Alzheimer's Disease

Question 1

Modifiable and Non-modifiable Risk Factors

Answer 1

Modifiable:
- HTN
- DM
- Smoking
- Alcohol binging
- Depression
- Hearing Loss
- Obesity
- Limited physical activity

Non-modifiable:
1. Age
2. Female

Question 2

Pathophysiology of AD

Answer 2

• Senile Plaque (Beta Amyloid from Beta Secretases)
• Neurofibrillary Tangles
  (Hyperphosphorylated Tau Protein aggregates)
• Brain Atrophy (Hippocampus), Asymmetric
• Neuronal Degeneration
• Cholinergic Hypothesis (Cholinergic neurons needed for learning and attentional processes)

Question 3

Types of Dementia

Answer 3

Alzheimer’s Disease
Vascular Dementia
Lewy Body Dementia
Mixed type
Frontotemporal Dementia

Question 4

Pharmacological Treatments for AD

Answer 4

1. Cholinesterase Inhibitors
   (Donepezil, Rivastigmine, Galantamine)
2. NMDA Antagonist (Memantine)

Question 5

How to dose cholinesterases and what to monitor?

Answer 5

• Slow titration over 4-8 weeks to reach target dose
• Lower the dose temporarily if ADR encountered before re-escalating more slowly
• Monitoring by caregiver and do routine cognitive tests (MMSE, MoCA)

Question 6

When is memantine considered?

Answer 6

Moderate to severe dementia (Switch therapy or first line in new diagnosis)

Intolerable to cholinesterase inhibitors

Question 7

Give the dosing, ADR, caution, contraindications for donepezil

Answer 7

Donepezil Tablets:
Indication: All stages
PO 5 mg QD for 6 weeks ⇒ 10 mg ⇒ 23 mg
ADR: NVD, loss of appetite, vivid dream, insomnia
Caution: PUD, Respiratory disease, Seizures
Contraindication: Bradycardia

Question 8

Give the dosing, ADR, caution, contraindications for rivastigmine

Answer 8

Rivastigmine Capsules:
Indication: Mild to Moderate
PO 1.5 mg BD for 2 weeks ⇒ 3 mg BD for 2 weeks ⇒ 6 mg BD
Patch 4.6 mg/24h, 4 wk ⇒ 9.5 mg/24h, 4 wk
Same cautions as Donepezil

Question 9

Give the dosing, ADR, caution, contraindications for galantamine

Answer 9

Galantamine XR or IR Capsules
Indication: Mild to Moderate
XR PO 8 mg QD for 4 weeks ⇒ 16 mg QD for 4 weeks ⇒ 24 mg QD
IR PO 4 mg BD

Question 10

Give the dosing, ADR, caution, contraindications for memantine

Answer 10

Memantine (Non-competitive NMDA Receptor Antagonist)
Indication: Moderate to severe dementia
PO 7 mg QD for 1 week ⇒ 14 mg QD ⇒ 21 mg ⇒ 28 mg (1 week intervals)
ADR: Headache, constipation, dizziness, hallucinations, confusion
Caution: CVD, Severe hepatic / renal impairment