Treatment of Alzheimer's Disease

Question 1

Screening only test:

Answer 1

MMSE
SLUMS
MOCA
Clock Drawing
- Then do a pharmacist's review of meds if there is a possible deficit

Question 2

Alzheimer’s Disease Assessment Scale, Cognitive Subscale (ADAS-cog)

Answer 2

• Primary outcome measure

* Sensitive

Question 3

Clinician’s Interview Based Impression of Change (CIBIC)

Answer 3

• Subjective

* More qualitative assessment

Question 4

Global Dementia Rating Scale (GDRS)

Answer 4

• Evaluate how well and intervention influence big cohorts of patients as they progress

Question 5

GDS, Cornell and NPI

Answer 5

Psychiatric and behavioral symptoms identification

Question 6

ADAS-cog change is score evaluations:

Answer 6

Magnitude of response: magnitude of change in the score before and after medication intervention and across points in time
Responder rate: Proportion of patients who achieve a minimum threshold of change expressed as a percentage

Question 7

What scale is used to determine stages on AD

Answer 7

Reisberg Scale or FAST scale

Question 8

Stage 1

Answer 8

• Last known period of normal function

* ID retrospectively

Question 9

Stage 2

Answer 9

• Very mild impairments
• Only the patient recognizes the problem
• Patient can compensate for deficits so others may not notice yet

Question 10

Stage 3

Answer 10

• Others begin to notice problems in memory, problem solving, following directions, managing finances (IADLs)
• Often a formal diagnosis is not made until this stage
• Could come with depression and anxiety
o Geriatric depression scale might be necessary
• Living at home might need to be evaluated at this point
• MMSE score might be 21-24

Question 11

Stage 4

Answer 11

• Self-care activities are affected
• Patient may need help with household tasks, personal hygiene (ADLs)
• Still fluid speech and usually topic appropriate but word finding gets difficult
• Shortened attention span and prone to restlessness and wandering
• Sleep can be disturbed
• Sundowning; agitation in the evening
• UNSAFE to live alone
• MMSE: 15-21

Question 12

Stage 5

Answer 12

• Less ambulatory and less able to perform ADLs
• Language is less spontaneous but still topic appropriate
• Physical aggression and psychosis can occur
• MMSE: 10-15
• GDS may not be helpful now
• Cornell Scale is more appropriate (observer-based)

Question 13

Stage 6

Answer 13

• Patients are dependent for most ADLs/IADLs
• Usually ambulatory at wheelchair level only
• Severe language impairments
o Speech is short
• Physical aggression and psychosis can occur in pts
• MMSE

Question 14

Stage 7

Answer 14

• Completely functionally dependent- bed bound
• Do not speak, eat or drink
• Pneumonia tends to be the cause of death
• Lots of physical care from caregivers
• No participation in MMSE at this point

Question 15

Tacrine

Answer 15

Cognex
Not available anymore
QID

Question 16

Tacrine Side Effects

Answer 16

Hepatotoxicity

Question 17

Tacrine Monitoring

Answer 17

o Cognitive function and GI tolerability
o LFTs every other week for 16 weeks then monthly for 2 months and then every 3 months after
 3X ULN = dose reduction and more monitoring

Question 18

Donepezil

Answer 18

Aricept
ALL stages of AD
QD and no hepatotoxicity

Question 19

Donepezil Dosing

Answer 19

5 mg and 10 mg are both efficacious
Also a 23 mg option
- Maintenance dose: 10 mg

Question 20

Donepezil Side Effects

Answer 20

N/D
Incontinence
Dizziness
- Most subside after 4 weeks

Question 21

Donepezil Monitoring

Answer 21

NO labs

HR, GI

Question 22

Rivastigimine

Answer 22

Exelon

Also for dementia with PD

Question 23

Rivastigimine Dosing

Answer 23

1.5 mg BID → 3 mg BID → 4.5 mg BID → 6 mg BID with 2 weeks in between increases
o Patch is 4.5 mg up to 9.6 mg transdermal

Question 24

Rivastigimine Side effects

Answer 24

GI intolerance

Question 25

Rivastigimine Monitoring

Answer 25

NO labs | HR and GI

Question 26

Galantamine

Answer 26

Razadyne | Derived from a plant

Question 27

Galantamine Dosing

Answer 27

4 mg BID → 8 mg BID → 12 mg BID with 4 weeks between each titration o ER is same total dose given QD

Question 28

Galantamine Side Effects

Answer 28

GI Bradycardia CNS Dizziness/lightheadedness

Question 29

Galantamine Monitoring

Answer 29

NO labs HR, GI, cognitive response Worsening mood/behavior

Question 30

Big caveat with Rivastigimine and Galantamine

Answer 30

If there is disruption of therapy, the patient CANNOT restart at the same dose, you have to start low and titrate up again.

