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Dementia Cases

Dementia Cases. Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012. Case 1.

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Dementia Cases

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  1. Dementia Cases Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

  2. Case 1 An 86 year old woman who lives alone and functions well is concerned about her memory and comes to see you. She has recently developed trouble remembering all of the birthdays in her family: 4 children, 11 grandchildren, 20 great-grandchildren, 2 living siblings, and 23 nieces and nephews. She has started keeping a calendar to help.

  3. Case 1 – PMH She has hypertension, well controlled by HCTZ and atenolol. She also has arthritis for which she takes Tylenol Arthritis ii po bid. There are no other medications. Her weight is steady and she eats all meals. She has had cataracts out and can see well. She has also had a hysterectomy, but no fractures. She has no allergies.

  4. Case 1 – SH, FH SH: She is a widow, lives alone, worked in retail sales, is a Seventh Day Adventist, and has 4 children as described above. FH: Positive for CAD in her father and NIDDM in her brother. There is no history of cancer, strokes, nor dementia.

  5. Case 1 - Exam HEENT – PERRLA, vision intact, mouth normal with dentures, ears normal with fair hearing Neck: normal with no bruits, nor masses. Thyroid is not prominent. Lungs: clear to auscultation and percussion Heart: RRR no murmurs, no irregularities, good pulses at the wrists, but no palpable pedal pulses. Abd: Soft, no masses, normal BS, no tenderness, no hernias. Ext: Fair ROM with DJD changes, but no inflammation. She can walk well. NEURO: Generally normal with no paralysis nor weakness. DTR’s 2+ to 3+ and equal. Alert. No tremor. MMSE score 24/30. Cranial nerves II – XII grossly intact. Skin: normal with seborrheickeratoses, but no rashes not suspicious lesions.

  6. Case 1 - Labs • CBC normal: Hgb 12.5, MCV 92 • BMP normal: creatinine 1.0, Na 139, K 3.5, BUN 20 • B12 456, folic acid 12 • TSH 4.5 • UA normal with no pyuria

  7. Question 1 The correct diagnosis in this woman is • Age-Related Cognitive Decline • Early Alzheimer’s • Lewy Body Dementia • Normal • Vascular Dementia

  8. Question 2 The proper medication for this woman’s condition is • Donepezil 5 mg po qhs • Galantamine 4 mg po bid • None • Rivastigmine patch 4.6 mg qd • Vitamin B12 1000 mcg po qd

  9. Question 3 She should be advised to • Discuss DNR and POA issues with her family • Prepare for nursing home placement • Rest as much as possible • Return for a check up in 1 year • Stop all current medication

  10. Case 2 A 76 year old man has dementia and is being started on donepezil for it. He has had 5 mg po qhs for 5 weeks and is no better yet.

  11. Question 4 The next step is • Switch to galantamine 4 mg po bid • Increase donepezil to 10 mg po qhs • Add a rivastigmine patch 4.6 mg qd • Stop the donepezil • Get a CT scan of the brain

  12. Question 5 If the donepezil is titrated to 23 mg po qhs and there is no change in function or mentation, then • Stop the donepezil • Double the donepezil to 23 mg bid • Add memantine 5 mg po qhs • Add Vitamin B12 1000 mcg po qd • Advise the family to arrange nursing home placement

  13. Question 6 If this man has some benefit from donepezil 23 mg po qhs, but needs more to stay independent at home, then • Stop the donepezil • Double the donepezil to 23 mg bid • Add memantine 5 mg po qhs • Add Vitamin B12 1000 mcg po qd • Advise the family to arrange nursing home placement

  14. Case 3 A 56 year old man has developed dementia characterized by rapid onset of • prolonged spells of staring off blankly • visual, scary hallucinations • pill rolling tremor and a festinating gait

  15. Question 7 The dementia diagnosis is most likely • Alzheimer’s • Lewy Body • Vascular • Multifactorial • Parkinson’s

  16. Question 8 Treatment principles for this dementia often exclude • Acetylcholinesterace Inhibitors • Memantine • Haloperidol • Sinement • SSRI’s

  17. Answers • A (Age-Related Cognitive Decline) This woman is functioning well and is not clinically demented. • C (None) This chief complaint would not be properly treated with any medication. • A (Discuss DNR and POA issues with her family) This is good advice for anyone. Excessive rest would be harmful. She needs twice yearly rechecks for progression. None of her meds are suspect. • B (Increase donepezil to 10 mg po qhs) As long as side effects are not an issue, then the donepezil should be titrated optimally. This is the next step. Switching meds is not indicated yet and imaging has no value in this situation.

  18. Answers • A (Stop the donepezil) When a fully titrated medication fails to work, then it should be stopped. • C (Add memantine 5 mg po qhs) If the benefit is real at full titration, then another medication may be added. • B (LewyBody) This is the classical description. • C (Haloperidol) All of the other meds have indications. Even haloperidol can be used for the psychosis, but expect adverse reactions with unresponsiveness or worsening Parkinsonism.

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