Therapeutics - Alzheimers

Question 1

true or false

all dementia is alzhemiers disease

Answer 1

false

Question 2

vascular dementia (multi-infarct) treatment

Answer 2

prevention is the best treatment! control HTN, lower cholesterol, stop smoking, use aspirin

Question 3

in what type of demention is a shunt placed to relieve pressure and can help to decrease progression

Answer 3

normal pressure hydrocephalus

Question 4

“dementia with lewy bodies”

Answer 4

parkinsonian symptoms

cognitive decline happens faster than alzhemiers

Question 5

what agents are used for dementia with lewy bodies

Answer 5

not levodopa - minimal response

atypical agents, SSRIs, trazodone, ACHE inhibitors

Question 6

what is pseudodementia

Answer 6

depression – NOT DEMENTIA

Question 7

what is mild cognitive impairment and what is the treatment

Answer 7

may be early marker for alzheimers

no definite tx - but potential benefit with ache inhibitors

Question 8

what drugs can cause dementia

Answer 8

CNS depressants, anticholinergics

Question 9

true or false

patients can get alzhemiers “overnight”

Answer 9

FALSE

progressive cognitive decline and slow onset

Question 10

true or false

the labs and tests of an alzhemiers patient will appear normal

Answer 10

TRUE

they’re awake and seem healthy, just not oriented

Question 11

do we have any drugs that actually modify alzhemier’s?

Answer 11

no

Question 12

symptomatic effect of cholinesterase inhibitors in alzhemier’s patients over time

Answer 12

drug will work at first, but then will stop working and the patient declines

Question 13

which 2 types of drugs are old drugs and should NOT BE USED in alzhemiers patients

Answer 13

cerebral vasodilators
ergoloid mesylates

if anything they made it worse

Question 14

which ACHE inhibitor is not used in AD because it has too much peripheral action

Answer 14

physostigmine

Question 15

name 4 ACHE inhibitors that can be used in alzheimers

Answer 15

donepezil
rivastigmine
galantamine
benzgalantamine

Question 16

the ACHE inhibitors are approved for MILD-MODERATE AD

which 2 are also approved for severe AD

Answer 16

donepezil and rivastigmine patch

Question 17

ACHE inhibitors tend to show more benefit in AD when started when?

Answer 17

early in the disease

Question 18

true or false

there is a clear time period when we should stop ACHE inhibitors

Answer 18

FALSE - unclear when to stop

Question 19

**ADRS of acetylcholinesterase inhibitors

Answer 19

bradycardia leading to syncope (if also on BB or CCB - be very cautious!!!)

SLUDG (salivation, lacrimation, urination, defecation, GI upset/emesis)

Question 20

how often is donepezil administered

Answer 20

QD

Question 21

big AE of rivastigmine

Answer 21

high GI effects - often not well tolerated

Question 22

if treatment of rivastigmine is interrupted for longer than 3 days, what must we do and why

Answer 22

RESTART the dosing at 1.5mg BID and titrate back up

otherwise they will throw up

1.5mg isnt even an effective dose - it’s just to taper them up to avoid GI side effects

Question 23

counseling point rivastigmine

Answer 23

take w meals to avoid GI upset

Question 24

AE of galantamine vs rivastigmine

Answer 24

galantamine has less GI side effects

same counseling tho to take w meals

also if treatment interrupted for 3 or more days - restart dosing at lowest

Question 25

prodrug of galantamine why is it a lil beneficial over galantamine

Answer 25

benzgalantamine less GI effects bc converts to galantamine after GI absorption

Question 26

memantine MOA and why was it designed to work like this

Answer 26

NMDA antagonist bc overstimulation of NMDA receptors by glutamate may be a cause of neurodegenerative disorders

Question 27

can memantine be used in combo with other drugs?

