1. Dementias As of 12Sep07. All items from DSM-IV or APA Practice Guidelines unless otherwise indicated.

2. Dx criteria • Q. What is the outline of the DSM dx criteria?

3. Dx criteria - general • Ans. • 1. Multiple cognitive deficits. • 2. Gradual onset and decline • 3. Not part of another Disorder

4. Dx criteria – Specific Cognitive deficits • Q. What cognitive deficits are part of the DSM criteria of dementia?

5. Dx – specific cognitive deficits • Ans. • 1. Memory impairment • AND • 2. At least one of the following: • Aphasia • Apraxia • Agnosia • Executive functioning deficits

6. Early onset • Q. What is the dividing line between early and late onset dementia?

7. Early Onset • Ans. • < or = 65, early onset • > 65, late onset

8. Reasons to hospitalize • Q. List reasons to hospitalize pts with dementia.

9. Reasons to hospitalize • Ans. • 1. Symptom severity: • Dangerousness to self or others, including inability of caretakers to care for the pt 2. Intensity of care and treatment needed: -- evaluations or treatments that cannot by done on outpt basis.

10. Follow-up • Q. If you have a “routine” pt with Alzheimer’s, how often should the pt be monitored by you?

11. Follow-up • Ans. Every 3 to 6 months.

12. MMSE • Q. What is the MMSE? And What does it evaluate?

13. MMSE • Ans. • MMSE = Mini-mental status examination. • MMSE tests cognitive functioning.

14. CT or MRI • Q. When is CT or MRI advised as part of the initial eval of people with dementia?

15. CT or MRI 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: • Early onset • Relatively rapid onset • High vascular risk factors suggested • Neurological exam suggests local lesions

16. Neuropsych testing • Q. When is neuropsych testing indicated?

17. Neuropsych testing Ans. When questions arise as to whether the individual actually has a “dementia.” • [Keep in mind that only Mental Retardation and Learning Disorders has psychological testing as part of a DSM criteria set.]

18. Gene testing • Q. Is gene testing recommended?

19. Gene testing Ans. Gene testing is not recommended. Dx is clinically based regardless of genes.

20. Apolipoprotein E-4 • Q. What is the significance of apolipoprotein E-4 (APOE-4)?

21. Apolipoprotein E-4 Ans. Apolipoprotein E-4 [APOE-4], on chromosome 19, is more common in individuals with Alzheimer’s – but not diagnostic.

22. Suicidal • Q. At what stage of a dementia is suicidal ideation most common?

23. Suicidal Ans. Most common when the disease is still mild.

24. Suicide and gender • Q. Which gender is suicide most common in this illness?

25. Suicide and gender Ans. Men [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.]

26. Falls • Q. Give one of major ways a physician can reduce the chances of falls in pts with dementia.

27. Falls Ans. Review and considered discontinuance of meds associate with falls.

28. Driving • Q. Should a physician report their pt who has dementia to the state department of motor vehicles?

29. Driving Ans. Varies by state. Required in some, forbidden in others.

30. Dosing in the elderly Q. What are the principles of medicating in the elderly?

31. Medicating the elderly Ans. -- lower starting doses. -- longer intervals between dose increases. -- smaller dose increase

32. Medicating rules - why Q. Why the go slow approach with the elderly?

33. Medicating rules - why Ans. slower hepatic metabolism decreased renal clearance

34. Goal of medicating Q. What is the goal of medicating a pt with Alzheimer’s?

35. Goal of medicating Ans. Delay progression of the disease. No med reverses.

36. FDA for Alzheimer’s Q. What meds have been approved for Alzheimer’s?

37. FDA for Alzheimer’s Ans. donepezil galantamine memantine rivestigmine tacrine [no longer in use]

38. FDA – med action Q. Which of the five is/are cholinesterase inhibitors? Which is/are NMDA antagonist?

39. Meds - actions Ans. donepezil, galantamine, rivestigmine, and tacrine are cholinesterase inhibitors. memantine is a noncompetitive N-methyl-aspartate antagonist.

40. Vitamin E • Q. What about high doses of Vitamin E for Alzheimer’s?

41. Vitamin E Ans. Not proven to be useful and high doses may be associated with increased risk of heart failure. Vitamin E must be avoided in pts with vitamin K deficiencies.

42. Selegiline • Q. Selegiline’s usefulness in dementia?

43. Selegiline Ans. Not proven to be useful.

44. tacrine Q. Tacrine status?

45. tacrine Ans. Regarded as less preferred to donepezil, rivestigmine, and galantamine because of tacrine’s hepatic toxicity.

46. ECT • Q. Indications for ECT in pts with Alzheimer’s?

47. ECT Ans. Indicated for pts with moderate to severe depression and Alzheimer’s and who do not respond to or cannot tolerate antidepressant meds.

48. Delusions and hallucinations • Q. Pt is moderately impaired from Alzheimer’s, has delusions and hallucinations and is not distressed or agitated, meds?

49. Hallucinations and delusions Ans. No meds, instead reassurance, redirection and distractions.

50. Hallucinations and delusions • Q. Alzheimer’s pt with hallucinations and delusions and combative, meds?