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Pharmacy Yr3 Central Nervous System > week 4- Medication Used In Dementia and Medicine Optimisation > Flashcards

week 4- Medication Used In Dementia and Medicine Optimisation Flashcards

1
Q

what are the 3 stages for giving medication in dementia?

A

 To prevent dementia
 At the onset of dementia
 During the later stages of dementia

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2
Q

what are the different types of medication that can be used for medication?

A 
 Acetylcholinesterase inhibitors (AChEIs), e.g. Donepezil, Rivastigmine,
Galantamine
 NMDA antagonists, e.g. Memantine
 Antioxidants, e.g. Ginkgo
 Anti-inflammatories, e.g. Ibuprofen
 Neurotrophic factors, e.g. Oestrogen
 Antiamyloid agents, e.g. Tramiprosate
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3
Q

is it useful to take acetylcholine esterase before a diagnosis?

A

no it isn’t

wont prevent the patient from progressing to Alzheimer disease

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4
Q

is it useful to take NSAIDs before a diagnosis?

A

if started early they could help

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5
Q

is it useful to take anti-hypertensives(ACE I, DIURETICS) before a diagnosis?

A

CAN DELAY PROGRESS AND HELP

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6
Q

is it useful to take beer before a diagnosis?

A

can help

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7
Q

is it useful to take oestrogen, lithium, statins,fish and vitamins before a diagnosis?

A

can help

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8
Q

what are some of the agents that have an effect on onset of dementia?

A
  • ginseng
  • folic acid
  • omega 3
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9
Q

what is aducanumab?

A
  • anti-amyloid antibody

- designed to target amyloid plaques in early stages of alzhemiers

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10
Q

when will disease modifying treatment work?

A

will only work if taken early enough, maybe
decades before diagnosis of dementia.
 Disease modifying treatment is expected to yield more dramatic benefits than
treatment of established dementia.

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11
Q

what medication is used for onset of dementia? type, function

A
  • they are acetylcholinesterase inhibitors
  • only for mild to mid Alzheimer but rivastigmine used in parkinsons
  • not cures but slow down progression of symptoms
  • donepezil 5-10mg OD ON
  • galantamine 4-12mg BD
  • rivastigmine 1.5-6mg BD
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12
Q

do acetylcholinesterase inhibitors work? outcomes?

A 
The three possible outcomes of AChEIs :
 Improvement
 Non-decline
 No response
 Each of these in equal proportions in the population

-about 1/3 will show improvement on daily activity can last 6-2yrs then decline will continue
 The progressive decline in functioning that would otherwise have occurred
can be delayed for several months or years
 This reduces carer burden
 This delays the need for transfer to a dementia-care home or hospital

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13
Q

what happenes if the AChEI’s dont work?

A

 Failure to benefit from one AChEI does not necessarily mean that someone
will not respond to another.
 Also, poor tolerance to one AChEI does not rule out good tolerance to another

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14
Q

how do you ensure the patient gets the best benefit and unwanted effects what should be done?

A

 Slow titration is recommended
 Rivastigmine patches are better tolerated than capsules
 Rivastigmine is best choice for patients taking multiple medications, and also
licensed in Parkinson’s disease

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15
Q

what does the NICE guidance say for treatment?

A

• Use the least expensive one first
• alternative AChE inhibitor could be prescribed if it is considered appropriate
when taking into account adverse event profile, expectations about
adherence, medical comorbidity, possibility of drug interactions and dosing
profiles
• Rivastigmine can be used in dementia associated with Parkinson’s disease

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16
Q

what are the adverse effects of AchEIs?

A

When they start to work, the AchEIs cause cholinergic stimulation of the body
too:
 Common side-effects: Nausea, Vomiting, Diarrhoea, Loss of appetite, Sleep
disturbance, Abnormal dreams, Headache, Incontinence, Fatigue, Agitation
 Bradycardia (dangerous in certain heart diseases, or if taking heart-slowing drugs,
e.g. Digoxin, beta-blockers, calcium-channel blockers)

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17
Q

what is the problem with commonly prescribed medicines and AchEIs?

A

Some commonly prescribed medicines are associated with increased anticholinergic burden, and
therefore cognitive impairment

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18
Q

what are some medication that can cause cognitive impairment?

