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45 Cards in this Set
- Front
- Back
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Dementia definition
Normal part of aging rising as cause of dealth |
‘A disorder which involves cognitive and
functional decline often accompanied by behavioural disturbance and psychosis’ While the risk of dementia increases with age, dementia is not a natural part of ageing |
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Dementia in Australia - occurence with age and total number
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Prevalence increases with age
65 years and over 1 in 15 80-84 years 1 in 9 85 years and over 1 in 4 Dementia sufferers 2008: 227,000 2050: 730, 000` |
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where will there be higher levels of dementia
what percentage of years does it contribute to living with disability |
The rate of increase is predicted to be three to four
times higher in developing areas. This is because of the rapid ageing of developing countries According to the Global Burden of Disease estimates for the 2003 World Health Report, dementia contributed 11.2% of years lived with disability in people aged 60 years and older; more than stroke (9.5%), musculoskeletal disorders (8.9%),cardiovascular disease (5.0%), and all forms of cancer (2.4%) |
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Difference between AD and normall
age-rellatted memory changes Alzheimer’s disease |
Forgets entire experience
Rarely remembers later Gradually unable to follow written/spoken directions Gradually unable to use notes as reminders Gradually unable to care for self |
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Difference between AD and normall
age-rellatted memory changes Age related memory loss |
Forgets part of an experience
Often remembers later Usually able to follow written/spoken directions Usually able to use notes as reminders Usually able to care for self |
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Why early detection?
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Dementia Symptoms
Early stages |
memory disorders
problems of orientation reduced ability to engage in abstract reasoning learning disabilities impaired ability to perform in social and economic spheres word finding problems limited visual-spatial abilities trouble with construction, i.e. drawing |
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Dementia Symptoms
Later stages |
intellectual activity ceases
apathy vegetative state muscles weakness the person becomes incontinent, including loss of control of bowel and bladder |
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Identifying people at risk
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Demonstration of trouble with
construction can be obtained by asking the patient to draw something. Example of a clock drawn by a patient who was told to put the hours on it, and set the time at three-thirty. Mini-Mental State Examination (MMSE) used to grade and monitor dementia |
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Cognition and Disease Progress
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Types of Dementia and occurence
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60%
Alzheimer’s Disease 15% Vascular dementia 10% lewy body 7% fronto temperol 3% parkisons diesease dementia 7% other |
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Alzheimer’s Disease - cause
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Caused by aggregation of beta-amyloid
protein in certain areas of brain tissue Characteristic plaques and tangles Progressive destruction of neurons |
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Alzheimer’s Disease - onset of symptoms, continue of symptoms, life expectency
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Gradual onset of symptoms
Initial forgetfulness progresses to profound memory impairment Deterioration in ADLs, behavioural changes Later stages - loss of motor skills and speech Life expectancy 8 -10 years |
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Vascular dementia- risk factors, whats lost, whats preserved, what clincial findings present, progression
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Onset may be abrupt or staged
Patients often have risk factors: diabetes, smoking, hypertension Most patients present with signs of stroke or ischaemic heart disease Often imaging evidence of cerebrovascular disease Physical problems such as incontinence, gait disturbance Emotional lability and impaired judgment Relative preservation of verbal memory and personality |
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Dementia with Lewy Bodies - clinical occurences, overlap with what disease, onset, sypmtoms, what drugs effective
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Lewy bodies found in high numbers in brain cortex
Neurons degenerate Overlap with Parkinson’s (where lewy bodies are found in mid brain) Progression rapid: severe dementia and parkinsonism within 1-2 years Frequent visual hallucinations/ delusions Sensitive to antipsychotics |
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Fronto-temporal dementia - sypmtoms matched to progression, age, risks,
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Occurs in younger patients – under 65yrs
Often patients have family history Personality change and social disinhibition early signs Language problems Memory deficits occur late in disease Many patients have mixed dementia 20-40% of dementia patients Often one type dominant |
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Reversible causes of
dementia |
D drugs
E emotional illness (depression) M metabolic / endocrine (hypothyroidism) E ear / eye / environment N nutritional / neurological T tumours / trauma I infection A alcoholism / anaemia / atherosclerosis |
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Cognitive impairment and
medication - why drug history important, what drugs impliacated, what symptoms, what should be done b4 dementia is diagnosed |
Taking a thorough drug history is important when
assessing an older patient, as use of medications may be the most common and most easily reversible factor contributing to cognitive impairment. Many drugs cause a multitude of psychiatric symptoms, including psychosis, disinhibition, and emotional lability. Further, there are a number of medications that may be linked to cognitive impairment by inducing delirium, confusion or memory loss. e.g Anticholinergics, anticonvulsants, tricyclic antidepressants, benzodiazepines, beta-blockers, histamine-2 antagonists, levodopa, methyldopa, metronidazole, and salicylates. Before dementia can be diagnosed, all psychoactive drugs should be eliminated if possible. |
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what is Delirium
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Altered/ fluctuating level of consciousness
Disturbances in memory, thought and behaviour Reversible Acute or subacute onset Prevalent in dementia patients Caused by a variety of illnesses or medications Must identify to treat appropriately |
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Pharmacottherapy ffor Dementtiia - drugs and borad clsses
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Symptomatic treatment of Behavioural and
