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Neuro Quiz 5 > Treatment of Alzheimer's Disease > Flashcards

Treatment of Alzheimer's Disease Flashcards

1
Q

Screening only test:

A 
MMSE
SLUMS
MOCA
Clock Drawing
- Then do a pharmacist's review of meds if there is a possible deficit
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2
Q

Alzheimer’s Disease Assessment Scale, Cognitive Subscale (ADAS-cog)

A
  • Primary outcome measure

* Sensitive

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3
Q

Clinician’s Interview Based Impression of Change (CIBIC)

A
  • Subjective

* More qualitative assessment

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4
Q

Global Dementia Rating Scale (GDRS)

A

• Evaluate how well and intervention influence big cohorts of patients as they progress

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5
Q

GDS, Cornell and NPI

A

Psychiatric and behavioral symptoms identification

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6
Q

ADAS-cog change is score evaluations:

A

Magnitude of response: magnitude of change in the score before and after medication intervention and across points in time
Responder rate: Proportion of patients who achieve a minimum threshold of change expressed as a percentage

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7
Q

What scale is used to determine stages on AD

A

Reisberg Scale or FAST scale

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8
Q

Stage 1

A
  • Last known period of normal function

* ID retrospectively

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9
Q

Stage 2

A
  • Very mild impairments
  • Only the patient recognizes the problem
  • Patient can compensate for deficits so others may not notice yet
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10
Q

Stage 3

A

• Others begin to notice problems in memory, problem solving, following directions, managing finances (IADLs)
• Often a formal diagnosis is not made until this stage
• Could come with depression and anxiety
o Geriatric depression scale might be necessary
• Living at home might need to be evaluated at this point
• MMSE score might be 21-24

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11
Q

Stage 4

A
  • Self-care activities are affected
  • Patient may need help with household tasks, personal hygiene (ADLs)
  • Still fluid speech and usually topic appropriate but word finding gets difficult
  • Shortened attention span and prone to restlessness and wandering
  • Sleep can be disturbed
  • Sundowning; agitation in the evening
  • UNSAFE to live alone
  • MMSE: 15-21
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12
Q

Stage 5

A
  • Less ambulatory and less able to perform ADLs
  • Language is less spontaneous but still topic appropriate
  • Physical aggression and psychosis can occur
  • MMSE: 10-15
  • GDS may not be helpful now
  • Cornell Scale is more appropriate (observer-based)
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13
Q

Stage 6

A

• Patients are dependent for most ADLs/IADLs
• Usually ambulatory at wheelchair level only
• Severe language impairments
o Speech is short
• Physical aggression and psychosis can occur in pts
• MMSE

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14
Q

Stage 7

A
  • Completely functionally dependent- bed bound
  • Do not speak, eat or drink
  • Pneumonia tends to be the cause of death
  • Lots of physical care from caregivers
  • No participation in MMSE at this point
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15
Q

Tacrine

A

Cognex
Not available anymore
QID

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16
Q

Tacrine Side Effects

A

Hepatotoxicity

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17
Q

Tacrine Monitoring

A

o Cognitive function and GI tolerability
o LFTs every other week for 16 weeks then monthly for 2 months and then every 3 months after
 3X ULN = dose reduction and more monitoring

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18
Q

Donepezil

A

Aricept
ALL stages of AD
QD and no hepatotoxicity

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19
Q

Donepezil Dosing

A

5 mg and 10 mg are both efficacious
Also a 23 mg option
- Maintenance dose: 10 mg

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20
Q

Donepezil Side Effects

A

N/D
Incontinence
Dizziness
- Most subside after 4 weeks

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21
Q

Donepezil Monitoring

A

NO labs

HR, GI

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22
Q

Rivastigimine

A

Exelon

Also for dementia with PD

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23
Q

Rivastigimine Dosing

A

1.5 mg BID → 3 mg BID → 4.5 mg BID → 6 mg BID with 2 weeks in between increases
o Patch is 4.5 mg up to 9.6 mg transdermal

24
Q

Rivastigimine Side effects

A

GI intolerance

25
Q

Rivastigimine Monitoring

A

NO labs

HR and GI

26
Q

Galantamine

A

Razadyne

Derived from a plant

27
Q

Galantamine Dosing

A

4 mg BID → 8 mg BID → 12 mg BID with 4 weeks between each titration
o ER is same total dose given QD

28
Q

Galantamine Side Effects

A

GI
Bradycardia
CNS
Dizziness/lightheadedness

29
Q

Galantamine Monitoring

A

NO labs
HR, GI, cognitive response
Worsening mood/behavior

30
Q

Big caveat with Rivastigimine and Galantamine

A

If there is disruption of therapy, the patient CANNOT restart at the same dose, you have to start low and titrate up again.

