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  1. 1. Dementias As of 12Sep07. All items from DSM-IV or APA Practice Guidelines unless otherwise indicated.
  2. 2. Dx criteria <ul><li>Q. What is the outline of the DSM dx criteria? </li></ul>
  3. 3. Dx criteria - general <ul><li>Ans. </li></ul><ul><li>1. Multiple cognitive deficits. </li></ul><ul><li>2. Gradual onset and decline </li></ul><ul><li>3. Not part of another Disorder </li></ul>
  4. 4. Dx criteria – Specific Cognitive deficits <ul><li>Q. What cognitive deficits are part of the DSM criteria of dementia? </li></ul>
  5. 5. Dx – specific cognitive deficits <ul><li>Ans. </li></ul><ul><li>1. Memory impairment </li></ul><ul><li>AND </li></ul><ul><li>2. At least one of the following: </li></ul><ul><ul><li>Aphasia </li></ul></ul><ul><ul><li>Apraxia </li></ul></ul><ul><ul><li>Agnosia </li></ul></ul><ul><ul><li>Executive functioning deficits </li></ul></ul>
  6. 6. Early onset <ul><li>Q. What is the dividing line between early and late onset dementia? </li></ul>
  7. 7. Early Onset <ul><li>Ans. </li></ul><ul><li>< or = 65, early onset </li></ul><ul><li>> 65, late onset </li></ul>
  8. 8. Reasons to hospitalize <ul><li>Q. List reasons to hospitalize pts with dementia. </li></ul>
  9. 9. Reasons to hospitalize <ul><li>Ans. </li></ul><ul><li>1. Symptom severity: </li></ul><ul><ul><li>Dangerousness to self or others, including inability of caretakers to care for the pt </li></ul></ul><ul><ul><li>2. Intensity of care and treatment needed: </li></ul></ul><ul><ul><li>-- evaluations or treatments that cannot by done on outpt basis. </li></ul></ul>
  10. 10. Follow-up <ul><li>Q. If you have a “routine” pt with Alzheimer’s, how often should the pt be monitored by you? </li></ul>
  11. 11. Follow-up <ul><li>Ans. Every 3 to 6 months. </li></ul>
  12. 12. MMSE <ul><li>Q. What is the MMSE? And What does it evaluate? </li></ul>
  13. 13. MMSE <ul><li>Ans. </li></ul><ul><li>MMSE = Mini-mental status examination. </li></ul><ul><li>MMSE tests cognitive functioning. </li></ul>
  14. 14. CT or MRI <ul><li>Q. When is CT or MRI advised as part of the initial eval of people with dementia? </li></ul>
  15. 15. CT or MRI <ul><li>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: </li></ul><ul><ul><li>Early onset </li></ul></ul><ul><ul><li>Relatively rapid onset </li></ul></ul><ul><ul><li>High vascular risk factors suggested </li></ul></ul><ul><ul><li>Neurological exam suggests local lesions </li></ul></ul>
  16. 16. Neuropsych testing <ul><li>Q. When is neuropsych testing indicated? </li></ul>
  17. 17. Neuropsych testing <ul><li>Ans. When questions arise as to whether the individual actually has a “dementia.” </li></ul><ul><li>[Keep in mind that only Mental Retardation and Learning Disorders has psychological testing as part of a DSM criteria set.] </li></ul>
  18. 18. Gene testing <ul><li>Q. Is gene testing recommended? </li></ul>
  19. 19. Gene testing <ul><li>Ans. Gene testing is not recommended. Dx is clinically based regardless of genes. </li></ul>
  20. 20. Apolipoprotein E-4 <ul><li>Q. What is the significance of apolipoprotein E-4 (APOE-4)? </li></ul>
  21. 21. Apolipoprotein E-4 <ul><li>Ans. Apolipoprotein E-4 [APOE-4], on chromosome 19, is more common in individuals with Alzheimer’s – but not diagnostic. </li></ul>
  22. 22. Suicidal <ul><li>Q. At what stage of a dementia is suicidal ideation most common? </li></ul>
  23. 23. Suicidal <ul><li>Ans. Most common when the disease is still mild. </li></ul>
  24. 24. Suicide and gender <ul><li>Q. Which gender is suicide most common in this illness? </li></ul>
  25. 25. Suicide and gender <ul><li>Ans. Men </li></ul><ul><li>[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.] </li></ul>
  26. 26. Falls <ul><li>Q. Give one of major ways a physician can reduce the chances of falls in pts with dementia. </li></ul>
