 points while on drug therapy indicates a beneficial effect.

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21
Q

What is galantamine indicated for?

A

Mild-moderate Alzheimer’s Disease (AD)

Galantamine has shown effectiveness in several studies, including in patients with mixed AD/vascular dementia (VD).

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22
Q

What are the common adverse effects of cholinesterase inhibitors?

A
  • Diarrhea
  • Nausea
  • Vomiting
  • Anorexia and/or weight loss
  • Vivid dreams
  • Tremor
  • Vertigo
  • Other cholinergic effects

Follow-up to monitor for side effects is advised.

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23
Q

True or false: Cholinesterase inhibitors typically provide large benefits for Alzheimer’s Disease.

A

FALSE

Benefits are usually small to moderate, mainly consisting of disease stabilization and minor improvements.

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24
Q

What is the duration of efficacy for cholinesterase inhibitors in Alzheimer’s Disease?

A

Variable between studies

Outcomes can range from no benefit to stabilization for a year or more.

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25
What is the **recommended starting dose** strategy for cholinesterase inhibitors?
Start at the lowest dose and increase incrementally every 4 weeks ## Footnote High starting doses without slow uptitration are associated with higher rates of serious events.
26
What is the **mechanism of action** of memantine?
Blocks glutamate-induced neuronal excitotoxicity ## Footnote This process is implicated in neuronal death.
27
What should be considered when **deprescribing** cholinesterase inhibitors?
* Patient or caregiver decision to stop * No clinically meaningful benefit * Intolerable adverse effects * Clinically meaningful progression of dementia * Progression to severe stage or terminal illness ## Footnote Decisions should be individualized and not based on a single measure.
28
What are the **nonpharmacologic approaches** for managing responsive behaviors in dementia?
* Psychosocial interventions * Environmental modifications * Structured psychological interventions (e.g., CBT) * Multidisciplinary care (e.g., recreation therapy) ## Footnote These approaches are first-line therapy due to low risk of adverse effects.
29
What is the **recommended treatment** for depression in patients with mild to moderate dementia?
Not routinely recommended unless there is a pre-existing mental health problem ## Footnote Many psychiatrists may still consider prescribing antidepressants based on individual circumstances.
30
What is the **half-life** of donepezil compared to other cholinesterase inhibitors?
Longest half-life (70 hours) ## Footnote Compared to galantamine (6–8 hours) and rivastigmine (1.5–3 hours).
31
What is the **role of cholinesterase inhibitors** in Lewy Body Dementia/Parkinson Disease Dementia?
Cognitive stabilization and reduction in visual hallucinations and behavioral symptoms ## Footnote Clinical trial data show effectiveness with small doses.
32
What is the **safety concern** regarding cholinesterase inhibitors?
Potential for bradycardia and QT interval prolongation ## Footnote Caution is recommended in patients with cardiac issues.
33
What is the **Cochrane review finding** regarding donepezil in vascular dementia?
Slight beneficial effect on cognition ## Footnote Clinical significance of the benefits remains unclear.
34
What should be monitored when **deprescribing** cholinesterase inhibitors?
* Emergent symptoms * Rapid decline in cognition * Decline in function ## Footnote If significant deterioration occurs, consider reinstating the cholinesterase inhibitor.
35
What is the **FDA-approved** treatment for mild Alzheimer's disease?
Aducanumab ## Footnote Experts in Canada do not believe it meets criteria for clinical efficacy and safety.
36
What is the **effect of high-dose vitamin E** on dementia progression?
Single study suggested slowing, but more recent data shows no benefit ## Footnote High-dose vitamin E is not recommended due to potential risk of harm.
37
The **guidelines** do not recommend the routine use of antidepressants to manage mild to moderate depression in people living with mild to moderate dementia, unless they have a _______.
pre-existing mental health problem ## Footnote Many psychiatrists may still consider prescribing antidepressants based on factors like stage of dementia and severity of symptoms.
38
Which class of antidepressants is less likely to cause **anticholinergic side effects** in elderly patients?
SSRIs (except paroxetine) ## Footnote Tricyclic antidepressants (TCAs) are generally avoided in dementia patients due to their side effects.
39
What is the increased risk associated with elderly patients taking **SSRIs**?
Hyponatremia/SIADH ## Footnote Monitoring of electrolytes is recommended due to the cognitive effects of hyponatremia.
40
True or false: **TCAs** are generally recommended for use in dementia patients.
FALSE ## Footnote If necessary, desipramine or nortriptyline are preferred due to lower anticholinergic effects.
41
What is the typical duration for observing signs of improvement in elderly patients receiving **antidepressant treatment**?
6–8 weeks ## Footnote Longer trials may be required for older adults with depression.
42
Which antidepressants have shown effectiveness in reducing **agitation** in dementia patients?
* Sertraline * Citalopram ## Footnote A Cochrane review indicated these medications reduced agitation compared to placebo.
43
What is the recommendation for using **antipsychotic medication** in dementia patients?
Reserve for severe, dangerous symptoms ## Footnote Antipsychotics should be used when symptoms cause clinically significant distress.
44
Which two **antipsychotics** have the most evidence for treating RBD?
* Risperidone * Olanzapine ## Footnote These are often the initial choice for treatment due to their efficacy.
45
What is the risk of **extrapyramidal side effects (EPS)** in elderly patients treated with antipsychotics?
