dementialec[1] (1)

81
DEMENTI EUFEMIO E. SOBREVEGA, MD FELLOW, PHIL. NEUROLOGICAL A SSOCIA TION FELLOW, PHIL. PSYCHIA TRIC ASSOCIA TION

Upload: twinkle-salonga

Post on 07-Aug-2018

224 views

Category:

Documents


0 download

TRANSCRIPT

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 1/83

DEMENTI

EUFEMIO E. SOBREVEGA, MDFELLOW, PHIL. NEUROLOGICAL ASSOCIATION

FELLOW, PHIL. PSYCHIATRIC ASSOCIATION

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 2/83

  PPRO CH TO P TIENTS COMPL INING OF

“FORGETFULLNESS”

Primary Care Visit

Diagnosis

Evaluation

Treatment

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 3/83

PRIMARY CARE VISIT

• Patient complains of

worsening of cognitive functioning

or caregiver/clinician noticescognitive impairment in the patient.

• suggestive of DEMENTIA?

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 4/83

  PPRO CH TO P TIENTS COMPL INING OF

“FORGETFULLNESS”

Primary Care Visit

Diagnosis

Evaluation

Treatment

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 5/83

DIAGNOSIS

• CONFIRM DEMENTIA:

•CLINICAL ASSESSMENT

• INTERVIEW WITH CAREGIVER/PATIENT

•NEUROPSYCHOLOGICAL EXAMS

•ANCILLARY PROCEDURES

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 6/83

DIAGNOSIS – Diagnostic Tests

• Exclude treatable causes which may be contributing to thedementia:

- BLOOD CHEMISTRIES

- CT SCAN

- MRI

- CSF EXAM

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 7/83

DIAGNOSIS - Exclusion

• Potentially treatable causes of dementia

A. Infections

- MENINGITIS

- HIV encephalitis

- Neurosyphilis

- Creutzfeldt-Jakob Disease

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 8/83

DIAGNOSIS - Exclusion

B. Metabolic and Toxic

- Alcoholism

- Hypothyroidism

- Hepatic or renal failure- Psychoactive medications

- Vitamin B12 or folate deficiency

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 9/83

DIAGNOSIS - Exclusion

C. Neoplastic

- Brain tumors

- Carcinomatosis

Others:- Subdural Hematoma

- Normal pressure hydrocephalus

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 10/83

DIAGNOSISGeneral Cognitive Screening Tests

1. Mini-Mental State Examination

2. Clock drawing test

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 11/83

MINI – MENTAL STATE

EXAMINATION

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 12/83

MINI – MENTAL STATE EXAMINATION

• ORIENTATION• TIME 5PTS

• PLACE 5PTS

• REGISTRATION 3PTS

• ATTENTION AND CALCULATION 5PTS

• RECALL 3PTS• LANGUAGE

• NAMING 2PTS

• REPETITION 1PT

• 3 STAGE COMMAND 3PTS

• READING 1PT

• WRITING 1PT

• COPYING 1PT

• TOTAL = 30PTS

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 13/83

A.1. Orientation

• What is the Points Score

Year? 1 1

Season? 1 1

Date? 1 1Day? 1 1

Month? 1 1

TOTAL = 5PTS

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 14/83

A.2. Orientation

• Where are we? Points Score

Province? 1 1

Country? 1 1

Town or City? 1 1Hospital? 1 1

Floor? 1 1

TOTAL=5PTS

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 15/83

B. Registration (Total points = 3)

• Name three (3) objects, taking one second to say each (e.g.apple, table, coin). Then ask the patient all three (3) after

you have said them.

• Repeat the answers until the patient learns three(3), up to 6trials

• Give one point for each correct answer

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 16/83

C. Attention and Calculation(Total points = 5)

• Serial sevens. Instruct patient to subtract 7 from 100 in increments.Stop after 5 answers. Alternate: Spell WORLD backwards (e.g.DLROW = 5, DLRW = 4, DLW = 3, OW = 2, DRLWO = 1 )

Give one(1) point for each correct answer or number of letter.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 17/83

D. Recall (Total points =3)

• Ask for names of three (3) objects learned in section B( e.g. apple, table, coin).

• Give 1 point for each correct answer.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 18/83

E. 1. Language – Naming

(Total points = 2)

• Point to a pencil and a watch.

