Chapter 4: Nervous System

Question 1

What is dementia?

Answer 1

Dementia is an umbrella term used to describe a range of medical conditions that involve the deterioration of cognitive function incl memory, thinking and behaviour.

Question 2

List the top causes of dementia?

Answer 2

1. Alzheimer’s disease
2. Dementia with Lewy bodies
3. Vascular dementia
4. Frontotemporal dementia

Question 3

What is the most common cause of dementia?

Answer 3

Alzheimer’s disease

Question 4

What is Alzheimer’s disease

Answer 4

• Thought to be caused by the abnormal build up of 2 proteins; amyloid and tau.
• Amyloid deposit and form plaques outside the brain cells and the taus form tangles inside the cells. These eventually damage the brain cells and cause them to die.
• People with alzheimer’s are found to have extremely low levels of acetylcholine neurotransmitters.

Question 5

What is dementia with Lewy bodies

Answer 5

Where tiny clumps of protein called alpha-synuclein develop inside the brain cells and damage the way the cells work and communicate with each other.

Question 6

What is vascular dementia

Answer 6

Caused by reduced blood flow to the brain which damages and eventually kills brain cells. This can happen as a result of narrowing and blockage of small blood vessels inside the brain, stroke or mini strokes.

Question 7

What is frontotemporal dementia.

Answer 7

Caused by abnormal clumping of proteins including tau in the frontal and temporal lobes at the front and sides of the brain. These clumping damages nerve cells causing the brain cells to die. This leads to shrinking of these areas of the brain.

Question 8

What is the first line of treatment for patients newly diagnosed with mild -moderate Alzheimer’s disease?

What is the alternative if they are not tolerated?

Answer 8

Monotherapy with acetylcholinesterase inhibitors:
• Donepezil
• Galantamine
• Rivastigmine

(These 3 are acetylcholinesterase inhibitors).

if above not tolerated → Memantine

Question 9

What is recommended for patients newly diagnosed with severe Alzheimer’s ?

Answer 9

Monotherapy with:

• Memantine

Question 10

What should be considered when treatment for dementia is initiated?

Answer 10

acquisition cost (treatment should be started with the lowest acquisition cost drug (considering dose and price per dose).

Question 11

Which medicine should be given to patients who have an established diagnosis of Alzheimer’s disease and are already on AChE inhibitors?

Answer 11

Consider addition of memantine

Question 12

Which unlicensed medicines should be given to patients with mild/moderate dementia with lewy bodies ?

And the alternative if they are not tolerated?

Answer 12

donepezil or rivastigmine (unlicensed)

if above not tolerated → Galantamine (unlicensed)

if AChEi not tolerated → memantine

Question 13

Which unlicensed medicines should be given patients with severe lewy bodies dementia ?

Answer 13

Donepezil or rivastigmine

memantine ( if AChEi not tolerated)

Question 14

Which patients should NOT be offered AChEi ?

Answer 14

Patients with:

• Frontotemporal dementia
• Cognitive impairment caused by MS
• Vascular dementia unless they have suspected comorbid Alzheimer disease, Parkinsons dementia disease of dementia with lewy bodies.

Question 15

Describe the dosing for donepezil

Answer 15

Initially 5mg OD for 1 month then increase if necessary to 10mg OD.

Question 16

When should donepezil be taken?

Answer 16

At bedtime

Question 17

Can patients with hepatic impairment take galantamine?

Answer 17

Avoid in severe hepatic impairment.

Question 18

Patients with what eGFR should avoid galantamine?

Answer 18

Avoid if eGFR is less than 9ml/min/1.73m2

Question 19

What are the counselling points for patients on galantamine ?

Answer 19

patients should be advised to look out for serious skin reactions (rash, steven-Johnson syndrome). They should stop taking the medication immediately.

Question 20

What are the common side effects of the Acetylcholinesterase inhibitors used in dementia?

