GPCOG

types of memory

Episodic memory

• information stored with mental tags about when/where/how it was picked up

• memories stored from minutes to years

• ability to learn new infromation and recall recently learned memory declines from middle age

• Remote memories more resistant to loss

Semantic memory

• memory of meanings

• volume of this memory increases gradually from middle age to young elderly, declines in very elderly

Procedural memory

• “how to”

• explicit - purposful conscious

• implicit - automatic

working memory

• information received over brief period of time before it is dismissed or transferred to longer-term memory

• phonological

• spacial

Framework to assess memory loss

1. rule out other causes

   1. medications

      1. drug/etoh

      2. signs/symtoms infection

      3. recent head trauma

   2. consider depression

      1. selective/patchy compared to generally impaired

      2. Geriatric Depression Scale may be used

   3. red flags

2. Differentiate normal age-related cognitive decline from early stage dementia

   1. normal =

      1. subjective memory concern

      2. mild episodic memory impairment

      3. preserved procedural and semantic memory

      4. mild non-memory cognitive dysfucntion

      5. no functional impairment or behaviourla abnormal

   2. mild cognitive impairment = greay area between normal and dementia

      1. frequently compared to occasionally

   3. dementia

      1. if memory loss + other cognitive

         1. aphasia

         2. apraxia

         3. agnosia

         4. disturbance in executive functioning

         5. change in bahaviour / modd

         6. phsyical signs

            1. gait change

            2. extra pyramidal

            3. focal or lateralising neurologcial signs

3. Consider performing memory test

   1. GPCOG

      1. administration time of \<5min

      2. misclassification rate less htan or equal to MMSE (15%)

      3. high sens and spec

4. Make a plan; follow-up, investigations, referral?

   1. investigations

      1. CBC

      2. crp

      3. tsh

      4. vitamin b12

      5. folate

      6. elecrolytes

      7. calcium

      8. glucose

      9. consider imaging

Red flags

age \<60yo

Rapid (1-2mo) decline in cognition or function

unexplained neurological symptoms

use of anticoagulants or history of bleeding disorder

history of cancer

fmaily history of neurodegenerative disease

new localising sing

unusual or atypical cognitive symptoms or presentation

Gait disturbance

prevention

Exercise

• incl level associated with improved memory and learining

• reduced age-related cognitive decline

EtOH

• small quantities

  • stimulate hippocampus

  • U or J shaped curve

Diet

• healthy, balance diet rich in antioixdfants and omega-3

• naturally occuring compared to supplements

Brain exercises

• exericse brain

• social interaction

• take up dancing!

Behavioural and psychological symptoms of dementia

behavioural and psychological symptoms of dementia = symptoms of disturbed percetption thought, mood or behaviour in a person with dementia which are not due to another major neuropsychiatric disorder (Major depressive episode)

Antipsychotics

• concern re overprescription to control inappropriate behaviour in people with dementia

• why behaviour is occuring

• evidence base for non-pharmacological treatments not strong

  • less risks associated with these interventions

target behaviours

• calling out

• aggression

• agitation

• hallucinations and illusions

• delusions

• wandering

• depression

• elevated mood

• “sundowning”

• insomnia

• apathy/lack of motivation

• extreme anxiety

• resistance or unease towards carers

• intrusive behaviours

• inappropriate sexualised behaviour

• inappropriate urination/defaecation

• inappropriate social behaviours

document and record response to treatment

Differential diagnosis

• Depression

  • weeks to months

  • sometimes abrupt with life changes

  • variable and uneven progression

  • thinking intact with temes of helplessness - negative

  • selective / patchy memory

  • reduced sleep

    • early morning wakening/oversleep

  • clear awareness

• Delerium

  • hours - days

  • duration hours to \<1/12

  • abrupt, fluctuating

  • disorganised, slow, incoherent thinking

  • memory ussen impaired

  • sleep :nocturnal confusin

  • reduced awareness

  • gluctuating alertness

  • attention impaired ad fluctuates

• Dementia

  • months - years onset

  • chronci and insidious

  • slow steady progression

  • impaired memory

  • disturbed sleep/nocturnal wandering

  • clear awareness

  • normal alertness/attention

Medicines that worsen

• anticholinergics

  • amitrip, oxybut

• anticonvulsants

  • carbamazepine, phenytoin

• Lithium

• systemic corticosteroids

• H2 antagonists

• Abx

  • cipro, norflox, metronidazole, clarithromycin

• opiates

• anti-parkinson’s

• acei

• Digoxin

Undetected medical conditions

• pain

• infection

• dehydration/hyponatraemia

• constipation

• urinary retention

• anxiety

• fatigue

• hearing/visual impairment

• poor dental health

Management

• Personal / environment

  • calm/tranquil environment

  • home/room comfortable temp

  • easy access to toilet

  • well lit surroundign

  • sings and memory aids for objects within home

  • improve time orientation

  • environment as home like

  • involvment group activities

  • ensure consitency

  • privacy

• antipsychotics = second line

  • aggression, agitiation, psychotic sympotms

  • not recommended for patients mild-moderate

    • not effective for wandering, social withdrawal, shouting, pacing, touching, incontinence

  • only modestly effective

  • atypical not better jhust better tolerated

  • risperidone, olanapine, aripriprazole

    • quetiapine not signifiant

  • common adverse effects

    • sedation

    • dizziness

    • postural hypotension

    • confusion

    • increase falls

    • anticholinergic effects

      • cognitive decline

      • delerium

    • extrapyramidal effects

      • occur more commonly with typical

      • can occur with risperidone

      • tardive dyskinesia can occur

    • metabolic changes

      • weight gain

      • hyperglycaemia

      • increase prolactin

      • not as frequently in older people

  • increased risk of cerebrovascular events

    • stroke

    • unknown mechanism

    • first weeks of use

    • past history more at risk

  • increased mortality

    • 1.6-1.7 times those treated with atypical antipsychotics

    • 1 in 87 treated will die

  • increased risk of pneumonia

  • Risperidone

    • only antipsychotic approved for this use in NZ

    • first line

    • 0.25 - 0.5mg initially

    • max 2mg daily in patients with dementia in 1-2 divided doses

  • Quetiapine

    • increase used

    • safer

    • well tolerated

    • 12.5mg initially

    • maximum 100mg/day in patients with demetia

  • Olanzapine

    • modestly effective treating agitation

    • evidence not as robust compared to riseridone

    • more metabolic side effects

    • 2.5mg initially then 10mg daily in 1-2 divided doses

  • aripiprazole

    • modestly effective

    • not subsidised for this use

    • SA required

  • Haloperidol

    • effective

    • high risk of extrapyramidal side effects

    • increase mortality compared to atypical antipsychotics

    • low dose haloperidol restricted place in short term management of acute symptoms of derlirium

    • 0.25mg twice daily titrated up to 3mg/day

• monitor for:

  • cns depression

  • anticholinergic effects

  • dizziness and postural hypotension

  • extrapyramidal effects

  • metabolic changes

    • weight, hba1c every 3 months for 1 yr then annually

  • infection

• try and withdraw every 3/12 or at least reduce dose

  • reduce dose 50% every 2 weeks then stop