alzheimer's dementia and therapeutics

Question 1

cognition

Answer 1

mental action or process of acquiring knowledge and understanding through thought, experience, and senses

Question 2

3 things needed for cognitive function

Answer 2

memory
attention
executive function

Question 3

dementia symptoms and diagnosis criteria

Answer 3

must have significantly impaired dysfunction of at least 2 of:

• memory
• communication and language
• ability to focus
• reasoning and judgment
• visual perception

Question 4

two schools of thought for alzheimer’s disease cause

Answer 4

• beta-amyloid deposits

- tau protein abnormalities

Question 5

beta-amyloid hypothesis

Answer 5

beta secretase cleaves APP (amyloid precursor protein) at a location that produces beta-amyloid which oligomerizes and forms fibers and plaques

Question 6

tau hypothesis

Answer 6

tau protein gets hyperphosphorylated which causes it to form helices with itself and thus tangles inside of the neuronal cell

Question 7

genetic mutation in what protein makes individuals susceptible to alzheimers at a younger age

Answer 7

presenilin

Question 8

drug therapies for alzheimer’s

Answer 8

• acetylcholinersterase inhibitors

- NMDA inhibitor

Question 9

dementia diagnosis tools

Answer 9

• MMSE
• MOCA
• mini-cog

Question 10

MMSE scale

Answer 10

24-30 normal
19-23 mild impairment
10-18 moderate
1-9 severe

Question 11

MOCA scale normal range

Answer 11

26-30

Question 12

drugs associated with cognitive impairment

Answer 12

• benzodiazepines
• anticholinergics
• opiods
• muscle relaxants
• antipsychotics
• H2 antagoinsts
• antihypertensives

Question 13

goal of dementia treatment

Answer 13

preserve function as long as possible

Question 14

nonpharmacological therapies for dementia

Answer 14

• caregiver education
• vision/hearing aids
• adjust expectations
• remain calm, firm, supportive
• keep consistent, structured environments
• provide frequent orientation cues
• reduce choices or complex tasks

Question 15

acetylcholinesterase inhibitors in dementia

Answer 15

donepezil
rivastigmine
galantamine

Question 16

NMDA receptor antagonist in dementia

Answer 16

memantine

Question 17

donepezil MoA

Answer 17

noncompetitive, reversible inhibition of acetylcholinesterase

Question 18

donepezil dosing

Answer 18

• start 5 mg QD, up to 23 mg QD

- most end up at 10 mg and stay there

Question 19

donepezil adverse effects

Answer 19

• diarrhea, headache, nausea

- rarely CNS and musculoskeletal side effects

Question 20

donepezil drug interactions

Answer 20

• CYP2D6 and CYP3A4 substrate

- antidepressants

Question 21

donepezil indication

Answer 21

mild to severe AD

Question 22

rivastigmine indication

Answer 22

mild-severe AD, parkinson’s dementia

Question 23

rivastigmine MoA

Answer 23

inhibits butyrylcholinesterase and acetylcholinesterase

Question 24

rivastigmine dosing

Answer 24

start 1.5 mg BID and increase slowly every 2 weeks to max dose of 6 mg BID

Question 25

what to do if patient is off rivastigmine for a few days

Answer 25

must retitrate because of the side effects

Question 26

rivastigmine adverse effects

Answer 26

- diarrhea, nausea, dizziness, anorexia | - worsens tremor in PD due to excessive ACh

Question 27

rivastigmine drug interactions

Answer 27

nicotine increases clearance by 23%

Question 28

galantamine indication

Answer 28

mild-moderate AD

Question 29

galantamine MoA

Answer 29

selective, competitive, reversible acetylcholinesterase inhibitor

Question 30

galantamine dosing

Answer 30

IR: 4 mg BID, slowly increase q4wk up to 8-12 mg BID ER: 8 mg QD, slowly increase q4wk up to 16-24 mg QD

Question 31

what to do if patient is off galantamine for a few days

Answer 31

must retitrate

Question 32

galantamine adverse effects

Answer 32

- nausea, vomiting, diarrhea, anorexia | - rarely SJS, CNS paroblems, bradycardia

Question 33

galantamine drug interactions

Answer 33

CYP2D6 and 3A4

Question 34

memantine MoA

Answer 34

NMDA receptor antagonist | -protects from overstimulation to preserve learning/memory

Question 35

memantine indication

Answer 35

moderate-severe AD

Question 36

memantine dosing

Answer 36

IR: 5 mg qd, increase weekly to 10 mg BID ER: 7 mg qd increase weekly to 28 mg QD

Question 37

memantine adverse effects

Answer 37

- generally well tolerated | - constipation, diarrhea, vomiting, increased urination, SJS

Question 38

approved combination therapy in AD

Answer 38

donepezil and memantine | approved for moderate to severe dementia

Question 39

monitoring in AD treatment

Answer 39

- AEs - adherence - at 3 months for cognitive effects - if treatment is successful

Question 40

successful treatment definition

Answer 40

MMSE/MOCA declines <2 points per year

Question 41

when to stop drugs for AD

Answer 41

- poor adherence/tolerance - deteriorating after 6 months at same rate before tx - deterioration accelerates after starting tx

Question 42

herbals in dementia

Answer 42

``` vitamine E ginkgo huperzine polyphenols omega fatty acids ```

Question 43

assessment of agitation

Answer 43

- what is the behavior? - what triggers the behavior? - what is the impact of the behavior? is it harmful?

Question 44

treatment of behavioral symptoms

Answer 44

- treat hunger, thirst, pain, or infection - correct sensory deficits - stable routine - simple 1-step commands - calm communication - avoid alcohol - home safety

Question 45

antipsychotics in dementia patients

Answer 45

- avoid unless non-pharmacological options have failed | - has increased risk of stroke and death

Question 46

features of delirium

Answer 46

- acute - fluctuating - reversible in days to weeks

Question 47

confusion assessment method

Answer 47

Feature 1: acute onset and fluctuating course (come and go) Feature 2: inattention Feature 3: disorganized thinking Feature 4: altered level of consciousness Must have 1 and 2, and either 3 or 4

Question 48

precipitating risk factors for delirium

Answer 48

infection | dehydration