Have the patient name the objectas you point.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 19/83

E. 2. Language – Repetition

(Total point = 1)

• Ask the patient to repeat the phrase,

“No ifs, ands or buts” after you.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 20/83

E.3. Language – 3 Stage Command

(Total points = 3)

• Have the patient follow a 3-stage command:

1. Take the paper in your right hand

2. Fold the paper in half 3. Put the paper on the floor

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 21/83

E.4. Language – Reading(Total point = 1)

• Have the patient read and obey the following: (1 point)

“CLOSE YOUR EYES”

(Write it in LARGE LETTERS)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 22/83

E. 5. Language – Writing

(Total point = 1)

• Have the patient write a sentence of his or her own choice. (1point)

• (The sentence should contain a subject and a verb and shouldmake sense. Ignore spelling errors when scoring)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 23/83

E.6. Language - Copying

(total point = 1)

• Have the patient copy the figure below. (Give one (1)point if all sidesand angles are preserved and if the intersecting sides form aquadrangle)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 24/83

SCORES

•Maximum Total Score is 30•Total Score ____

•Suggested guidelines for determining the severityof cognitive impairment

Mild: MMSE > 21

Moderate:MMSE 10 -- 20

Severe: MMSE < 9

Expected decline in MMSE scores in untreatedmild to moderate Alzheimer’s patient is 2 to 4points per year.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 25/83

  PPRO CH TO P TIENTS COMPL INING OF

“FORGETFULLNESS”

Primary Care Visit

Diagnosis

Evaluation

Treatment

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 26/83

EVALUATION

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 27/83

COMMON CAUSES OF DEMENTIA

56.8% AD

19.3% Others

13.3%

Multi-inflarct

dementia

1.5%

Medications

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 28/83

ALZHEIMER’S DISEASE

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 29/83

EVALUATION

ALZHEIMER,S DISEASE

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 30/83

Alzheimer’s disease

• Alzheimer’s disease (AD) is the most frequent cause ofdementia  – it represents more than half of all dementiacases.

• AD is most likely to occur in people aged over 65 –70 years of age (late-onset), although it can occur earlier (early- onset).

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 31/83

Alzheimer’s disease

• Alzheimer’s disease (AD) develops slowly over a period of years.

• progression of early-onset AD is more rapid.

•AD is associated with general impairment of higher cortical functions.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 32/83

EVALUATION

•Alzheimer’s disease (AD)

-diagnosis should only be made after other causes ofdementia have been excluded by lab test, physical and

neurological exams and patient history.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 33/83

DSM- IV DEFINITION OF DEMENTIA OFALZHEIMER’S TYPE

•MEMORY LOSS

• IMPAIRMENT IN AT LEAST 1 OTHER COGNITIVEDOMAIN

•GRADUAL ONSET AND SLOWLY PROGRESSIVE

•NOT DELIRIOUS

•DISABLING

•NO ALTERNATE EXPLANATION

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 34/83

DSM-IV DEFINITION OF DEMENTIA OFALZHEIMER’S TYPE

• MEMORY LOSS:

* INABILITY TO LEARN NEW MATERIAL ;POOR REMOTE RECALL

• IMPAIRMENT IN AT LEAST 1 OTHER COGNITIVEDOMAIN:

* APHASIA (LANGUAGE) *APRAXIA (MOTOR ACTS, VISUOSPATIAL) * AGNOSIA

(VISUAL RECOGNITION) * DISTURBEDEXECUTIVE FUNCTION (PLANNING, ETC.)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 35/83

MEMORY and the FORGOTTEN SELF

•SYSTEMATIC RETROGRADE AMNESIA: *

CANNOT LEARN NEW INFORMATION. * CANNOTRECALL MOST RECENT LEARNEDINFORMATION.

•PROGRESSIVE RETROGRADE AMNESIA: * ERASING

THE “LINE OF LIFE” FROM NEAREST TO OLDEST.* LOSS OF SEMANTIC (FACTUAL) AND

EPISODIC (PERSONAL) MEMORY.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 36/83

CRITERIA FOR DIAGNOSIS OF ALZHEIMER’SDISEASE

• PROBABLE ALZHEIMER’S DISEASE:

* DEMENTIA BY DSM-IV AND MMSE

* PROGRESSIVE MEMORY IMPAIRMENT* NO DISTURBANCE IN

CONCIOUSNESS

* BETWEEN 40 AND 90 AGE OF ONSET* ABSENCE OF SYSTEMICBRAIN DISEASE; SUPPORTED BY FAMILYHISTORY; CEREBRAL ATROPHY BY CT SCAN.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 37/83

CRITERIA FOR THE DIAGNOSIS OFALZHEIMER’S DISEASE

• DEFINITE ALZHEIMER’S DISEASE:

* CLINICAL CRITERIA FORPROBABLE ALZHEIMER’S D.