  27. 27. Falls <ul><li>Ans. Review and considered discontinuance of meds associate with falls. </li></ul>
  28. 28. Driving <ul><li>Q. Should a physician report their pt who has dementia to the state department of motor vehicles? </li></ul>
  29. 29. Driving <ul><li>Ans. Varies by state. Required in some, forbidden in others. </li></ul>
  30. 30. Dosing in the elderly <ul><li>Q. What are the principles of medicating in the elderly? </li></ul>
  31. 31. Medicating the elderly <ul><li>Ans. </li></ul><ul><li>-- lower starting doses. </li></ul><ul><li>-- longer intervals between dose increases. </li></ul><ul><li>-- smaller dose increase </li></ul>
  32. 32. Medicating rules - why <ul><li>Q. Why the go slow approach with the elderly? </li></ul>
  33. 33. Medicating rules - why <ul><li>Ans. </li></ul><ul><li>slower hepatic metabolism </li></ul><ul><li>decreased renal clearance </li></ul>
  34. 34. Goal of medicating <ul><li>Q. What is the goal of medicating a pt with Alzheimer’s? </li></ul>
  35. 35. Goal of medicating <ul><li>Ans. Delay progression of the disease. No med reverses. </li></ul>
  36. 36. FDA for Alzheimer’s <ul><li>Q. What meds have been approved for Alzheimer’s? </li></ul>
  37. 37. FDA for Alzheimer’s <ul><li>Ans. </li></ul><ul><li>donepezil </li></ul><ul><li>galantamine </li></ul><ul><li>memantine </li></ul><ul><li>rivestigmine </li></ul><ul><li>tacrine [no longer in use] </li></ul>
  38. 38. FDA – med action <ul><li>Q. Which of the five is/are cholinesterase inhibitors? Which is/are NMDA antagonist? </li></ul>
  39. 39. Meds - actions <ul><li>Ans. </li></ul><ul><li>donepezil, galantamine, rivestigmine, and tacrine are cholinesterase inhibitors. </li></ul><ul><li>memantine is a noncompetitive N-methyl-aspartate antagonist. </li></ul>
  40. 40. Vitamin E <ul><li>Q. What about high doses of Vitamin E for Alzheimer’s? </li></ul>
  41. 41. Vitamin E <ul><li>Ans. Not proven to be useful and high doses may be associated with increased risk of heart failure. </li></ul><ul><li>Vitamin E must be avoided in pts with vitamin K deficiencies. </li></ul>
  42. 42. Selegiline <ul><li>Q. Selegiline’s usefulness in dementia? </li></ul>
  43. 43. Selegiline <ul><li>Ans. Not proven to be useful. </li></ul>
  44. 44. tacrine <ul><li>Q. Tacrine status? </li></ul>
  45. 45. tacrine <ul><li>Ans. Regarded as less preferred to donepezil, rivestigmine, and galantamine because of tacrine’s hepatic toxicity. </li></ul>
  46. 46. ECT <ul><li>Q. Indications for ECT in pts with Alzheimer’s? </li></ul>
  47. 47. ECT <ul><li>Ans. Indicated for pts with moderate to severe depression and Alzheimer’s and who do not respond to or cannot tolerate antidepressant meds. </li></ul>
  48. 48. Delusions and hallucinations <ul><li>Q. Pt is moderately impaired from Alzheimer’s, has delusions and hallucinations and is not distressed or agitated, meds? </li></ul>
  49. 49. Hallucinations and delusions <ul><li>Ans. No meds, instead reassurance, redirection and distractions. </li></ul>
  50. 50. Hallucinations and delusions <ul><li>Q. Alzheimer’s pt with hallucinations and delusions and combative, meds? </li></ul>
  51. 51. Hallucinations and delusions <ul><li>Ans. Low dose antipsychotic. </li></ul><ul><li>[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.] </li></ul>
  52. 52. Profoundly impaired <ul><li>Q. What meds to help the cognition of the severely impaired? </li></ul>
  53. 53. Profoundly impaired <ul><li>Ans. Memantine is approved for the profoundly/severely impaired. Cholinesterase inhibitors are not. </li></ul>
  54. 54. Meds & Delirium <ul><li>Q. What classes of meds can cause delirium in those with Alzheimer’s? </li></ul>
  55. 55. Delirium & meds <ul><li>Ans. Virtually all psychotropic meds, even more so, those having anticholinergic activity. </li></ul>
  56. 56. Anticholinergic <ul><li>Q. What are some meds psychiatrists use that have anticholinergic activity? </li></ul>