Psychological symptoms of Dementia (BPSD) Antipsychotics Antidepressants - SSRIs Anticonvulsants - Carbamazepine Disease modifying treatment Cholinesterase Inhibitors Memantine |
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Common BPSD
mental health conditions |
anxiety
depressed mood hallucinations delusions sleep disturbance |
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common BPSD
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symptoms/signs
aggression screaming agitation wandering Hoarding sundowning (worsening of behaviour from 5pm) shadowing (following carer closely) culturally inappropriate behaviour |
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BPSD - costs, most common BPSD- consists of, delusions %, hallucinations BPSD and
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Agitation is the most common BPSD occurring
in over 50% of people with dementia. e.g. disinhibition, verbal abuse, hitting out, damaging property Delusions occur in about 30% of people with dementia. Typically arise in middle to late dementia Hallucinations occur in about 20%. Usually limited episodes but may be sustained Associated with lower function, increased burden on caregivers and ACH staff, higher costs of care and admission to ACH |
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Assessment of BPSD
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Identify and map one target behaviour
Examine patient to assess for preventable cause such as delirium, UTI, pain etc. Review medication list Investigate possible triggers Review patient’s psychiatric and social history |
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Non-Pharmacollogiicall ttreattment of
BPSD- advantages |
Two main advantages of not using drugs:
- Attempts to address reasons for behaviour - Side effects, drug interactions and limited efficacy avoided |
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Behavioural Problems resolved non pharmacologically in dementia
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Social and Environment Interventions
Music – especially classical Decrease aggressive outbursts, agitation, and anxiety Combined with dance or movement, improves orientation and self-expression Exercise Improves cognitive function and general wellbeing Environmental modification Prevent injury or misadventure from wandering increase or decrease light or noise |
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Evidence for non-pharmacological
techniques - and one disadvantage |
Clinical evidence plus a few small studies support nondrug
techniques in individual patients Many of the studies are conducted in patients with mild symptoms Two Australian studies demonstrated the best outcomes for aged care home residents with severe BPSD using psychosocial interventions, developed in conjunction with staff, producing strategies workable in the aged care home environment. Recent trial of collaborative care management showed improvement in overall severity of BPSD Requires staff, resources, training and time……… |
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Drug treatment of BPSD - in general practice
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Benzodiazepines often used but not
recommended as they cause confusion, agitation, apathy, falls and social disinhibition Treat underlying depression with SSRIs and behaviour may improve Anticonvulsants have been trialed but are not recommended due to adverse effects and limited evidence of effect |
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Antipsychotics
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Most commonly used drug class to manage
BPSD In older people the most prevalent indication for use is for BPSD Some modest benefit upon aggression and psychosis Appear to be more effective in patients with severe symptoms Overall evidence for modest effect countered by high side effect rate |
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Side effects of typical
antipsychotics |
Associated with a risk of falls, somnolence,
orthostasis Cardiac toxicity (i.e. thioridazine) Associated with Extra Pyramidal Symptoms Parkinsonism (bradykinesia, rigidity, tremor) Akathisia Tardive dyskinesia: 28% after 1 year, 50% after 2 years, 63% after 3 years |
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Adverse effects of atypical
antipsychotics in people with dementia |
Cerebrovascular risk:
- CSM (UK) meta-analysis of RCTs for risperidone and olanzapine in dementia patients. - risk of cerebrovascular events increased almost four-fold. Working group for the faculty of old age psychiatry. Summary guidance for the management of BPSD. March 2004. www.rcgp.org.uk Mortality risk: - FDA (US) analysis based on 17 RCT with atypical antipsychotics - increased risk of death (1.6-1.7 fold increase) Singh S, Wooltorton A. ‘Increased mortality among elderly patients with dementia using atypical antipsychotics.’ JAMA 2005;353:2335-2341. |
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Behaviours Responding Poorly
to Drugs |
wandering, pacing, entering rooms uninvited, attemoting to leave, making disruption vocalisations, voiding inappriopiately
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Antipsychotic withdrawal - % of no relapse, process
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UK study examined the effect of ceasing antipsychotic
treatment in 100 aged care home residents, with stable behaviour/s, who had been treated for at least 3 months. Over two thirds of the residents experienced no deterioration of CB when assessed at 1 month and 3 months after discontinuation. Ballard C, Thomas A, Fossey J et al. A 3-month , randomised, placebo-controlled, neuroleptic discontinuation study in 100 people with dementia: the neuropsychiatric median cutoff is a predictor of clinical oputcome. J Clin Psychiatry 2004;65:114-119. A gradual withdrawal is recommended to avoid relapse and withdrawal symptoms such as tachycardia, sweating and insomnia. |
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Disease Modifying
Treatments - classes and names, comparative info |
Cholinesterase Inhibitors
Donepezil (Aricept ®) Rivastigmine (Exelon ®) Galantamine (Reminyl ®) Tacrine (not available in Australia) NMDA Antagonist Memantine (Ebixa ®) Comparative Information - almost nonexistent |
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Cholinesterase Inhibitors- benefit, fraction that benefit, time to assessment,
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Cholinesterase inhibitors offer modest benefits to patients with mild
to moderate dementia due to Alzheimer’s disease. They are expensive, require supervision, improve alertness and function and maintain cognitive scores at or above the baseline for up to 12 months, but do not modify the underlying progression of pathology. Open-label trials have shown continued benefit for up to 4 years. Six month studies suggest that between 5 and 15 patients need to be started on treatment in order to see a significant improvement in 1 patient. Two out of three treated patients have their apparent rate of cognitive decline slowed by cholinesterase inhibitor therapy. Patients should be treated for at least 2 months at the maximum tolerated dose of medication before a final assessment of response is made. |
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cholinesterase inhibitors - comparative, swapping?