31
Q

Memantine

A

Nemenda

NMDA receptor antagonist

32
Q

Memantine Dosing

A

IR, oral, or XR
Titrate up to 10 mg BID if using tablets but us 5 mg BID if CrCl less than 30
XR capsules: titrate up to 18 mg QD

33
Q

Memantine Side effects

A

CNS or behavioral changes
Elevated BP
Incontinence
Cough

34
Q

Memantine should be avoid if:

A

Severe renal impairment or seizure disorders

35
Q

Memantine Monitoring

A

Side effects and efficacy

36
Q

Memantine + Donepezil =

A

Namzaric

37
Q

OTC with Conflicting Data

A 
Vitamin E/C- won't hurt
Ginkgo biloba- increased bleed with NSAIDs
Vitamin B12- no data
NSAIDs- risk greater than benefits
Estrogen- negative association 
Statins- can induce confusional state
38
Q

Drugs that can worsen AD

A
  • Atropine, benztropine
  • Antihistamine
  • Antidepressants (TCA, paxil)
  • Antipsychotics (traditional, olanzapine)
  • Muscle relaxants
  • Bladder antispasmodics
  • GI antispasmodic
  • Antiarrhythmic
39
Q

Medications that need good adherence so should be careful in pts with AD

A

 Medications with complicated direction or techniques
 Medications requiring intensive monitoring or frequent dose adjustments
 Medications with finite duration or shelf-life stability
 Medication with irregular dosing intervals
 Situations where crushing is required
 Self-monitoring requirements

40
Q

Psychiatric Behavioral Disturbances

A

Depression
Anxiety
Psychosis (hallucination, etc)
Mania

41
Q

Behavioral Disturbances

A

Verbal (yelling, repetitive, etc)
Physical restless
Physical Aggressive
Disinhibited (disrobing, urinating, inappropriate sexual behavior)

42
Q

First-line treatment of behavioral/psychosis distrubances

A
  • Redirection, reassurance
  • Modifying approach to pt
  • Leaving and re-engaging later
  • Indulging wants/needs
  • Story telling and reminiscing
  • Familiar people/objects/photos
  • Never punish!!!
43
Q

Psychiatric Symptoms Treatment

A
  • Depression- antidepressants
  • Psychosis: antipsychotic
  • Insomnia: hypnotic
44
Q

Behavioral Symptoms Treatment

A

Psychoactive medication but be careful to not over treat
Use ONLY if behaviors are interfering with a pt’s function, safety or safety of others, caregivers ability to provide care
Use the lowest possible dose for the shortest time
- Use Neuropsychiatric Inventory to monitor therapy

45
Q

SSRIs (fluoxetine, sertraline, paroxetine, citalopram, escitalopram)

A

Preferred antidepressant in elderly

Minimal anticholienrgic effects

46
Q

Buproprion as antidepressant

A

Avoid in patients with seizures

47
Q

Venlafaxine or Cymbalta (5HT/NE) as antidepressants

A

Pain related to depression

Monitor BP

48
Q

Mirtazepine as antidepressant

A

More sedating with weight gain

49
Q

Trazadone as an antidepressant

A

Sedating at full dose

Low-dose: sleep induction or behavior intervention

50
Q

Atypical Antipsychotics

A

Not FDA approved in AD
Risk of EPS
CNS side effects

51
Q

Lorazepam, temazepam and oxazepam as antiaxiety/hypnotic

A

Preferred

Can produce cognitive impairments, falls, psychomotor retardation, over-sedation or hang-over

52
Q

Zolpidem (z drug) as hypnotic

A

Short Acting with hang over

53
Q

Buspirone (5HT) as antiaxiety

A

Several weeks to start working

54
Q

Lithium, valproate, carbamazepine as mood stabilizers

A

Manic symptoms

Second or third line for most behavioral disturbances

55
Q

Avoid at all cost

A 
TCAs
Typical antipsychotics
Alprazolam, diazepam, triazolam, chlordiazepoxide (benzodiazepams)
Antihistamine
Methylphenidate
Provigil

Neuro Quiz 5 (4 decks)

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