  57. 57. Anticholinergic <ul><li>Ans. Tricyclics, low-potency antipsychotics, and diphenhydramine. </li></ul>
  58. 58. Dopaminergic meds <ul><li>Q. Dopaminergic meds used in Parkinson’s disease in pt who also has Alzheimer’s predisposes that pt to? </li></ul>
  59. 59. Dopaminergic meds <ul><li>Ans. Visual hallucinations </li></ul>
  60. 60. Vascular dementia <ul><li>Q. Treatment for vascular dementia? </li></ul>
  61. 61. Vascular dementia <ul><li>Ans. </li></ul><ul><li>-- control BP </li></ul><ul><li>-- low-dose aspirin </li></ul><ul><li>[2 of 3 trials with donepezil found some positive results, but the 3 rd trial lack of effectiveness probably precludes it being the correct answer.] </li></ul>
  62. 62. Fronto-temporal dementia <ul><li>Q. What med has been shown to decrease problematic behaviors of fronto-temporal dementia, e.g., agitation? </li></ul>
  63. 63. Fronto-temporal dementia <ul><li>Ans. Trazodone. </li></ul><ul><li>[If trazodone is not one of the choices, amantadine has some anecdotal support.] </li></ul>
  64. 64. Caregivers and depression <ul><li>Q. To what degree does depression occur in caregivers? </li></ul>
  65. 65. Caregivers and depression <ul><li>Ans. </li></ul><ul><li>30% of spousal care-givers experience a depressive disorder. </li></ul><ul><li>22-37% of adult children care-givers, the higher percentage, > 30%, in those with a prior hx of a mood disorder. </li></ul>
  66. 66. Federal Regulation <ul><li>Q. A major law, passed in 1987, that regulates the use of physical restraints and use of meds in nursing home is? </li></ul>
  67. 67. Federal Regulation <ul><li>Ans. The Omnibus Budget Reconciliation Act of 1987 [OBRA]. </li></ul>
  68. 68. Gender <ul><li>Q. In Alzheimer’s, which gender is more frequent? </li></ul>
  69. 69. Gender <ul><li>Ans. More common in women. </li></ul><ul><li>[Not just more common in absolute numbers, but in percentage of the gender.] </li></ul>
  70. 70. African Americans <ul><li>Q. Relative to Caucasians, Which dementias do African Americans have more and which do they have less? </li></ul>
  71. 71. African Americans <ul><li>Ans. More vascular dementia [could guess from their higher hypertension rate] and less Parkinsonian dementias. </li></ul>
  72. 72. Family Hx <ul><li>Q. If Mrs. X has Alzheimer’s, what the chances of her siblings or children getting Alzheimer’s? </li></ul>
  73. 73. Family hx <ul><li>Ans. Two to four times that of the general population. </li></ul>
  74. 74. Genes – early onset <ul><li>Q. What are the three genes that have an increased association with early on-set Alzheimer’s? </li></ul>
  75. 75. Genes – early onset <ul><li>Ans. </li></ul><ul><li>1. Amyloid precursor protein [APP] on chromosome 21 </li></ul><ul><li>2. Presenilin 1 [PSEN1] on chromosome 14 </li></ul><ul><li>3. Presenilin 2 [PSEN2] on chromosome 1 </li></ul>
  76. 76. Vascular dementia <ul><li>Q. Onset and course of vascular dementia? </li></ul>
  77. 77. Vascular dementia <ul><li>Ans. Acute onset and step-wise decline. </li></ul>
  78. 78. Alzheimer’s onset - age <ul><li>Q. Give the approximate onset of Alzheimer’s per the age of the individual, such as % per year of: </li></ul><ul><li>< 65 </li></ul><ul><li>65-70 </li></ul><ul><li>70-75 </li></ul><ul><li>75-80 </li></ul><ul><li>80-85 </li></ul><ul><li>>85 </li></ul>
  79. 79. Alzheimer’s onset - age <ul><li>< 65 – rare </li></ul><ul><li>65-70 – 0.5%/ year [i.e., one in 200 will develop Alzheimer’s within a year] </li></ul><ul><li>70-75 – 1% </li></ul><ul><li>75-80 – 2% </li></ul><ul><li>80-85 – 3% </li></ul><ul><li>>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.] </li></ul>
  80. 80. Mild cognitive impairment <ul><li>Q. Criteria for “mild cognitive impairment”? </li></ul>