*HISTOPATHOLOGIC EVIDENCE(AUTOPSY OR BIOPSY)

NINCDS-ADRDA

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 38/83

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 39/83

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 40/83

Neuropathological changescharacteristic of AD

Normal AD

AP NFT

AP = amyloid plaques

NFT = neurofibrillary tangles

Courtesy of George Grossberg, St Louis University, USA

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 41/83

 Amygdala

Hippocampus

Entorhinal region and

the nucleus basalis of

Meynert

Hippocampus

DISEASE PROGRESION

Near regions

of cortexfrontal

Lobe

Parietal

Lobe

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 42/83

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 43/83

Paired helical

filaments

accumulate in

neuron

2

 These develop into NTFs, w/c

build up in the neuron, disrupting

function

3

 Abnormal tau protein

and paired helical

filaments also promote

development of

neuritic plaques

4

Neuron

NTFs

Phosphateaccumulation on

tau protein leads to

development of

 paired helical

filaments

1

 Abnormal Tau protein

Microtubules

Neuritic

 plaque

Paired

helicalfilament

 The neuron

eventually dies

5

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 44/83

Structural Changes in Alzheimer’s D. Brain

Neuron Loss

• Large Cortical Neurons

• Amygdala

• Hippocampus• Entorhinal cortex

• Basal forebrain cholinergic

nuclie

• Locus ceruleus

• Dorsal raphe neurons

Structural Alterations

• Neuritic plaques

• Neurofibrillary tangles

• Amyloid deposition• Inflammation

• Neuropil threads

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 45/83

Two Important Histological Markers

• Neuritic Plaques

• Amyloid PrecursorProtein(APP) A β 1-42

• Extracellular deposit

6-10nm fibrils

• Neurofibrillary Tangles• Derived from Tau protein

• Microtubule associated protein(MAP)

• Collection of paired helicalfilaments (intracellular)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 46/83

Neuritic

Plaques

Neurofibrillary

Tangles

Neuronal

Dysfunction and

Synapse Loss

Acetylcholine andOther

Neurotransmitter

Deficiencies

Clinical

Symptoms

Peter Whitehouse, MD 1997 

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 47/83

Amyloid cascade

Histologic changes

Biochemical deficits

Dementia syndrome

Jeffrey L. Cummings, MD

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 48/83

Amyloid

Cascade

Regional

CholinergicDeficiency

Regional

Cell Loss

OrbitofrontalFrontal

andTemporal

Reticulofrontal

AgitationPsychosisDelirium Disinhibition

Medial

Frontal

Apathy

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 49/83

OTHER DEGENERATIVE DEMENTIAS

• PICK DISEASE• RARE TYPE OF DEMENTIA CHARACTERIZED BY SELECTIVE ATROPHY OF THE FRONTAL

AND TEMPORAL LOBES OF THE BRAIN

DEMENTIA WITH LEWY BODIES• DEMENTIA IN THE ELDERLY

• Presence of Lewy bodies in the neurons of the brainstem and cerebral cortex

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 50/83

OTHER DEGENERATIVE DEMENTIAS

• HUNTINGTON’S DISEASE (CHOREA)• HEREDITARY DEGENERATIVE DISEASE (AUTOSOMAL DOMINANT) CHARACTERIZED BY:

• COGNITIVE DISTURBANCES,

• SLOWLY PROGRESSIVE DEMENTIA,

• EXTRAPYRAMIDAL MOTOR SYPTOMS OF CHOREA,RIGIDITY, BRADYKINESIA

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 51/83

  PPRO CH TO P TIENTS COMPL INING OF

“FORGETFULLNESS”

Primary Care Visit

Diagnosis

Evaluation

Treatment

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 52/83

TREATMENT

Non-pharmacological•Pharmacotherapy

•Non-cognitive symptoms

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 53/83

TREATMENT

•Non-pharmacological

- Patient, caregiver and healthcare workers

education

-Caregiver support

- Patient psychosocial treatment

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 54/83

Pharmacological Treatment of AD

Practice Recommendations:(AAN 2001)

• Cholinesterase inhibitors should be considered

in mild to moderate AD patients(standard).