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There is no convincing evidence that any of the 3 available
cholinesterase inhibitors is more efficacious than the other 2, however donepezil’s once-daily dosing regime and fewer adverse effects should make it the first choice medication for most patients. In the event of nonresponse, there is a lack of clear evidence to indicate that switching to another cholinesterase inhibitor will produce a response, though individual cases who respond to one |
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Cholinesterase inhibitors - PBS, other than alzeihmers, severe dementia, long term efficacy
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Only available on PBS as authority
prescription for mild to moderately severe Alzheimer’s disease Limited evidence for use in other dementias though may be of benefit Limited evidence for use in severe dementia Long term use efficacy unknown |
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Side effects of Cholinergic
Agents - when should care be excercised |
Cholinergic stimulation
nausea / vomiting diarrhoea anorexia (weight loss) dizziness dyspepsia agitation vivid dreams Care is needed bradycardia caution in sick sinus syndrome monitor in patients receiving other drugs that slow heart rate ulcers (increase risk on NSAIDs) COPD and asthma ureteric obstruction Galantamine is contraindicated in severe renal failure. |
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Practice points of cholinesterase inhibtiors
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Doses should be titrated to minimise side effects
If treatment is interrupted may require restart at initial dose and retitrate. Rivastigmine comes as an oral liquid and patch Abrupt cessation in patients with dementia with Lewy bodies may cause a rapid decline in benefits Donepezil – morning dose to avoid vivid dreams No washout is needed when switching agents or retitration |
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PBS Cholinesterase Inhibitors
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Eligible patients
AD and with mild to moderate disease (MMSE score 10) Continued benefit Subsidised treatment can only be continued in those patients who demonstrate evidence of cognitive improvement (MMSE score 2 points better or ADAS-cog 4 points better) from baseline. Where a patients MMSE score falls below 10 treatment should be discontinued. In patients with noticeable decline in cognition, behaviour or functional status within 2 weeks of discontinuation of a cholinesterase inhibitor, drug therapy should be reinitiated starting with a low dose and titrating upwards. |
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Memantine - PBS, NTT, MOA
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Regulates glutamate transmission
Thus may protect neurons from over stimulation and neurotoxicity Approved for moderate to severe Alzheimer’s disease Small benefit on cognition, behaviour and ADL 17 patients needed to be treated for 6 months to prevent one incident of agitation No effect on course of disease Recently approved on PBS Memantine clinical trials suggest benefit with combining with donepizil |
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Prevention benefits?
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Dementia process starts long before onset
of clinical symptoms Therapies to delay or prevent dementia developing for 5 years – would reduce cases by 50% in one generation. Many therapies proposed ………. |
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Preventative therapies- types, evidence
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Oestrogen?
Vitamin E? Statins? NSAIDS (e.g. naproxen, ibuprofen)? Folic acid? Gingko biloba? …Insufficient evidence to endorse use |
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Preventative treatment in vascular
dementtiia |
Main aim in management of vascular
dementia is to prevent new strokes Reduce risk factors for vascular disease - control BP - control hyperlipidaemia - control blood glucose - address lifestyle e.g. smoking |
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Prevention of Alzheimer’s
disease |
Right now, there's no proven way to prevent the onset of
Alzheimer's disease. Human trials of a promising vaccine against Alzheimer's had to be stopped several years ago because some of the people who received the vaccine developed encephalitis. However, you may be able to reduce your risk of Alzheimer's disease by reducing your risk of heart disease. Many of the same factors that increase your risk of heart disease can also increase your risk of dementia. The main players appear to be blood pressure, cholesterol and blood glucose levels. Keeping active —physically, mentally and socially — also seems to reduce the risk of Alzheimer's disease. |