Answer 20

Nausea & vomiting 
Diarrhea 
Hallucinations 
Headache 
Insomnia

Question 21

Name the 4 drugs used in dementia

Answer 21

Donepezil
Rivastigmine
Galantamine
Memantine

Question 22

Which acetylcholinesterase inhibitor comes as a patch?

Answer 22

Rivastigmine 24 hour patch

Question 23

What does ADHD stand for and what is it?

Answer 23

Attention deficit hyperactivity disorder. It is a condition characterized by hyperactivity, impulsivity and inattention which often lead to social and psychological difficulties.

Question 24

What are the 4 main drugs used for the management of ADHD?

Answer 24

Lisdexamfetamine
Dexamphetamine
Methylphenidate
Atomoxetine

Question 25

What is the first line of treatment for ADHD?

Answer 25

1. Monotherapy with: • 𝗟𝗶𝘀𝗱𝗲𝘅𝗮𝗺𝗳𝗲𝘁𝗮𝗺𝗶𝗻𝗲 or • 𝗠𝗲𝘁𝗵𝘆𝗹𝗽𝗵𝗲𝗻𝗶𝗱𝗮𝘁𝗲 If no improvement in symptoms after a 𝟲 𝘄𝗲𝗲𝗸 trial: 2. Switch & use the alternative (if Lisdexamfetamine was used first then try Methylphenidate next etc).

Question 26

What drug is given if the patient with ADHD benefit from 𝗟𝗶𝘀𝗱𝗲𝘅𝗮𝗺𝗳𝗲𝘁𝗮𝗺𝗶𝗻𝗲 however cannot tolerate it due to it longer duration of effect?

Answer 26

𝗗𝗲𝘅𝗮𝗺𝗽𝗵𝗲𝘁𝗮𝗺𝗶𝗻𝗲

Question 27

What drug is given if a patient with ADHD is intolerant to both lisdexamfetamine and methylphenidate?

Answer 27

𝗔𝘁𝗼𝗺𝗼𝘅𝗲𝘁𝗶𝗻𝗲

Question 28

Why are modified release preparations of stimulants preferred?

Answer 28

* Pharmacokinetic profile (reduced fluctuations; peaks and troughs in drug plasma concentration. * Convenience * Improved adherence * Reduced risk of drug diversion (drugs being forwarded to others for non-prescription use of misuse * Lack of need to be taken to work.

Question 29

Is Atomexetine, dexamphetamine and lisdexamfetemaine suitable for use in pregnancy and breastfeeding?

Answer 29

Pregnancy: Avoid unless benefit outweighs risk Breastfeeding: Avoid

Question 30

What are the dosing instructions for a patient on atomoxetine with HEPATIC impairment?

Answer 30

Moderate HI: 1/2 dose | Severe HI: 1/4 dose

Question 31

What monitoring needs to be done for people taking atomoxetine, methylphenidate and lisdexamfetamine ?

Answer 31

Appearance of worsened anxiety, depression, or tics Aggressive behaviour (only for lisdexamfetamine). Pulse, BP, psychiatric symptoms, appetite, height should be recorded at the initiation of therapy, following each dose adjustment and at least every 6 months thereafter.

Question 32

What are the counselling points for Atomoxetine?

Answer 32

Recognise symptom of hepatic impairment (abdominal pain, unexplained nausea, malaise, darkening of urine, jaundice.

Question 33

Name brands for methylphenidate?

Answer 33

``` Delmosart Concerta Medikinet Xaggitin Equasym ```

Question 34

Different versions of the MR preparations of methylphenidate may not have the same clinical effect. To avoid confusion prescribers must specify the brand to be dispensed.

Answer 34

Concerta Xl: IR (22% of dose) + MR (78% of dose). Medikinet XL: IR (50% of dose) + MR (50% of dose). Equasym XL: IR (30% of dose) + MR (70% of dose).

Question 35

What are the overdose symptoms of lisdexamfetamine?

Answer 35

``` Wakefulness excessive activity Paranoia Hallucinations Hypertension by exhaustion Convulsions Hyperthermia ```