Question 31

Memantine

Answer 31

Nemenda | NMDA receptor antagonist

Question 32

Memantine Dosing

Answer 32

IR, oral, or XR Titrate up to 10 mg BID if using tablets but us 5 mg BID if CrCl less than 30 XR capsules: titrate up to 18 mg QD

Question 33

Memantine Side effects

Answer 33

CNS or behavioral changes Elevated BP Incontinence Cough

Question 34

Memantine should be avoid if:

Answer 34

Severe renal impairment or seizure disorders

Question 35

Memantine Monitoring

Answer 35

Side effects and efficacy

Question 36

Memantine + Donepezil =

Answer 36

Namzaric

Question 37

OTC with Conflicting Data

Answer 37

``` Vitamin E/C- won't hurt Ginkgo biloba- increased bleed with NSAIDs Vitamin B12- no data NSAIDs- risk greater than benefits Estrogen- negative association Statins- can induce confusional state ```

Question 38

Drugs that can worsen AD

Answer 38

* Atropine, benztropine * Antihistamine * Antidepressants (TCA, paxil) * Antipsychotics (traditional, olanzapine) * Muscle relaxants * Bladder antispasmodics * GI antispasmodic * Antiarrhythmic

Question 39

Medications that need good adherence so should be careful in pts with AD

Answer 39

 Medications with complicated direction or techniques  Medications requiring intensive monitoring or frequent dose adjustments  Medications with finite duration or shelf-life stability  Medication with irregular dosing intervals  Situations where crushing is required  Self-monitoring requirements

Question 40

Psychiatric Behavioral Disturbances

Answer 40

Depression Anxiety Psychosis (hallucination, etc) Mania

Question 41

Behavioral Disturbances

Answer 41

Verbal (yelling, repetitive, etc) Physical restless Physical Aggressive Disinhibited (disrobing, urinating, inappropriate sexual behavior)

Question 42

First-line treatment of behavioral/psychosis distrubances

Answer 42

* Redirection, reassurance * Modifying approach to pt * Leaving and re-engaging later * Indulging wants/needs * Story telling and reminiscing * Familiar people/objects/photos * Never punish!!!

Question 43

Psychiatric Symptoms Treatment

Answer 43

* Depression- antidepressants * Psychosis: antipsychotic * Insomnia: hypnotic

Question 44

Behavioral Symptoms Treatment

Answer 44

Psychoactive medication but be careful to not over treat Use ONLY if behaviors are interfering with a pt’s function, safety or safety of others, caregivers ability to provide care Use the lowest possible dose for the shortest time - Use Neuropsychiatric Inventory to monitor therapy

Question 45

SSRIs (fluoxetine, sertraline, paroxetine, citalopram, escitalopram)

Answer 45

Preferred antidepressant in elderly | Minimal anticholienrgic effects

Question 46

Buproprion as antidepressant

Answer 46

Avoid in patients with seizures

Question 47

Venlafaxine or Cymbalta (5HT/NE) as antidepressants

Answer 47

Pain related to depression | Monitor BP

Question 48

Mirtazepine as antidepressant

Answer 48

More sedating with weight gain

Question 49

Trazadone as an antidepressant

Answer 49

Sedating at full dose | Low-dose: sleep induction or behavior intervention

Question 50

Atypical Antipsychotics

Answer 50

Not FDA approved in AD Risk of EPS CNS side effects

Question 51

Lorazepam, temazepam and oxazepam as antiaxiety/hypnotic

Answer 51

Preferred | Can produce cognitive impairments, falls, psychomotor retardation, over-sedation or hang-over

Question 52

Zolpidem (z drug) as hypnotic

Answer 52

Short Acting with hang over

Question 53

Buspirone (5HT) as antiaxiety

Answer 53

Several weeks to start working

Question 54

Lithium, valproate, carbamazepine as mood stabilizers

Answer 54

Manic symptoms | Second or third line for most behavioral disturbances

Question 55

Avoid at all cost

Answer 55

``` TCAs Typical antipsychotics Alprazolam, diazepam, triazolam, chlordiazepoxide (benzodiazepams) Antihistamine Methylphenidate Provigil ```