Higher risk, especially with first-generation agents ## Footnote Tardive dyskinesia can occur in a significant percentage of patients over time.
46
What is the **number needed to harm (NNH)** for haloperidol in elderly patients?
26 ## Footnote This indicates the number of patients who would need to be treated for one to experience a negative outcome.
47
What is the **advisory** issued by Health Canada regarding second-generation antipsychotics in elderly patients with dementia?
1.6 times greater mortality rate compared to placebo ## Footnote There is also a risk of cerebrovascular events, especially in mixed and vascular dementia.
48
What is the mainstay of treatment for cognitive and functional symptoms of **dementia**?
Cholinesterase inhibitors ## Footnote These are commonly used with less risk of serious adverse events compared to antipsychotics.
49
What is the effect of **trazodone** in managing agitated behavior in dementia patients?
Successful management with RCT evidence ## Footnote Trazodone is also used for disrupted sleep/wake cycles.
50
What is the recommendation for using **benzodiazepines** in dementia patients?
Use low doses of short-acting agents ## Footnote They may be indicated for severe agitation when other agents fail.
51
What are some **modifiable risk factors** for dementia?
* Less education * Social isolation * Late-life depression * Mid-life obesity * Physical inactivity * Hearing impairment * Diabetes * Mid-life hypertension * Smoking * Air pollution * Traumatic brain injury * Alcohol consumption (>21 units/wk) ## Footnote Up to 40% of dementia cases can be attributed to these factors.
52
What type of **diet** may protect against cognitive decline?
Mediterranean diet ## Footnote This diet includes high levels of mono- and polyunsaturated fatty acids and low intake of saturated fatty acids.
53
What is the recommended amount of **exercise** to reduce dementia risk?
30 minutes of vigorous exercise at least 3 times per week ## Footnote This may improve cognitive outcomes in older adults.
54
What is the role of **statins** in dementia prevention?
Controversial ## Footnote Some reviews suggest a preventive role, especially for those at higher risk, but evidence remains mixed.
55
True or false: **Vitamin E** is recommended for the prevention of dementia.
FALSE ## Footnote The PREADViSE trial failed to show benefit from vitamin E and selenium in dementia prevention.
56
What is the **ApoE4 genotype** associated with?
Increased risk of dementia ## Footnote Carriers of the ApoE4 genotype are predisposed to a rise in amyloid-beta peptide.
57
True or false: The use of **NSAIDs** is effective in reducing dementia risk.
FALSE ## Footnote There does not appear to be a role for NSAIDs in reducing dementia risk.
58
Is **estrogen** recommended for reducing dementia risk?
No ## Footnote The use of estrogen does not show effectiveness in reducing dementia risk.
59
What is the conclusion regarding **Vitamin E** in dementia prevention?
Not recommended ## Footnote The PREADViSE trial failed to show benefit from Vitamin E and selenium in preventing dementia.
60
What association exists between **vitamin D levels** and dementia risk?
Lower vitamin D levels associated with increased risk ## Footnote Interpretation of results can be difficult due to observational study limitations.
61
In clinical trials, which vitamin supplementation may be beneficial for preventing progression of mild cognitive impairment?
Vitamin B ## Footnote Beneficial only in individuals with elevated baseline levels of homocysteine.
62
What medications are not effective for the **prevention of progression** of mild cognitive impairment or preclinical dementia?
* Cholinesterase inhibitors * Memantine ## Footnote These medications are used for treatment but not prevention.
63
What is the **initial dosage** for **olanzapine**?
2.5 mg/day PO ## Footnote Maximum dosage is 10 mg/day PO.
64
List the **adverse effects** of olanzapine.
* Extrapyramidal symptoms (EPS) * Sedation * Constipation * GI upset * Weight gain * Metabolic dysregulation * Increased risk of stroke and death ## Footnote Toxicity may be increased by certain CYP1A2 inhibitors.
65
What is the **maximum dosage** for **quetiapine**?
200 mg/day PO ## Footnote Initial dosage is 12.5 mg/day PO.
66
What are the **adverse effects** of quetiapine?
* Extrapyramidal symptoms (EPS) * Sedation * Constipation * GI upset * Weight gain * Metabolic dysregulation * Increased risk of stroke and death ## Footnote Toxicity may be increased by certain CYP3A4 inhibitors.
67
What is the **initial dosage** for **risperidone**?
0.25 mg/day PO ## Footnote Maximum dosage is 2 mg/day PO.
68
List the **adverse effects** of risperidone.
* Extrapyramidal symptoms (EPS) * Sedation * Constipation * GI upset * Weight gain * Metabolic dysregulation * Increased risk of stroke and death ## Footnote Toxicity may be increased by certain CYP2D6 or CYP3A4 inhibitors.
69
What is the **initial dosage** for **donepezil**?
5 mg/day PO ## Footnote Target dosage is 10 mg/day PO.
70
What are the **adverse effects** of donepezil?
* Headache * Nausea * Diarrhea * Vomiting * Anorexia * Fatigue * Sleep disturbance * Syncope * Muscle cramps * Urinary frequency ## Footnote Uncommon effects include bradycardia and heart block.
71
What is the **initial dosage** for **galantamine extended-release**?
8 mg daily PO ## Footnote Target dosage is 16–24 mg PO daily.
72
List the **adverse effects** of galantamine extended-release.
* Nausea * Vomiting * Diarrhea * Bradycardia * Syncope * Dizziness * Headache * Sleep disturbance * Fatigue * Abdominal pain ## Footnote Uncommon effects include heart block and seizures.
73
What is the **initial dosage** for **rivastigmine oral**?
1.5 mg BID PO ## Footnote Target dosage is 6–12 mg/day PO in 2–3 divided doses.
74
List the **adverse effects** of rivastigmine oral.
* Headache * Dizziness * Nausea * Vomiting * Diarrhea * Abdominal pain * Anorexia * Fatigue * Insomnia * Syncope ## Footnote Uncommon effects include heart block and seizures.
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