Neurology Book

http://www.fpnotebook.com/

Dementia Management

Advertisement

  1. See Also
    1. Dementia
  2. Evaluation Tools
    1. See Dementia for diagnostic criteria
    2. Cognitive Scales
      1. Mini-Mental State Examination
    3. Daily Function
      1. Activities of Daily Living Scale (ADL)
      2. Instrumental Activities of Daily Living Scale (IADL)
      3. Functional Activities Questionnaire
    4. Caregiver assessment
      1. Caregiver Burden Scale
    5. Scales used in research
      1. Alzheimer's Disease Assessment Scale (Cognitive)
      2. Behavioral Pathology in Alzheimer's (BEHAVE-AD)
      3. Neuropsychiatric Inventory Questionnaire (NPI-Q)
      4. Clinical Global Impression of Change
  3. Management: Specific concerns in Dementia
    1. Dementia Related Malnutrition
    2. Behavior Problems in Dementia
    3. Agitation in Dementia
    4. Sleep Problems in Dementia
    5. Wandering Behavior in Dementia
  4. Management: Protocol (monitor cholinesterase inhibitors)
    1. Confirm diagnosis of Alzheimer's Disease
      1. See Dementia
      2. See Altered Level of Consciousness
    2. Complete baseline scales
      1. Mini-Mental State Examination
      2. Activities of Daily Living Scale (ADL)
      3. Instrumental Activities of Daily Living Scale (IADL)
    3. Implement non-pharmacologic measures
      1. Educate patient and family regarding diagnosis
      2. See specific concerns in Dementia above
      3. Regular Exercise improves quality of life
        1. Teri (2003) JAMA 290:2015
    4. Start acetylcholinesterase inhibitor (see below)
      1. Titrate medication to most effective dose
    5. Re-evaluate at 6 month intervals
      1. Repeat scales performed at baseline (MMSE, ADL, IADL)
      2. Indicators to continue acetylcholinesterase inhibitor
        1. Patient improved or stable on current agent
      3. Indicators to switch to other agent
        1. Decline in MMSE (>2 points)
        2. Decline in ADL or IADL
      4. Indicators to discontinue cholinesterase inhibitors
        1. Persistent decline in MMSE and ADL or IADL
        2. Intolerable side effects
        3. MMSE <10 with dependency in all ADLs
  5. Management: Medications
    1. Acetylcholinesterase Inhibitors
      1. Efficacy
        1. Improve neuropsychiatric scores 7 points
          1. Seven point improvement equals ~1 year of decline
          2. Benefits may persist for 1-2 years
          3. Rogers (1998) Arch Intern Med 158:1021
        2. Meta-analysis shows marginal benefit to risk ratio
          1. Where NNT is Number Needed to Treat
          2. NNT for global improvement: 10
          3. NNT for cognitive improvement: 12
          4. NNT for significant side effects to stop med: 16
          5. Lanctot (2003) CMAJ 169:557
      2. Agents
        1. Donepezil (Aricept): May be preferred agent
          1. Delays nursing home placement by 17-21 months
          2. Geldmacher (2003) J Am Geriatr Soc 51:937
        2. Galantamine (Reminyl)
        3. Rivastigmine (Exelon)
          1. Adverse effects limit use (new patch may be better tolerated)
        4. Tacrine (Cognex)
          1. Rarely used now due to hepatotoxicity
    2. N-Methyl-D-Aspartate (NMDA) Receptor Blocker
      1. Memantine (Namenda, Ebixa in Europe)
        1. May prevent nerve damage
        2. Better tolerated than cholinesterase inhibitors
        3. Dose: Start 5 mg PO qd and titrate to 10 mg PO bid
        4. Improves cognition and function
        5. Tariot (2004) JAMA 291:317
    3. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Treat comorbid depression
      2. Significant impact on quality of life
      3. References
        1. Lyketsos (2003) Arch Gen Psychiatry 60:737
    4. Light Alcohol consumption (1-6 drinks per week)
      1. Appears to have protective effect against Dementia
      2. However also has negative cognitive effects
      3. Mukamal (2003) JAMA 289:1405
    5. Sleep Disturbance
      1. Trazodone 25 to 150 mg PO qhs
  6. Management: Medications to avoid (due to risk or lack of benefit)
    1. NSAIDs: No benefit in prospective trials
      1. Netherlands Study (n=6989 over age 55, for 8 years)
        1. Continuous NSAID use decreased Alzheimer's risk
        2. Relative Risk Reduction 80% for >2 years of use
        3. Aspirin did not confer same benefit as NSAID use
        4. Veld (2001) N Engl J Med 345:1515
      2. Johns Hopkins Retrospective study (n=209)
        1. NSAIDS (n=32) slowed Alzheimer's progression
        2. Based on MMSE, Boston Naming, and Benton scales
        3. Rich (1995) Neurology 45:51
      3. Recent evidence does not support routine use
        1. Cummings (2004) N Engl J Med 351:56
    2. Vitamin E 400 to 1000 IU bid
      1. Initial studies showed slower functional decline
        1. Sano (1997) N Engl J Med 336:1216
      2. Insufficient evidence to recommend by Cochrane
        1. Tabet (2003) Cochrane Database Syst Rev :
    3. Selegiline (Eldepryl) 10 mg PO qd
      1. Vitamin E is less expensive and as effective
      2. Meta-analysis with not enough evidence to support
        1. Birks (2003) Cochrane Database Syst Rev :
    4. Hormone Replacement Therapy (Estrogen Replacement)
      1. Initial studies showed possible benefit
      2. Recent studies have shown no benefit or worsening
      3. References
        1. Buckwalter (2004) J Am Geriatr Soc 52:182
        2. Espeland (2004) JAMA 291:2959
    5. Ginkgo Biloba 40 mg PO tid
      1. Appears mildly effective in improving cognition
      2. Case reports of coma, bleeding, and Seizures
      3. High drop out rate in studies
      4. References
        1. Le Bars (1997) JAMA 278:1327
        2. Oken (1998) Arch Neurol 55:1409
  7. References
    1. Cummings (2002) Am Fam Physician 65(12):2525
    2. Cummings (2004) N Engl J Med 351:56
    3. Delagarza (2003) Am Fam Physician 68(7):1365
    4. Delagarza (1998) Am Fam Physician 58(5):1175
    5. Sloane (1998) Am Fam Physician 58(7):1577
    6. Tariot (1997) Postgrad Med 101(6):73

Dementia (C0497327)

Definition (MSH)An acquired organic mental disorder with loss of intellectual abilities of sufficient severity to interfere with social or occupational functioning. The dysfunction is multifaceted and involves memory, behavior, personality, judgment, attention, spatial relations, language, abstract thought, and other executive functions. The intellectual decline is usually progressive, and initially spares the level of consciousness.
Definition (CSP)loss of intellectual functions such as memory, learning, reasoning, problem solving, and abstract thinking while vegetative functions remain intact.
ConceptsMental or Behavioral Dysfunction (T048)
ICD9290, 294.8
MSHD003704
EnglishAmentia, Amentias, Dementia, Dementias
Spanishdemencia
Parent ConceptsOrganic psychotic condition (C0520473), Organic brain syndrome (C0029221), Brain Diseases (C0006111), COGNITIVE/CORTICAL DISORDERS (C0549639), Delirium, Dementia, Amnestic, Cognitive Disorders (C0029227), Neurodegenerative Disorders (C0524851), [X]Dementia in other diseases classified elsewhere (C0349079)
SourcesAOD, COSTAR, CSP, CST, DXP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



Navigation Tree