Pharmacotherapy of Neurocognitive disordeers

Question 1

Donepezil

Answer 1

5 mg po QHS–> increase to 10 mg po QHS after 4-6 weeks with or without food

SE:
GI bleeding
N/V/D
Bradycardia
Syncope
Insomnia
Weight loss

Pearls:
CYP3A4 and CYP2D6 substrate

Question 2

Rivastigmine

Answer 2

IR: 1.5 mg BID x weeks–> increase by 1.5 mg BID every 2 weeks

Patch:4.6 mg–> increase to 9.6 every 4 weeks

SE:
GI bleeding
N/V/D
Bradycardia
Syncope
EPS
Esophageal rupture
Withdrawal syndrome

Pearls:
CYP3A4 and CYP2D6 substrate

Question 3

Galantamine

Answer 3

IR: 4 mg po BID with breakfast and dinner–> increase by 8 mg every 4 weeks
ER: 8 mg po QD–> increase by 8 mg every 4 weeks
>16 mg/day is not recommended in renal/hepatic impairment

SE:
GI bleeding
N/V/D
Bradycardia
Syncope
Insomnia
Weight loss

Question 4

Memantine

Answer 4

NMDA antagonist that blocks glutamatergic neurotransmission via a noncompetitive mechanism to reduce excitotoxicity

IR: 5 mg po QD x1week–>

SE:
HA, dizziness
Hallucinations
insomnia
contipation, confusion
caution in seizure disorders
caution with CA-I and NaCO3-

reduce clearance by 80%

Question 5

Memantine + Donepezil

Answer 5

Donepezil 10 mg: 7/10 mg QD à increase by 7 mg to 28/10
Memantine: 10 mg BID: 28/10 mg QD with evening meal

SE:
GI bleeding
N/V/D
Urinary incontinence
Bradycardia
Heart Block

Question 6

Aducanumab

Answer 6

Indication: MCI due AD

Requires presence of amyloid-beta plaque before initiating–>MRI

ARIA: with 1 year before 7th and 12th doses

Question 7

Lecanemab

Answer 7

MCI due to AD

Requires presence of amyloid-beta prior to initiating

ARIA with 1 year before 5th, 7th, and 14th doses

Question 8

Neurocognitive domains

Answer 8

complex attention: sustained/divided attention

Executive function: planning/decision-making/flexibility

Learning and memory: storing memory

Language: naming/word finding

Perceptual/motor: visual perception

Social cognition: recognition of emotions, range of behaviors in yourself and others

Question 9

Dementia

Answer 9

chronic, irreversible

focused on memory

Question 10

Delirium

Answer 10

short-term and reversible

focused on complex attention

Question 11

Reversible neurocognitive

Answer 11

B12 or folate deficiency

Hypothyroidism

CBC, infection

Electrolytes

LFT

Depression

RPR/VDRL– syphilis