Alzheimer's

Question 1

Alzheimer’s Disease

A. Criteria met for ?
B. What kind of onset and progression ?
C. Criteria met for either probable or possible AD
D. What determines if it’s PROBABLE AD?
E. Not better explained by ?

Answer 1

A. Major or mild NCD

B. Insidious, gradual of impairment in >=2 cognitive domains

D. If either of the following is present :
-Evidence of causative AD genetic mutation from FamHX or genetic testing
-All 3 of the following
1. Clear e/o decline in mem and learning and >=1 other cognitive domain
2. Steadily progressive, gradual decline in cognition w/o extended plateaus
3. No evidece of mixed etiology

OTHERWISE the diagnosis is POSSIBLE AD

E. Cerebrovascular disease, another neurodegen disease, substances or another mental, neurological, or systemic disorder

Question 2

AD is more than just memory loss : What other sx’s can occur? (4)

Answer 2

1. Loss of memory and cog function
2. decline in ability to perform activities of daily living
3. Change in personality and behavior
4. incr in resource utilization

Question 3

Clinical Progression :
1. Mild can have cog sx’s such as?
2. From mild to mod can have LOSS OF ADL’s such as?
3. Moderate has Behavioral problems like? CAn also lead to ?
4. Severe can lead to ?

Answer 3

1. Forgetfullness, mood swings, difficulty word finding, personality changes
2. memory deficits, aphasia, assistance w/bathing, grooming, and feeding
3. Wandering, sleep disturbances, agitation and confusion –> Nursing home placement (motor disturbances, incontinence , inability to perform ADL’s)
4. Death

Question 4

Symptom Assessment : MONKEY

What does it stand for and explain

Answer 4

1. Money - managing finances and bills
2. online, using phone apps and GPS
3. Navigation , getting lost or into accidents
4. Keys , misplacing common objects
5. Emergency , having to call 911 for incidents
6. Yelling , crying or acting aggressively

Question 5

Treating Cognitive Sx’s : For each class of drugs, name some and what they’re fda indicated for

1. Cholinesterase inhibs –> block enzyme so that u incr Ach to synapse
2. NMDA receptor antag
3. Monoclonal Antibody

Answer 5

1. Donepezil, Rivastigmine (Mild-mod, and mod-severe) *Riva covers severe thru patch only**
   -Galantamine (Mild -Mod only)
2. Memantine (mod -severe)
3. Aducanumab and Lecanemab (mild)

Question 6

1. What are the cholinergic affects of Cholinesterase inhibs?
2. Donepezil (Aricept)
   - Oral initial dose?
   -TD dose?
   -Food considerations?
   -Metabolism by ?
3. Rivastigmine (exelon)
   - Oral initial dose?
   -TD initial dose?
   -What happens if u miss >3days?
   -Give oral doses with ?
   -ALso indicated for?

Answer 6

1. GI upset, bradycardia, syncope
   -Possible long term : anorexia, weight loss, falls, hip fractures, cardiac pacemaker insertion
2. 5mg everyday
   - 5mg/24hrs qweek
   -With or without food
   CYP2D6 3A4 , glucoronidation
3. 1.5mg BID (Titrate q2wks by 3mg/day)
   - 4.6mg/24hr everyday
   -retitrate from initial dosing
   -Food
   -Mild to mod parkinson’s dementia

Question 7

Galantamine (Razadyne)
1. Oral initial dose IR vs ER
2. What happens if u miss >= 3 days?
3. Dose adjustments for CrCL 9-59 mL/min and CrCL < 9 ?
4. Food considerations?
5. Enzyme metab?

Answer 7

1. IR = 4 mg BID, ER = 8mg everyday
   Titrate q 4wks, (Max IR/ER= 24mg)
2. Re-titrate from initial dosing
3. max 16mg/day, Avoid
4. Give with food
5. CYP2D6 and 3A4 , renal excretion

Question 8

Guideline Consensus for Cholinesterase Inhibs :
1. Modest benefit for ___ in mild -severe AD
2. Does not alter what ?
3. Higher doses dont necesarily offer?
4. Discontinuation may

Answer 8

1. cog sx’s
2. progression of disease
3. clinically meaningful additional benefit
4. worsen cog function

Question 9

NMDA Receptor Antag : Memantine
1. Whats MOA?
2. AE’s?
3. Discontinuation is not associated with ?
4. ORAL IR TAB DOSE? ER TAB?
5. DOse adjust for CrCL < 30 ?
6. IR doses > 5 mg/day often ?
7. Food considerations

