Dementias

As of 12Sep07. All items from DSM-IV or APA Practice Guidelines unless otherwise

indicated.

Dx criteria

• Q. What is the outline of the DSM dx criteria?

Dx criteria - general

• Ans.

• 1. Multiple cognitive deficits.

• 2. Gradual onset and decline

• 3. Not part of another Disorder

Dx criteria – Specific Cognitive deficits

• Q. What cognitive deficits are part of the DSM criteria of dementia?

Dx – specific cognitive deficits

• Ans. • 1. Memory impairment • AND• 2. At least one of the following:

– Aphasia– Apraxia– Agnosia– Executive functioning deficits

Early onset

• Q. What is the dividing line between early and late onset dementia?

Early Onset

• Ans.

• < or = 65, early onset

• > 65, late onset

Reasons to hospitalize

• Q. List reasons to hospitalize pts with dementia.

Reasons to hospitalize

• Ans.

• 1. Symptom severity:– Dangerousness to self or others, including

inability of caretakers to care for the pt

2. Intensity of care and treatment needed:

-- evaluations or treatments that cannot by done on outpt basis.

Follow-up

• Q. If you have a “routine” pt with Alzheimer’s, how often should the pt be monitored by you?

Follow-up

• Ans. Every 3 to 6 months.

MMSE

• Q. What is the MMSE? And What does it evaluate?

MMSE

• Ans.

• MMSE = Mini-mental status examination.

• MMSE tests cognitive functioning.

CT or MRI

• Q. When is CT or MRI advised as part of the initial eval of people with dementia?

CT or MRI

Ans. Some would say in all, but the question is more likely to focus on when one of these tests is more indicated than most pts with dementia:– Early onset– Relatively rapid onset– High vascular risk factors suggested– Neurological exam suggests local lesions

Neuropsych testing

• Q. When is neuropsych testing indicated?

Neuropsych testing

Ans. When questions arise as to whether the individual actually has a “dementia.”

• [Keep in mind that only Mental Retardation and Learning Disorders has psychological testing as part of a DSM criteria set.]

Gene testing

• Q. Is gene testing recommended?

Gene testing

Ans. Gene testing is not recommended. Dx is clinically based regardless of genes.

Apolipoprotein E-4

• Q. What is the significance of apolipoprotein E-4 (APOE-4)?

Apolipoprotein E-4

Ans. Apolipoprotein E-4 [APOE-4], on chromosome 19, is more common in individuals with Alzheimer’s – but not diagnostic.

Suicidal

• Q. At what stage of a dementia is suicidal ideation most common?

Suicidal

Ans. Most common when the disease is still mild.

Suicide and gender

• Q. Which gender is suicide most common in this illness?

Suicide and gender

Ans. Men

[In answering examiner’s questions as to “successful” suicides, keep in mind that men do so far more often than women, and that gets to be especially true in the elderly.]

Falls

• Q. Give one of major ways a physician can reduce the chances of falls in pts with dementia.

Falls

Ans. Review and considered discontinuance of meds associate with falls.

Driving

• Q. Should a physician report their pt who has dementia to the state department of motor vehicles?

Driving

Ans. Varies by state. Required in some, forbidden in others.

Dosing in the elderly

Q. What are the principles of medicating in the elderly?

Medicating the elderly

Ans.

-- lower starting doses.

-- longer intervals between dose increases.

-- smaller dose increase

Medicating rules - why

Q. Why the go slow approach with the elderly?

Medicating rules - why

Ans.

slower hepatic metabolism

decreased renal clearance

Goal of medicating

Q. What is the goal of medicating a pt with Alzheimer’s?

Goal of medicating

Ans. Delay progression of the disease. No med reverses.

FDA for Alzheimer’s

Q. What meds have been approved for Alzheimer’s?

FDA for Alzheimer’s

Ans.

donepezil

galantamine

memantine

rivestigmine

tacrine [no longer in use]

FDA – med action

Q. Which of the five is/are cholinesterase inhibitors? Which is/are NMDA antagonist?

Meds - actions

Ans.

donepezil, galantamine, rivestigmine, and tacrine are cholinesterase inhibitors.

memantine is a noncompetitive N-methyl-aspartate antagonist.