  81. 81. Mild cognitive impairment <ul><li>Ans. While there is no agreed upon definition, the following will probably reach examiner’s questions: </li></ul><ul><li>1. Subjective memory complaints </li></ul><ul><li>2. Objective cognitive deficits on testing </li></ul><ul><li>3. Functioning OK </li></ul>
  82. 82. Vascular dementia - onset <ul><li>Q. Relative to age, what is the incidence of the onset of vascular dementia? </li></ul>
  83. 83. Vascular dementia - onset <ul><li>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. </li></ul>
  84. 84. Lewy body disease <ul><li>Q. Lewy body disease differs in clinical presentation from Alzheimer’s in what ways? </li></ul>
  85. 85. Lewy body disease <ul><li>Ans. Differs: </li></ul><ul><li>-- early and more prominent visual hallucinations </li></ul><ul><li>-- early and more prominent Parkinsonian features [leading to falls] </li></ul><ul><li>-- more rapid decline </li></ul>
  86. 86. Lewy body disease - meds <ul><li>Q. When you decide to prescribe antipsychotic medications to someone with Lewy body disease has, what prominent signs are your concern? </li></ul>
  87. 87. Lewy body disease - meds <ul><li>Ans. Very sensitive to extrapyramidal signs. </li></ul>
  88. 88. Frontotemporal dementia <ul><li>Q. Characteristics of frontotemporal dementia in comparison to Alzheimer’s? </li></ul>
  89. 89. Frontotemporal dementia <ul><li>Ans. </li></ul><ul><li>-- personality change early </li></ul><ul><li>-- apathy early </li></ul><ul><li>-- emotional blunting early </li></ul><ul><li>-- disinhibition early </li></ul><ul><li>-- language abnormalities early </li></ul><ul><li>-- memory problems late </li></ul><ul><li>-- apraxia late </li></ul><ul><li>[the examiner may use “Pick’s disease” for this entity] </li></ul><ul><li>[Hard to remember all 7 items, but recalling that memory is relatively late may get you the correct answer.] </li></ul>
  90. 90. Frontotemporal dementia - onset <ul><li>Q. Common age of onset? </li></ul>
  91. 91. Frontotemporal dementia - onset <ul><li>Ans. Onset tends to be between 50 and 60. </li></ul>
  92. 92. Huntington’s disease - gene <ul><li>Q. Genetic aspect of Huntington’s? </li></ul>
  93. 93. Huntington’s - genes <ul><li>Ans. Autosomal dominate. </li></ul>
  94. 94. Huntington’s - pathology <ul><li>Q. Pathology of Huntington’s? </li></ul>
  95. 95. Huntington’s - pathology <ul><li>Ans. While there is damage to many subcortical structures, the answer they are probably looking for is basal ganglia. </li></ul>
  96. 96. Creutzfeldt-Jakob disease - etiology <ul><li>Q. What two etiologies are seen in this disease? </li></ul>
  97. 97. Creutzfeldt-Jakob disease - etiology <ul><li>Ans. </li></ul><ul><li>-- slow virus </li></ul><ul><li>OR </li></ul><ul><li>-- a prion [proteinaceous infectious particle] </li></ul>
  98. 98. Mild cognitive impairment <ul><li>Q. Donepezil or galantamine help with mild cognitive impairment? </li></ul>
  99. 99. Mild cognitive impairment <ul><li>Ans. Neither have been shown to be helpful. </li></ul>
  100. 100. TD risks <ul><li>Q. Relatively to age, gender, and dementia, what are TD risks? </li></ul>
  101. 101. TD risks <ul><li>Ans. Relative to use of antipsychotics, increased risk: </li></ul><ul><li>1. in women, </li></ul><ul><li>2. increased risk in the elderly and </li></ul><ul><li>3. increased in those with dementia </li></ul>
  102. 102. delirium <ul><li>Q. What meds used in psychiatry are associated with delirium when used with people with Alzheimer’s? </li></ul>
  103. 103. delirium <ul><li>Ans. “Virtually all” [Practice Guideline] </li></ul>
  104. 104. Exercise <ul><li>Q. Role of exercise in pts with Alzheimer’s? </li></ul>
  105. 105. Exercise <ul><li>Ans. Reduces depression in addition to other health benefits. </li></ul>
  106. 106. MMSE & “moderate level” <ul><li>Q. Moderate level of dementia is associated with what MMSE score? </li></ul>
  107. 107. MMSE & “moderate level” <ul><li>Ans. < 15. </li></ul>