• Vitamin E (1000 IU po bid) should be considered

in an attempt to slow progression of AD(guideline).

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 55/83

Treatment - Pharmacotherapy

A. Mild to moderate AD

- Cholinesterase inhibitors

(e.g. Rivastigmine, Donepezil and Galantamine)

B. Moderate to severe AD

- NMDA receptors

( e.g. Memantine)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 56/83

Treatment: Pharmacotherapy

• Cognitive Symptoms

A. Cholinesterase Inhibitors

- considered for mild to moderate AD

Mechanism of Action:

*all inhibit cholinesterase in the synaptic cleft thereby

enhancing central cholinergic function.

(e.g. Rivastigmine, Donezepil, Galantamine)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 57/83

Treatment: Pharmacotherapy

A. Cholinesterase Inhibitors1. Rivastigmine (exelon):

- inhibits both acetylcholinesterase andbutyrylcholinesterase.

- initial dose: 1.5 mg PO BID; may increase to3 mg PO BID after > if tolerated.

- may increase dose by 1.5 mg/dose every 2

weeks as tolerated.- maximum dose: 12 mg/day

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 58/83

Treatment: Pharmacotherapy

A. Cholinesterase Inhibitors

2. Donepezil (aricept):- inhibits acetylcholinesterase but not

butyrylcholinesterase which may be acomponent of neuritic plaques andtangles.

- initial dose: 5mg PO once daily at HS;

may increase to 10 mg PO OD at HS after4-6 weeks, if tolerated.

- maximum dose: 10mg/day

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 59/83

Treatment: Pharmacotherapy

A. Cholinesterase Inhibitors

2. Galantamine (reminyl):

- inhibits acetylcholinesterase and providesallosteric modulation of nicotinic

receptors which may have a disease-modifying benefit.

- initial dose: 4mg PO BID X 4 weeks; iftolerated, increase to 8 mg PO BID X > or

equal to 4 weeks; if still tolerated,increase to 12 mg PO BID.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 60/83

Treatment: Pharmacotherapy

B. NMDA – receptor antagonist

1. Memantine (abixa):

- considered in patients with moderate-

severe AD.ACTIONS:

- low to moderate affinity, uncompetitiveN-methyl-D-aspartate receptor

antagonist that block the pathological butnot physiological activation of NMDA receptor.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 61/83

Memantine

DOSAGE:-

* 1st week > 5 mg PO OD

* 2nd week > 5 mg PO BID

* 3rd week > 10 mg PO am and 5 mg

PO in the evening* 4th week & thereafter > 10 mg PO BID

Treatment: Pharmacotherapy

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 62/83

Treatment: Pharmacotherapy

Memantine

EFFECTS:

- to decrease the decline cognition and daily

functioning in patients with moderate to severeAD.

- combination with cholinesterase inhibitors hasbeen shown to be safe and effective with

cholinesterase inhibitor alone.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 63/83

Treatment: Pharmacotherapy

Vitamin E- considered in AD patients to slow diseaseprogression.

ACTION:- antioxidant; it slows nerve cell damage.

EFFECT:

- decrease the rate of functional decline of ADpatients.

- few drug interactions or side effects.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 64/83

TREATMENTNon-cognitive symptoms

-Antipsychotics

-Benzodiazepines-Antidepressants

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 65/83

TreatmentNon-cognitive symptoms

Rationale:

To minimize psychotic symptoms

(paranoia, hallucinations )orindependent symptoms (e.g.screaming, violence).

To help to increase comfort andsafety of patients and families.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 66/83

Treatment :Non-cognitive symptoms

for psychosis and agitation

Principles in Tx:

-Intervention used should be directed

by the level of anguish experienced bythe patient and risk to caregivers andpatient.

-Violent behavior needs to be treatedwith pharmacotherapy.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 67/83

Treatment :Non-cognitive symptoms

For psychosis and agitation

Principles in Tx:

Agitation needs to be investigatedfurther to reveal underlying causes.

If agitation continues repeatedly,psychosocial measure should be the1st line therapy.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 68/83

Treatment :Non-cognitive symptoms

For psychosis and agitation

Principles in Tx:

If psychosocial measures areunsuccessful or if agitation is thought

to be dangerous to patient/caregiverthen pharmacotherapy is warranted.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 69/83

Treatment :Non-cognitive symptoms

For psychosis and agitation

1. ANTIPSYCHOTICS

- 2nd line therapy to control psychosis oragitation in demented patients.

