Alzheimer's

Question 1

Epidemiology of Alzheimer’s

Answer 1

5.3 million people in the US

Prevalence changes based on age
6% of individuals aged 65-74
44% of individuals aged 75-84
46% of individuals age 85 and older

Disease impacts a greater percentage of Americans as our population ages. In 2050:
20% of population will be > 65 years

Question 2

3 hallmark features of Alzheimer’s

Answer 2

Cognitive impairment
Often identified first

Noncognitive (behavioral) impairment
Typically seen later in disease progression

Functional impairment
Motor and sensory defects not common until more advanced stages

Question 3

Genetic Risk Factors/Etiology of Alzheimer’s

Answer 3

Chromosome mutations
Apolipoprotein E (APOE)

Question 4

Environmental Risk Factor/Etiology of Alzheimer’s

Answer 4

Age
Reduced brain size
Low education and occupational attainment
Reduced mental and physical activity late in life
Down Syndrome
Depression
head injury

Question 5

What is the definitive marker for Alzheimer’s Disease?

Answer 5

The only definitive marker of AD is NFTs – found postmortem

Question 6

5 Clinical Presentations that occur with Alzheimer’s

Answer 6

Gradual onset and progressive deterioration
Memory and cognitive impairments
Visuospactial abnormalities
language impairment
behavioral and psych symptoms

Question 7

4 memory and cognitive impairments associated with Alzheimer’s

Answer 7

Inability to learn new information at first
Procedural memory loss follows
Executive function impairments
Long-term memory impaired in late stages

Question 8

2 Visuospatial abnormalities associated with Alzheimer’s

Answer 8

Difficulty recognizing faces

Disorientation in familiar surroundings

Question 9

2 Language impairment associated with Alzheimer’s

Answer 9

Initially manifested as difficulty in word finding and impaired naming ability (anomia)
Comprehension and meaningful language decreases as AD progresses

Question 10

What are some medications associated with memory loss

Answer 10

Anticholinergic agents
Benzodiazepines and other sedative hypnotics
Opioid analgesics
Antipsychotics
Anticonvulsants
NSAIDs
Histamine H2 receptor antagonists
Digoxin 
Amiodarone 
Corticosteroids 
Antihypertensives

Question 11

4 Stages of Alzheimers

Answer 11

Mild Cognitive Impairment (MCI): 
Mild AD (MMSE 26-18): 
Moderate AD (MMSE 17-10
Severe AD (9-0):

Question 12

Severe stage of Alzheimer’s includes what symptoms

Answer 12

agitation, altered sleep patterns, assistance is required for dressing, feeding, bathing, established behavioral and psychological symptoms of dementia, become bedbound, no speech, incontinent, basic psychomotor skills lost

Question 13

Mild stage of AD includes what symptoms

Answer 13

forgetfulness, short term memory loss, repetitive questions, hobbies and interests lost, impaired activities of daily living

Question 14

Moderate AD includes what symptoms

Answer 14

progression of cognitive deficits, further impaired activities of daily living, transitions in care, emergence of behavioral and psychological symptoms of dementia

Question 15

Mild Cognitive impairment stage of AD includes what symptoms?

Answer 15

Complaints of memory loss, intact activities of daily living, no evidence of AD

Question 16

Therapy for Alzheimer’s is aimed at what 3 things?

Answer 16

Symptom control
Delay of progression
Improvement in quality of life

Question 17

1st line Cholinesterase inhibitors are FDA approved for mild-to-moderate AD
What are the 3 medications?

Answer 17

Donepezil hydrochloride (Aricept®)
Galantamine hydrobromide (Razadyne®)
Rivastigmine tartrate and transdermal (Exelon®)

Question 18

What do cholinesterase inhibitors do?

Answer 18

enhance cholinergic activity

Question 19

Efficacy of the Cholinesterase inhibitor medications for AD

Answer 19

All have similar efficacy
First 6 months
MMSE: 1-1.5 point improvement
ADAS-Cog: 2.8-4 point improvement
After first 6 months
Declined efficacy but still better than not treating

Question 20

Average efficacy for a patient with AD not on medication

MMSE and AGAS

Answer 20

MMSE: 2-4 point decline
AGAS-Cog: 7 point decline
Consider therapy effective if decline less than above

Question 21

DONEPEZIL – ARICEPT®

MOA, dose, adjustments, Side effects

Answer 21

Reversible CI
mild to mod AD
Dosed QD
CYP interactions
no renal/hepatic adjustments
High specificity for acetylcholinesterase and not butyrylcholinesterase--> causing less ADR

Question 22

GALANTAMINE – RAZADYNE® MOA

Answer 22

Dual MOA
Inhibits acetylcholinesterase
Modulates nicotinic receptors  increased release and enhancement of cholinergic function

Question 23

GALANTAMINE – RAZADYNE®

titrate, adjustment, when to take

Answer 23

Titrate every 4 wks
adjust for hepatic dysfunction
take at morning and evening meals

Question 24

RIVASTIGMINE – EXELON® MOA

Answer 24

Reversible CI (but very slow dissociation from acetylcholinesterase)
Substantially inhibits butyrylcholinesterase

Question 25

RIVASTIGMINE – EXELON®

Dose, adjustments, when to take

Answer 25

BID
take with food, morning and evening meals
longer titration and decrease doses to alleviate GI side effects
NO DOSE Adjustments

Question 26

MEMANTINE (NAMENDA®) MOA

Answer 26

Specific, noncompetitive NMDA receptor antagonist with moderate affinity
Interferes with glutamatergic excitotoxic neurotoxicity

Question 27

MEMANTINE (NAMENDA®)

Adjustments, when to use

Answer 27

FDA approved for treatment of moderate-to-severe AD
BID
Adjust for CrCl of <30

Question 28

Caprylidene (Axona)

Answer 28

Medical food

Caution in patients at risk for ketoacidosis