A 
EXAMPLES (List not Exhaustive)
 Antihistamines e.g Diphenhydramine
 Tricyclic Antidepressants
 Antipsychotics- e.g Quetiapine
 Drugs used in Urinary Incontinence- e.g Solfenacin
 Hyoscine
 Pain Killers- e.g Morphine
 Some Asthma and COPD meds
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19
Q

what is the tool that can be used to assess anticholinergic burden

A

There are validated tools for assessing anticholinergic burden- e.g. the Anticholinergic Cognitive
Burden Scale

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20
Q

how can medicines be optimised? routines?

A

Donepezil can cause sleep disturbance and nightmares – give dose in the
morning.
• Rivastigmine patches can cause a rash. If mild, an emollient cream can be
used to soothe it. If severe then prescriber should be informed. Rotation of
the application site helps.
• Nausea is a common side-effect. This may be minimised by taking doses after
food.
• Bradycardia may occur. Check pulse every few months and seek advice if less
than 50 bpm.

21
Q

what medication is used during the later stages of dementia? drug, dose, side effects?

A

-memantine
- Licenced for moderate to severe Dementia in Alzheimer’s Disease
 Monotherapy is recommended for managing moderate Alzheimer’s disease who are intolerant
of or have a contraindication to AChE inhibitors or severe Alzheimer’s disease
 NMDA receptor Antagonist that maybe neuroprotective and thus disease modifying
 Usually started at 5 mg daily for one week and then increased by 5 mg per week,until 20 mg
daily is reached. Some practitioners do titrate faster than this in some cases.
 Common side-effects: Headache, Constipation, Dizziness, Hypertension, Dyspnoea

22
Q

what treatment is given to patents that have dementia other than alzhemiers?

A

UNLICENCED USE
 Offer donepezil or rivastigmine to people with mild to moderate dementia with
Lewy bodies.
 Only consider galantamine for people with mild to moderate dementia with Lewy
bodies if donepezil and rivastigmine are not tolerated.
 Consider donepezil or rivastigmine for people with severe dementia with Lewy
bodies.
 Only consider AChE inhibitors or memantine for people with vascular dementia if
they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or
dementia with Lewy bodies.
 Do not offer

23
Q

what is the evidence that has come from key trials for medicines for Alzheimer?

A

• Reduced carer burden with galantamine
• Adverse drug reactions more frequent with rivastigmine
• No significant difference in cognitive function between AChE inhibitors
• Significant delay in worsening symptoms with memantine (compared with
placebo)

24
Q

what are some behavioural symptoms of dementia from observation?

A

-Physical Aggression -Screaming
-Wandering
-Culturally inappropriate
behaviour
-Sexual Disinhibition
-Swearing

25
Q

what are some psychological symptoms of dementia from interview?

A
  • Anxiety
  • Depression
  • Hallucinations
  • Delusions
26
Q

how does BPSD (Behavioural
and Psychological Symptoms
of Dementia) progress over the stages?

A

mild- depression
moderate-physical aggression, hallucinations, screaming, swearing, wandering
severe-some symptoms disappear but depression hallucinations, paranoia, screaming

27
Q

what are some other causes that can be due to non-dementia causes THAT CAUSE SYMPTOMS?

A
  • stressed
  • hungry
  • anxiety
  • pain
  • thirst
  • hypoxia
  • infection
  • medication induced
  • constipation
28
Q

what are some other causes that can be die to non-dementia causes that cause physical aggression?

A 
-Medicines
(anticholinergic /
sedatives)
-alcohol withdrawal
-loss of dignity
-unfamiliar environment
-pain
-anger
-inability to speak
-exhaustion 
-being rushed
29
Q

how are patients managed for BPSD?

A

FIRST LINE - non drugs
Modification of behaviour of the carer may:
•reduce the occurrence of BPSD
•remove the need to treat the BPSD
-many symptoms may natural resolve themselves after 4-6 weeks

30
Q

what are some non-drug treatment principles?

A
  • Identify what symptom(s) cause most concern
  • Describe each symptom in detail
  • The ABC approach, antiseedants what happened before, behaviour, the consequence what happened after
31
Q

what is pain like for patients with dementia? how to manage

A

Under-reported by patient in both frequency and intensity, but they are still in pain

  • could go undetected or under-dosed
  • non vocals- facial expressions, point at face on chart, using abbey pain scale
32
Q

what are the princles of psychiatric drug treatment for BPSD?

