aging brain

• brain volume shrinks

• neurons lost greater than regenerated

• synapses deterioate

• neurotransmitters less efficient

Types of memory

• episodic

  • information stored with mental tags

    • when, where, how it was picked up

  • minutes - years

  • declines from middles age

  • remote memories longer

• semantic

  • memory of meanings

  • colume increases gradually from middle age to young elderly

    • declines very elderly

• procedureal

  • how to

  • usually retained into late life

• working

  • brief period

    • seconds to minutes

  • phonological

  • spatial

Normal memory loss:

1. rule out other causes

   1. consider depression

   2. red flags

2. differentiate noraml from early stage dementia

3. consider memory test

4. make plan

   1. f/u

   2. investigations

   3. referral

1. rule out

• reversible

  • medications

  • history of drug or etoh misuese

  • signs/symptoms of infection

  • recent head trauma

• depression

  • consider GDS

• medical conditions

  • mental illness

  • cerevrovascular disease

  • neurodegenerative disease

  • medications

  • substance misues/dependence

  • brain tumour and infections

  • epilepsy

  • chronic pain, anxieyt, stress

  • sleep disorder

  • thyroid disease

  • malnutrition

red flags

Age \<60yo

rapid decline in cognition/function (2mo)

use of anticoagulants or history of bleeding disorder

history of cancer

family history of neurodegenerative disease

any new localising sign

unusual or atypical cognitive symptoms or presentation

gait disturbance

2. differnetiate from noraml

• noraml =

  • subjective memory concern

  • mild episodic memory impairment

  • preserved procedural and semantic memory

  • possible mild non-memory cognitive dysfunction

  • no functional impairment or behavioural abnormalities

• main distinction = do not affect daily functioning or ability to live independently

• other signs of cognitive impairment

  • Aphasia - producting/understanding speech

  • Apraxia

    • difficulty performing motor

  • Agnosia - recongise fmailiar people/places/objectives

  • disturbance executive function

    • sequencing, organinsg, abstracting, planning

    • change in behaviour/mood

    • physical signs

  • ask:

    • trouble managing money

    • using telephone

    • transportation

    • remembering to take medications

3. memory test

• MMSE

• MiniCOG

• GPCOG

  • 5min

  • high sensitivity and spec (≥ 80%)

  • misclassification = mmse = 15%

Keep brain healthy

• exercise

• etoh

  • teetotal nad heavy disadvantaged

• diet

  • antioxidants

  • omega-3

• supplements

  • gingo biloba

Donepezil

• cholinesterase inhibitors

  • specific and reversible

• registered in NZ for symptomatic treatment of alzheimer’s disease and vascular dementia

• moderate = MMSE 10-20

• cost effective

• evidence that slow underlying progression of disease

• may expect 6mo of preserved cognitive function

• before initiating - clear diagnosis

  • 5mg/day at night

  • 1 month

    • if tolerated increase to 10mg

  • assess treatment response at 3mo and again at 6mo

  • reduce to 5mg if intolerable

  • no effect = discontinue

• adverse effects

  • cholinergic effects in 20%

  • other

    • fatigue

    • dizziness

    • headahce

    • syncope

    • bradycardia

    • agitation

    • confjsiton

    • fyspepsisa

    • increase sweating and tremor

  • dose dependent

• precautions

  • asthma

  • copd

  • epilepsy

  • seizure disorder

  • urinary retention

  • history of peptic ulcer disease

• cause bradycardia - sick sinus syndrome

  • watch with betablockers

behavioural and psychological symptoms (BPSD) of dementia

• antipsychotic second line

• useful for treating aggression, agitation or psychotic symtoms

  • if causing severe distress or an immediate risk of harm to the patient or others

• not useful for wandering, shouting, touching or social withdrawal

• only modestly effectivel

• atypical better tolerated

• risperidone, olanzapine, aripriprazole = small but significant effect

• quetiapine not significantly better

• Risperrdone

  • 0.25-0.5mg initially to max 2mg/day

  • most studied

  • only one approved

  • others are considered off label use

  • adverse effects

    • moderate weight gain

    • higher risk hyperprolactinaemia

    • medum - dyslipidaemia, extrapyrimdal

• quetiapine

  • 12.5mg initially - max 100mg

  • safer compared to other antipsychotics in terms of mortality but not as effective

  • low dose \<100mg better tolerated

• olanzapine

  • modestly effective for treating agitation

  • not as robust as risperidone

• Aripiprazole

  • not subsidsed for this use

  • SA

    • doesn’t cover BPSD

• issues with antipsychotics

  • increase cerebrovascluar events

    • risperidone

    • olanzapine

  • increased mortality

    • long QT

      • erythrmoycin, citalopram, venlafaxine

  • increase risk of pneumonia

  • tardive dyskinesia

    • orofacial and trunk movements

    • 3% risperidone

    • 1-2% for other atypical

    • 20% in typical antipsychotics

GP COG

patient

• 9 = no cognitive impairment - interview not necessary

• 5-8 = informant interview

• 0-4 cognitive impairment - interview not necessary

• recall

  • name and address (4 attempts to repeat address)

  • John Brown, 42 West street, kensington

• time

  • date = 1

• clock

  • mark all numbers to indicate hours of a clock = 1

  • mark in hands to show 10minutes poast 11 = 1

• information

  • something happened in news = 1

• recall name and address

  • 1 point each

    • John, Brown, 42, West street, kensington

Informant

• does pt have more trouble remmebering things that have happened recently

• does he or she have more trouble recalling conversations a few days later

• when speaking, does patient have more difficulty in finding ther right word or tend to use the wrong words more often

• less able to manage money/financial affairs

• less able to manage his or her medication

• more assistance with transport

• socre;

  • 4-6 ok

  • 0-3 cognitive impairment