Vitamin E

• Q. What about high doses of Vitamin E for Alzheimer’s?

Vitamin E

Ans. Not proven to be useful and high doses may be associated with increased risk of heart failure.

Vitamin E must be avoided in pts with vitamin K deficiencies.

Selegiline

• Q. Selegiline’s usefulness in dementia?

Selegiline

Ans. Not proven to be useful.

tacrine

Q. Tacrine status?

tacrine

Ans. Regarded as less preferred to donepezil, rivestigmine, and galantamine because of tacrine’s hepatic toxicity.

ECT

• Q. Indications for ECT in pts with Alzheimer’s?

ECT

Ans. Indicated for pts with moderate to severe depression and Alzheimer’s and who do not respond to or cannot tolerate antidepressant meds.

Delusions and hallucinations

• Q. Pt is moderately impaired from Alzheimer’s, has delusions and hallucinations and is not distressed or agitated, meds?

Hallucinations and delusions

Ans. No meds, instead reassurance, redirection and distractions.

Hallucinations and delusions

• Q. Alzheimer’s pt with hallucinations and delusions and combative, meds?

Hallucinations and delusions

Ans. Low dose antipsychotic.

[This is true of the Guides, but recent FDA warnings would suggest ordering antipsychotics as quite low levels to begin -- given the increased death rate of the elderly on antipsychotics.]

Profoundly impaired

• Q. What meds to help the cognition of the severely impaired?

Profoundly impaired

Ans. Memantine is approved for the profoundly/severely impaired. Cholinesterase inhibitors are not.

Meds & Delirium

• Q. What classes of meds can cause delirium in those with Alzheimer’s?

Delirium & meds

Ans. Virtually all psychotropic meds, even more so, those having anticholinergic activity.

Anticholinergic

• Q. What are some meds psychiatrists use that have anticholinergic activity?

Anticholinergic

Ans. Tricyclics, low-potency antipsychotics, and diphenhydramine.

Dopaminergic meds

• Q. Dopaminergic meds used in Parkinson’s disease in pt who also has Alzheimer’s predisposes that pt to?

Dopaminergic meds

Ans. Visual hallucinations

Vascular dementia

• Q. Treatment for vascular dementia?

Vascular dementia

Ans.

• -- control BP

• -- low-dose aspirin

[2 of 3 trials with donepezil found some positive results, but the 3rd trial lack of effectiveness probably precludes it being the correct answer.]

Fronto-temporal dementia

• Q. What med has been shown to decrease problematic behaviors of fronto-temporal dementia, e.g., agitation?

Fronto-temporal dementia

Ans. Trazodone.

[If trazodone is not one of the choices, amantadine has some anecdotal support.]

Caregivers and depression

• Q. To what degree does depression occur in caregivers?

Caregivers and depression

Ans.

• 30% of spousal care-givers experience a depressive disorder.

• 22-37% of adult children care-givers, the higher percentage, > 30%, in those with a prior hx of a mood disorder.

Federal Regulation

• Q. A major law, passed in 1987, that regulates the use of physical restraints and use of meds in nursing home is?

Federal Regulation

Ans. The Omnibus Budget Reconciliation Act of 1987 [OBRA].

Gender

• Q. In Alzheimer’s, which gender is more frequent?

Gender

Ans. More common in women.

[Not just more common in absolute numbers, but in percentage of the gender.]

African Americans

• Q. Relative to Caucasians, Which dementias do African Americans have more and which do they have less?

African Americans

Ans. More vascular dementia [could guess from their higher hypertension rate] and less Parkinsonian dementias.

Family Hx

• Q. If Mrs. X has Alzheimer’s, what the chances of her siblings or children getting Alzheimer’s?

Family hx

Ans. Two to four times that of the general population.

Genes – early onset

• Q. What are the three genes that have an increased association with early on-set Alzheimer’s?

Genes – early onset

Ans.