- ATYPICAL agents are BETTER tolerated than typicalantipsychotics.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 70/83

Treatment :Non-cognitive symptoms

For psychosis and agitation

1. Antipsychotics

- choice of agent is based on the

side effect profile that is mostsuited to the patient.

- administered in the evening to help

sleep and treat sundowningeffect.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 71/83

Treatment :Non-cognitive symptoms For

psychosis and agitation

1. Antipsychotics

- oral route is preferred

- start with low doses; increase dosecarefully and cautiously.

* elderly are more sensitive to the side effects ofantipsychotic.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 72/83

Treatment :Non-cognitive symptoms For

psychosis and agitation

•Atypical or Novel Anti-psychotics

*Olanzapine (Zyprexa)

*Quetiapine (Seroquel)

*Clozapine (Leponex)

*Risperidone (Risperdal)

*Aripiprazole (Abilify)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 73/83

Treatment :Non-cognitive symptoms For

anxiety and agitation

2. Benzodiazepines

- for agitation, where anxiety is a prominent feature.

- useful as start doses for occasional agitation or whesedation is needed.

- risk of disinhibition, over sedation falls or delirium.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 74/83

Treatment :Non-cognitive symptoms For

anxiety and agitation

2. Benzodiazepines

- start with low doses; increase dose carefully andcautiously.

- short acting agents that do not require metabolism for

activation are preferred.- elderly are more sensitive to the side effects ofbenzodiazepines.

T N i i

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 75/83

Treatment :Non-cognitive symptomsfor depression and apathy

3. Tricyclic antidepressants (TCA), MAOIs and SSRI

- may be used to treat depression

- SSRI are preferred agents

- occasionally cognitive deficits, may recover partially or

fully ( in pseudo- dementia) with treatment ofdepression.

T N i i

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 76/83

Treatment :Non-cognitive symptomsfor depression and apathy

1. Tricyclic antidepressants (TCA), MAOIs and SSRI

- choice of agents depends on drug interactions, side effects and desiredaction:

a. TCAs have significant CVS side effects and anticholinergicproperties.

b. SSRI have better side effect profile

c. Dietary restrictions (high tyramine food), drug interactions andside effects tend to limit the usefulness of MAOIs.

T t t N iti t

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 77/83

Treatment :Non-cognitive symptomsfor depression and apathy

1.Tricyclic antidepressants (TCA), MAOIs andSSRI

- Start with low doses; increase dose

carefully and cautiously.- elderly are more sensitive to the

side effects of antidepressants.

T t t N iti t

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 78/83

Treatment :Non-cognitive symptomsfor depression and apathy

•Selective Serotonin Re-uptake Inhibitors

*Fluoxetine (Prozac)

*Sertralline (Zoloft)*Citalopram (Lupram)

*Paroxetine (Seroxat)

T t t N iti t

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 79/83

Treatment :Non-cognitive symptomsfor depression and apathy

•Selective Norepinephrine – SerotoninReuptake Inhibitor

* Duloxetine (Cymbalta)

* Venlafaxine (Efexor)

T t t N iti t

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 80/83

Treatment :Non-cognitive symptomsfor depression and apathy

•Tricyclics

*Imipramine (Tofranil)

*Maprotilline (Ludiomil)*Dothiapine (Prothiadine)

T t t N iti t

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 81/83

Treatment :Non-cognitive symptomsfor depression and apathy

•Reversible MAO-Inhibitor A

*Meclobemide (Aurorix)

•Other Antidepressants

*Tianeptine (Amineptine)

*Mirtazapine (Remeron)

*Trazodone (Depresil)

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 82/83

Long Term Goals Of lzheimer’s

Disease Management

•Monitor treatment of cognitive symptoms.

•Detect and treat non-cognitive symptoms.

•Balance supervision with meaningful activity.

•Educate and advise regarding prognosis and transitions.

8/20/2019 dementiaLEC[1] (1)

http://slidepdf.com/reader/full/dementialec1-1 83/83

  PPRO CH TO P TIENTS COMPL INING OF

“FORGETFULLNESS”

Primary Care Visit

Diagnosis

Evaluation

Treatment