Alzheimer's Disease

Question 1

Diagnosis

Answer 1

MMSE — a score

Question 2

Symptoms

Answer 2

Memory loss
Difficulty communicating
Inability to learn or remember new information
Difficulty with planning and organizing
Poor coordination and motor functions
Personality changes
Inappropriate behavior
Paranoia, agitation, hallucinations

Question 3

Pathophysiology

Answer 3

Neuritic plaques & tangles in brain tissue; neuron signaling IS interrupted
Alteration of neurotransmitters (e.g. decreased acetylcholine)

Question 4

Natural products used for dementia

Answer 4

• Vitamin E (but > 150 IU carries risk)
• Ginkgo biloba (increased risk of bleeding)
• Huperzine A
• A-phosphatidylserine
• Acetyl-L-carnitine
• Vitamin D

Question 5

Drugs that can worsen dementia

Answer 5

• Peripheral Anticholinergics (IBS and incontinence drugs, oxybutinin, diphenhydramine)
• Central Anticholinergics (Benztropine, (congentin for Parkinsons))
• Antihistamines and Antiemetics
• Antipsychotics
• Barbiturates
• Benzodiazepines
• Skeletal muscle relaxants
• Other CNS depressants

Question 6

Drug Treatment

Answer 6

Acetylcholinesterase Inhibitors

• Donepezil (Aricept, Aricept ODT)
• Memantine (Namenda, Namenda XR)
• Rivastigmine (Exelon, Exelon Patch)
• Galantamine (Razadyne, Razadyne ER)

For depression and anxiety
- Sertraline, citalopram, escitalopram

For delusion and anger
- Antipsychotics (increase the risk of death in elderly)

Question 7

Acetylcholinesterase Inhibitors

• Donepezil (Aricept, Aricept ODT)
• Used alone or with memantine in more severe disease
• Aricept 23 mg used for advanced disease — minimal additional benefit

Answer 7

• 5-10 mg QHS for mild to moderate disease
• 23 mg QHS, for advanced disease, if stable on lower dose 1st x 3 mos
• Do not crush or chew

Question 8

Acetylcholinesterase Inhibitors

Rivastigmine (Exelon, Exelon Patch)

Answer 8

1.5-6 mg BID
4.6, 9.5, 1-3.3 mg/24 hr patch
2 mg/mL Liquid

Question 9

Acetylcholinesterase Inhibitors

Galantamine (Razadyne, Razadyne ER)

Answer 9

4-12 mg BID
4mg/mL solution
ER: start at 8 mg daily, then increase to 16-24 mg

Question 10

Acetylcholinesterase Inhibitors

Side Effects

Answer 10

GI side effects (nausea, vomiting, loose stools)
Donepezil given QHS to help with nausea
Bradycardia, fainting, insomnia, tremors, weight loss

Question 11

Acetylcholinesterase Inhibitors MOA

Answer 11

Inhibits centrally-active acetylcholinesterase, the enzyme responsible for hydrolysis (breakdown) of acetylcholine, which results in increase of ACh

Question 12

Acetylcholinesterase Inhibitors Notes

Answer 12

Other oral formulations are BID or daily if long-acting

Rivastigmine and Galantamine IR is with food (breakfast and dinner). Galantamine ER with breakfast. Galantamine solution can be mixed with liquid and taken within 4 hrs.

Recommend Exelon patch or Aricept ODT to decrease GI side effects — if the cost difference is acceptable

Exelon patch : titrate Q 4 weeks, apply first patch the day after last oral dose
Fiazadyne solution: can mix in 100 mL of non-alcohol liquid