A

Discuss risks and benefits of treatment
Check that symptoms have:
-no physical cause e.g. infection
-no iatrogenic cause e.g. medication
-no environmental
cause e.g. room being too hot or too cold
-no response to(or not treatable by)non-drug interventions

33
Q

how are psychiatric medicines introduced?

A

prescribing should involved:

  • the pateint kowing their capacity and medicine plan
  • informed concsent
  • use slow and cautious dose titrations to avoid side effects
  • use cautious dose regimes
34
Q

how are psychiatric medicine monitored in BPSD?

A
  • psychiatric medicines should be reviewed every 3 month and antipsychotic medicines should be reviewed every 6 weeks
  • review symptoms and behaviour
  • review any side effects and stop medication if no response or risk higher than benefit
35
Q

what are the benefits of combination medication?

A

use medicines that address several different symptoms to avoid unnecessary polyprescribing
-sedating antidepressants help with agitation, depressants and sleep disturbance

36
Q

how is management with psychiatric medicines done for dementia?

A
  • 50% of patients with dementia also experience depression

- use of AChEI to improve symptoms of apathy

37
Q

what are some non-antipsychotics medicines for BPSD?

A
  • AChEI like rivastimine, galantamine, Donepezil

- memantine

38
Q

when is it appropriate to use antipsychotics in the management of BPSD?

A

IF THE PATIENT HAS:

  • persistent aggression
  • Risk of harm to self or others
  • Unresponsive to non-drug approaches
  • Moderate to severe Alzheimer’s dementia
39
Q

how can antipsychotics help with dementia symptoms?

A

-can help people with hallucinaions that 50% of patients get

40
Q

what are the 5 types of delusions that patent with BPSD?

A
  • PEOPLE STEALING FROM THEM
  • spouse or care givers are imposters
  • abandonment
  • spouse being unfaithful
  • misidentification in the mirror
41
Q

what are the 4 types of misidentification a patient with BPSD can have?

A
  • presence of persons in the patient’s own house (the ‘phantom boarder’ syndrome)
  • cannot identify own self in mirror
  • cannot identify others
  • Television / photographs are seen as “real”
42
Q

what are some major adverse outcomes with antipsychotics in bpsd?

A
  • can cause over sedation and dehydration that can lead to stroke and infections
  • can double chances to falls and fractures
43
Q

what re some major adverse side effects ?

A
  • sedation
  • parkinsonism symptoms
  • dehydration
  • chest infections
  • confusion
  • movement problems e.g. tremors
  • agitation
  • dry mouth
44
Q

what is risperidone used for in BPSD?

A
  • SHORT TERM UP TO 6 WEEKS FOR PEOPLE WITH mild-moderate Alzheimer’s dementia that are unrepsonsve to other medication where they are a harm to themselves or others
  • Superior to placebo for aggression and psychosis in dementia
  • Others are ineffective or have harmful side-effects
  • Greater cognitive decline with quetiapine when compared to placebo
45
Q

what is the dose and regime for prescribing risperidone?

A
  • starting at 0.25mg BD
  • Adjust by increments of 0.25 mg twice daily, not more frequently than every other day, if needed
  • Optimum dose is 0.5 mg twice daily for most patients
  • Some patients need 1 mg twice daily
  • Maximum 6 weeks

Evaluate frequently and regularly

Reassess the need for continuing treatment reassessed

46
Q

how does discontinuation of antipsychotics work?

A
  • Many patients can stop antipsychotics for BPSD safely without worsening of symptoms
  • monitoring may be carried out by healthcare profession
  • may remove them after 6 weeks not all are discontented
  • never discontinuation if they have schizophrenia
47
Q

why shouldnt benzodiazepines in people with BPSD?

A

-AS BENZODIAZEPINES INCREASE THE CHANCE OF FALLS BY X8

48
Q

what the first line treatment for BPSD?

A
  • Non-drug psychosocial interventions
  • Most BPSD resolve after 4 - 6 weeks
  • Assessment and appropriate treatment of medical conditions, e.g. pain, infection, depression
  • in servere aggression in demetnia only prescribe risperidone

Pharmacy Yr3 Central Nervous System (17 decks)

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