Alzheimer's Disease Flashcards
What are s/sx of dementia?
- Memory loss
- Difficulty planning/organizing
- Getting lost in familiar places
- Repeating words/information
- Agitation/delusions
- difficulty finding words/common objects
- Inability to learn/remember new info
- apathy/social disengagement
- poor coordination/motor function
What is the most common type of dementia?
Alzheimer’s disease
What causes Alzheirmer’s?
amyloid beta plaques and tau tangles lead to death of cholinergic neurons and decreased acetylcholine
What score on the Mini-Mental State Exam indicated memory disorder?
<24/30
What are reversible causes of memory impairement?
- vit D deficiency
- B12 deficiency
- drugs
- depression
- infection
How is the type of dementia determined?
- Symptoms
- Brain imaging
- Amyloid beta and tau conc (blood test)
What drugs can worsen dementia?
- Antipsychotics (aripiprazole, chlorpromazine)
- Barbituates
- Benzodiazepines
- Opioids
- Hypnotics (eszopiclone, zolpidem)
- Skeletal muscle relaxants
- Antiemetics (prochlorperazine)
- Antihistamines (diphenhydramine, doxylamine)
- Central anticholinergics
- Peripheral anticholinergics (oxybutinin, dicyclomine)
- TCAs
What are natural products used for AD?
- Vitamin E 2000 IU
- Ginkgo biloba
- acetyl- l-carnitine
- vinpocetine
What is the purpose of AD treatment?
Slow clinical decline
What is the first line treatment for all stages of AD?
Acetylcholinesterase inhibitors (donepezil)
When should antipsychotics be considered for AD?
agitated and poses harm to themselves or others
What is used in addition to acetylcholinesterase inhibitors for moderate-severe AD?
memantine
What interventions can be made to prevent AD?
- D/C drugs that worsen dementia
- exercise
- eat healthy
- control blood glucose/BP/cholesterol
- engage in brain stimulating activities
What is the MOA of acetylcholinesterase inhibitors?
inhibit centrally active acetylcholinesterase, the enzyme responsible for hydrolysis of Ach; increases Ach
What are warnings with acetylcholinesterase inhibitors?
- Cardiac effects: Bradycardia, AV block, syncope
- GI effects: N/V/D, weight loss/anorexia (risk increased with high doses and patients with low body weight <55kg)
- Skin reactions: Allergic contact dermatitis (rivastigmine), SJS (galantamine)
- Donepezil: QT prolongation
What are SEs with acetylcholinesterase inhibitors?
- Insomnia
- dizziness
- diarrhea
- decreased HR
How is donepezil dosed/administered?
Oral: 5mg QHS (QHS to decrease nausea; if insomnia occurs dose AM), can increase to 10mg QHS after 4-6 wk
Mod-severe: can increase to 23mg after >3 months of 10mg QHS
Adlarity patch: start 5mg/24h weekly, can increase to 10mg/24h weekly after 4-6 wk
1. >/=3 day treatment interruption, retitrate from starting dose
2. slower titration over 6 weeks may decrease GI SEs
3. Adlarity patch: Store in refrigerator; apply patch within 24h of removal from fridge; if transitioning from oral to patch, apply patch at the same time as last oral dose
4. If stable on 10mg, can switch to Namzaric (memantine 7mg/donepezil 10mg QHS) and titrate weekly
Donepezil
Aricept (tab, ODT)
Adlarity (patch)
Donepezil + Memantine
Namzaric
How is rivastigmine dosed/administered?
Capsule: start 1.5mg BID, can increase every 2 weeks to 6mg BID
Patch: start 4.6mg/24h QD can increase every 4 wk to 13.3mg/24h QD; max dose 4.6mg/24h with hepatic impairment
1. take with food
2. >/=3 day treatment interruption, retitrate from starting dose
3. If transitioning from oral rivastigmine to the patch, apply the patch the day after the last oral dose
4. Rivastigmine patch may contain metals, remove before MRI
How is galantamine dosed/administered?
IR tablet/soln: start 4mg BID, can increase every 4 weeks to 12mg BID
ER capsule: start 8mg QD can increase every 4 weeks to 24mg QD
1. Do not use in severe hepatic or renal impairment
2. take with food
3. Solution can be mixed with liquid; drink immediately
4. >/=3 day treatment interruption, retitrate from starting dose
Rivastigmine
Exelon (patch/capsule)
What is the MOA of memantine?
NMDA receptor blocker; prevents glutamate from binding to NMDA receptor and causes overstimulation/neuron death
What are warnings with memantine?
Caution with drugs (sodium bicarb, acetazolamide) or conditions (severe UTI) that increase urine pH, which causes decreased clearance of memantine
What are SEs with memantine?
Generally well tolerated:
1. Dizziness
2. Confusion
3. Headache
4. constipation
How is memantine dosed/administered?
IR: start 5mg PO QD titrate weekly to 10mg PO BID
ER: start 7mg PO QD titrate weekly to 28mg PO QD
oral soln: use provided dosing syringe and squirt into mouth
1. can switch IR 10mg BID to ER 28mg QD begin ER dose after last IR dose
2. CrCl<30: max dose 5mg BID (IR) or 14mg PO QD (ER)
3. Do not crush/chew ER capsule or Namzaric; capsules can be opened and sprinkled on applesauce (swallow immediatly)
Memantine
Namenda
Namenda XR
Namenda Titration Pack
What are DIs with acetylcholinesterase inhibitors?
- caution with other drugs that lower HR
- Anticholinergics can reduce efficacy
- Increase gastric acid secretion; use caution in patients at risk of GI bleed (NSAID use, hx of ulcers)
Where should the Adlarity patch be placed?
Apply new patch at the same time each week:
1. Upper back/ Lower back (preferred)
2. Upper buttocks
3. Upper outer thigh
Rotate sites and do not apply on the same site within 14 days
Remove patch after 7 days
Fold patch with sticky sides together and throw in trash
Where should the Exelon patch be placed?
Apply new patch at the same time each day:
1. Upper/Lower back
2. Upper arm
3. Chest
Rotate sites and do not apply on the same site within 14 days
Remove patch after 24h
Fold patch with sticky sides together and throw in trash