Answer 9

1. Stop excess NMDA receptor activation –> less glutamate
2. Dizzy, HA, Confusion and GI upset
3. Signif worsening of cognition
4. IR 5mg everyday for a week –> titrate by 5mg to max 10mg BID , ER 7mg everyday , max 28mg qdaily
5. IR target 5mg BID , ER target 14mg everyday
6. Divided into 2 doses
7. with or without food

Question 10

Anti -Amyloid Monoclonal AB : Aducanumab and Lecanemab

1. MOA?
2. AE’s
3. When was aducanumab discontinued?
4. Lecanemab had statistically signif and clinically ___ reduction of cog decline at ?
5. Leqembi indications?
6. dosing ?
7. WHat do u need to monitor?

Answer 10

1. Promote clearance of Beta amyloid aggregates
2. dizzy, HA, confusion and GI upset
3. 2024
4. meaningful , 18 months
5. AD w/confirmed amyloid pathology; initiated in pt’s w/mild cog impairment or mild dementia stage of disease
6. 10mg/kg IV q2wks –> can have amyloid related imaging abnorms , infusion rxns, flu like sx’s , N/V , hypotension
7. Apo E4 status at baseline, do an MRI at baseline and prior to 5,7,14th dose

Question 11

Non cog Behavioral Sx’s : BPSD
1. What r some earlier signs?
2. Later signs?
3. Evaluate for ?
4. Non drug therapy? **1st step! **
5. Medication
6. Reassess what ?

Answer 11

1. anxiety, depression, sleep disturb, agitation
2. hallucinations, delusions, aggression, wandering, irritable, wandering
3. medical causes, environment factors , pain or discomfort
4. Environment mods, coping skills, unmet needs , caregiver education, socialization , animal visits, sensory tehrapy
5. Antipsychs, antidepress, anticonvulsants
6. Discontinue meds if not needed or working

Question 12

Atypical Antipsychotics in Dementia :
1. Boxed warning ?

2. Which is only FDA approved ?
3. Whats it indicated for?
4. NOT For use as?
5. Oral initial dosing for a week?
6. Renal adjust?
7. Food considerations?
8. Enzyme interxns?

Answer 12

1. Incr mortality in elderly pt’s w/dementia related psychosis
   - cerebrovascular ae’s (stroke and TIA), HF, sudden death, pneumonia
2. Brexpiprazole (Rexulti)
3. Agitation associated w/dementia due to AD
4. PRN
5. 0.5 mg everyday , titrate each week to max 3 mg everyday at day 30
6. CrCL < 60, max of 2mg everyday
7. with or without food
8. CYP 3A4 inhibs –> decr dose by 75%
   CYP2d6 PM –> Decr dose by 50%

Question 13

Guideline Consensus : Antipsychs

1. Should only be used to treat ___ in pt’s with dementia that is ___, ___ or causes ____ , AND IS NOT RESPONSIVE TO ___
2. Use ___ doses, titrate slowly
3. Need to assess response after ?
4. Use caution in what kinds of dementia

Answer 13

1. Agitation/psychosis
   - severe, dangerous to pt’s/others, signif distress to the patient
   -NONPHARM MEASURES
2. Lower initia/max doses
3. 4week trial
   -If ineffective, taper and discontinue
   -If effective -discuss risks/benefits, attempt to taper within 4 months of initiation
4. Parkinson and Lewy BOdy

Question 14

Recc for Depression :
1. NOn pharm?
2. Pharm tx using ?

Recc for Insomnia :
3. Non pharm is 1st line such as ?
4. Pharm can use
5. Meds to avoid

Answer 14

1. Psychotherapy, social or meaningful activities that maintain pt’s past roles such as workshops and volunteering
2. SSRi’s
3. Sleep hygiene, CBT for insomnia
4. Melatonin , trazodone, doxepin
5. BZD’s, diphenhydramines, antipsychotics (not for sleep) , TCA

Question 15

Patient Education :

1. AD is a progressive disease with ___
2. Behavioral disturbances are common, u should use what as first line?
3. Ae’s of cholinesterase inhibs?
4. See provider for ?

Answer 15

1. No cure! Meds dont reverse ur sx’s but may slow rate of decline
2. non pharm strategies (education for family on re-directing)
3. N/V, weight loss, fainting (syncope), monitor HR
4. sudden changes in cognition