70. Alzheimer's

Question 1

Alzheimer’s symptoms

Answer 1

Memory loss, getting lost
Difficulty communicating, repeating words and information
Inability to learn or remember new info
Difficulty with planning and organizing
Poor coordination and motor function
Personality changes
Inappropriate behavior
Paranoia, agitation, hallucinations

Question 2

Drugs that can worsen dementia

Answer 2

Antiemetics (e.g. promethazine)
Antihistamines (e.g. diphenhydramine, doxylamine)
Antipsychotics (e.g. chlorpromazine, aripiprazole)
Barbiturates (e.g. phenobarbital, butalbital)
BZDs (e.g. alprazolam, clonazepam)
Central anticholinergics (e.g. benztropine)
Peripheral anticholinergics (including incontinence and IBS drugs)
Skeletal muscle relaxants (e.g. baclofen)
Other CNS depressants (e.g. opioids, sedative hypnotics)

Question 3

What tools are used to screen for dementia?

Answer 3

Folstein Mini-Mental State Exam (MMSE, max score 30, score <24 indicates a memory disorder)
Montreal Cognitive Assessment (MoCA)
DSM-5 Criteria

Question 4

____ should be avoided in the elderly d/t risk of acute cognitive impairment and, occasionally, psychosis and hallucinations. (Beers Criteria)

Answer 4

Centrally-acting anticholinergics (e.g. benztropine)

Question 5

Anticholinergics and memory impairment: Anticholinergics are used to treat incontinence (e.g ___), allergies or insomnia (e.g. ____), dystonic reactions (e.g. ____, ____) and other conditions

Answer 5

oxybutynin
Diphenhydramine
benztropine, diphenhydramine

Question 6

Natural products used for alzheimers

Answer 6

Vit E (2000 IU daily) and ginko
Note: both can increase bleeding risk

Question 7

___ are the mainstay of treatment for alzheimer’s.. They are used alone or with ____ in more advanced stages of the disease

Answer 7

ACEi (e.g. donepezil)
with memantine (Namenda)

Question 8

Clinical improvement with ACEi ± memantine is usually modest but at a minimum, the pt can have ____ than with no treatment

Answer 8

slower clinical progresion

Question 9

If nausea is present, administration in the ___ can help (___ is taken at bedtime for this reason)
If ____ is a concern, the pt can take dose in the morning

Answer 9

evening
Donepezil
insomnia

Question 10

_____ is approved for use alone or with donepezil for moderate-to-severe disease.
____ is a combination product of these meds.

Answer 10

Memantine (Namenda)
Namzaric (donepezil + memantine)

Question 11

Pts stabilized on donepezil ___ can be switched to Namzaric

Answer 11

10mg

Question 12

What are some ACEi meds used for Alzheimer’s

Answer 12

Donepezil (Aricept, Adlarity patch)
rivastigmine (Exelon)
galantamine (Razadyne ER)

Question 13

how often is donepzil (Adlarity) patch changed?

Answer 13

Weekly

Question 14

How often is Rivastigmine (Exelon) patch changed?

Answer 14

daily

Question 15

Warnings for ACEi used in alzheimer’s disease

Answer 15

Cardiac effects, bradycardia, syncope, QT prolongation
Anorexia/weight loss
Pts < 55kg can have more nausea and weight loss
Neuroleptic malignant syndrome and rhabdomyolysis (both rare)

Question 16

Side effects of ACEi used in alzheimer’s disease

Answer 16

Nausea, diarrhea (both dose-related, transient)

Others: insomnia, decreased appetite/weight loss

Question 17

Donepezil is dosed QHS to help decrease ___

Answer 17

Nausea

Question 18

Which ACEi used in Alzheimer’s has less GI side effects?

Answer 18

Rivastigmine (Exelon) Patch and donepezil ODT

Question 19

How is Adlarity patch (donepezil) stored?

Answer 19

in refrigerator, allow patch to reach room temp before use, apply within 24 hrs after removal from fridge

Question 20

Rivatigmine (Exelon) patch administration notes

Answer 20

apply first patch the day after last PO dose
rotate sites - do not use same site for 14 days
Does not contain metal - no need to remove prior to MRI

Question 21

Memantine (Namenda) MOA

Answer 21

blocks NMDA receptors, which inhibits glutamate (excitatory NT) from binding and decrease abnormal neuron activation

Question 22

Side effects of memnatine (Namenda)

Answer 22

generally well tolerated
Can cause dizzines, confusion, HA, constipation, syncope

Question 23

What formulations of memantine can be sprinkled on apple sauce?

Answer 23

ER capsule and Namzaric (combo med with donepezil)
but do NOt crush or chew

Question 24

Drugs that have ___ effects can reduce efficacy of ACEi used in Alzheimer’s

Answer 24

Anticholinergic effects
D/c incontinence drugs if no benefit

Question 25

Use caution with other drugs that can lower HR such as ___ when using ACEi in Alzheimer’s disease

Answer 25

beta-blockers, diltiazem, verapamil, digoxin

Question 26

Where is donepezil (Adlarity) patch applied?

Answer 26

Upper or lower back, upper buttocks, or upper outer thigh
Remove used patch after 7 days
do not use same site within 14 days, rotate