• 1. Amyloid precursor protein [APP] on chromosome 21

• 2. Presenilin 1 [PSEN1] on chromosome 14

• 3. Presenilin 2 [PSEN2] on chromosome 1

Vascular dementia

• Q. Onset and course of vascular dementia?

Vascular dementia

Ans. Acute onset and step-wise decline.

Alzheimer’s onset - age

• Q. Give the approximate onset of Alzheimer’s per the age of the individual, such as % per year of:

• < 65• 65-70• 70-75• 75-80• 80-85• >85

Alzheimer’s onset - age

• < 65 – rare• 65-70 – 0.5%/ year [i.e., one in 200 will develop

Alzheimer’s within a year]• 70-75 – 1%• 75-80 – 2%• 80-85 – 3%• >85 – 8% [Means that the odds of someone who does

not have Alzheimer’s at 85 has an 8% chance of having the onset over the next 12 months. The jump from 3% to 8% doesn’t seem correct for 85 y/o compared to 84 y/o, so the “8” percent must be based on the average of all over 85. I’m not sure.]

Mild cognitive impairment

• Q. Criteria for “mild cognitive impairment”?

Mild cognitive impairment

Ans. While there is no agreed upon definition, the following will probably reach examiner’s questions:

• 1. Subjective memory complaints

• 2. Objective cognitive deficits on testing

• 3. Functioning OK

Vascular dementia - onset

• Q. Relative to age, what is the incidence of the onset of vascular dementia?

Vascular dementia - onset

Ans. Gradually increases until the age of 75, then plateaus, unlike Alzheimer’s which continues to have an increased incidence with each year one ages.

Lewy body disease

• Q. Lewy body disease differs in clinical presentation from Alzheimer’s in what ways?

Lewy body disease

Ans. Differs:

• -- early and more prominent visual hallucinations

• -- early and more prominent Parkinsonian features [leading to falls]

• -- more rapid decline

Lewy body disease - meds

• Q. When you decide to prescribe antipsychotic medications to someone with Lewy body disease has, what prominent signs are your concern?

Lewy body disease - meds

Ans. Very sensitive to extrapyramidal signs.

Frontotemporal dementia

• Q. Characteristics of frontotemporal dementia in comparison to Alzheimer’s?

Frontotemporal dementia

Ans. • -- personality change early• -- apathy early• -- emotional blunting early• -- disinhibition early• -- language abnormalities early• -- memory problems late• -- apraxia late• [the examiner may use “Pick’s disease” for this entity]• [Hard to remember all 7 items, but recalling that memory

is relatively late may get you the correct answer.]

Frontotemporal dementia - onset

• Q. Common age of onset?

Frontotemporal dementia - onset

Ans. Onset tends to be between 50 and 60.

Huntington’s disease - gene

• Q. Genetic aspect of Huntington’s?

Huntington’s - genes

Ans. Autosomal dominate.

Huntington’s - pathology

• Q. Pathology of Huntington’s?

Huntington’s - pathology

Ans. While there is damage to many subcortical structures, the answer they are probably looking for is basal ganglia.

Creutzfeldt-Jakob disease - etiology

• Q. What two etiologies are seen in this disease?

Creutzfeldt-Jakob disease - etiology

Ans.

-- slow virus

OR

-- a prion [proteinaceous infectious particle]

Mild cognitive impairment

Q. Donepezil or galantamine help with mild cognitive impairment?

Mild cognitive impairment

Ans. Neither have been shown to be helpful.

TD risks

Q. Relatively to age, gender, and dementia, what are TD risks?

TD risks

Ans. Relative to use of antipsychotics, increased risk:

1. in women,

2. increased risk in the elderly and

3. increased in those with dementia

delirium

Q. What meds used in psychiatry are associated with delirium when used with people with Alzheimer’s?

delirium

Ans. “Virtually all” [Practice Guideline]

Exercise

Q. Role of exercise in pts with Alzheimer’s?

Exercise

Ans. Reduces depression in addition to other health benefits.

MMSE & “moderate level”

Q. Moderate level of dementia is associated with what MMSE score?

MMSE & “moderate level”

Ans. < 15.