Answer 27

usually it's used in combo with an ACHE inhibitor however, pts may also use as monotherapy if they cant tolerate the AE of ACHE inhibitors

Question 28

true or false memantine is usually well tolerated

Answer 28

true

Question 29

true or false ACHE I + memantine has shown improvement in outcomes and is well tolerated

Answer 29

true

Question 30

true or false the results of studies of ACHEI with or without memantine are both statistically and clinically significant

Answer 30

FALSE - statistically significant but not really clinically. they decline eventually, also studies are mostly less than a year so long term effect is unknowns

Question 31

name 3 monoclonals for AD which isn't on the market anymore? are these used a lot and why?

Answer 31

aducanumab (not on market) lecanemab donanemab very expensive. have been shown to reduce amyloid plaques, BUT MINIMAL CLINICAL EFFICACY

Question 32

big issue with the monoclonals for AD

Answer 32

they reduce amyloid plaques however, created ARIAs (amyloid-related imaging abnormalities) maybe test for certain alleles beforehand ARIA-H = microhemorrhage ARIA-E - brain edema

Question 33

for the monoclonals the patient should confirm what first

Answer 33

the patient should get a PET scan or LP (lumbar puncture) 1st to confirm that the AD patho is amyloid-related bc thats how they work

Question 34

5 misc agents for AD

Answer 34

vitamin E NSAIDS estrogen statins gingko biloba

Question 35

chemical name of vitamin E

Answer 35

alpha-tocopherol

Question 36

role of vitamin E in AD

Answer 36

may have benefit, but high dose vitamin E can kill you

Question 37

AE of vitamin E

Answer 37

increased fall risk dental effects increased bleeding with warfarin

Question 38

true or false NSAIDS are NOT HELPFUL in patients with established AD OR with advanced preclinical AD pathology

Answer 38

true more studies may be needed,,, but as of now not beneficial

Question 39

true or false estrogen has clinically been shown to decrease AD symptoms

Answer 39

false

Question 40

true or false statins have clinically been shown to prevent dementia

Answer 40

FALSE MAY BE A POTENTIAL LINK, BUT NOT RN

Question 41

ginkgo biloba in AD patients

Answer 41

not effective AE - increased risk of spontaneous bleeding! has an effect on platelet aggregation

Question 42

name some things that HAVE been shown to prevent/slow cognitive decline

Answer 42

-physical activity -control BP -cognitive training -manage obesity, diabetes exercise!

Question 43

which type of exercise has the most favorable effect on delaying a decline in cognitive function

Answer 43

aerobic - take a walk! :)

Question 44

which drugs should be AVOIDED when treating symptoms of AD, due to memory loss and falls

Answer 44

benzodiazepines

Question 45

what drugs can be used to treat the delusions, paranoia, and hallucinations of an AD patient

Answer 45

atypical antipsychotics like risperidone, olanzapine, quetiapine, abilify low dose!

Question 46

what should be used to treat the depression of an AD patient

Answer 46

SSRI

Question 47

what may be used to treat the aggression of an AD patient

Answer 47

potentially valproic acid

Question 48

what is the 1 antipsychotic that is FDA approved for agitation associated with dementia due to alzheimers?

Answer 48

rexulti (brexpiiprazole) used SHORT TERM if pt doesnt get significant response after 4 weeks, dicontinue

Question 49

what can be used for sleep for AD patient

Answer 49

low dose trazodone

Question 50

what 2 drugs can potentiall be used for aggression and agitation of an AD patient

Answer 50

buspirone or citalopram

Question 51

AE citalopram

Answer 51

decreased cognition and prolonged QT

Question 52

BBW of antipsychotic use in dementia

Answer 52

increased risk of death in patients with dementia - for both atypical agents AND conventional therefore, should really try to avoid antipsychotics if we can only one approved is rexulti!

Question 53

nonpharm interventions for AD patients

Answer 53

set environment - make it feel homey, have soft colors mild activities - music, pets, dolls, exercise respite care - relive burden on caregivers

Question 54

concern with ACHEI dosing

Answer 54

complicated titration