Chapter 70 - Alzheimer's Disease Flashcards
Mild cognitive impairment
does not interfere with daily functioning
not severe
Dementia Sx
- Memory loss, getting lost
- Difficulty communicating, repeating words and info
- Inability to learn or remember new information
- Difficulty with planning and organizing
- Poor coordination and motor function
- Personality changes
- Inappropriate behavior
- Paranoia, agitation, hallucinations
Dementia Types
- Alzheimer’s disease (most common type)
- Vascular dementia
- Lewy body dementia
patho of alzheimer
Alzheimer’s dementia involves
- Neuritic plaques (clusters of beta- amyloid protein)
- Tangles (accumulation of tau protein) in brain tissue,
which
- interrupt neuron signaling, and/or
- alteration of neurotransmitters (e.g., decreased acetylcholine).
The FDA approved — as a radioactive imaging drug to estimate the — in adult patients being evaluated for Alzheimer’s disease.
- flortaucipir Fl8 (Tauvid)
- tau protein tangles
Rule out factors that could lead to memory loss
- Vitamin B12
- Depression
- Infection
Key drugs that can worsen dementia
- Antiemetics (e.g., promethazine}
- Antihistamines (e.g., diphenhydramine, doxylamine)
- Antipsychotics (e.g., chlorpromazine, aripiprazole)
- Barbiturates (e.g., phenobarbital, butalbital)
- Benzodiazepines (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)
Screening tools
- Mini–Mental State Examination (MMSE) or Folstein test
<24/30 –> memory disorder - Montreal Cognitive Assessment (MoCA)
- DSM-5 criteria
Functional abilities could be assessed with:
- Alzheimer’s Disease Cooperative Study - Activities of Daily Living (ADCS - ADL) tool.
Anticholinergics and memory impairment
Anticholinergic drugs:
- incontinence (e.g., oxybutynin),
- allergies or insomnia (e.g., diphenhydramine),
- dystonic reactions (e.g., benztropine, diphenhydramine)
- A drug with strong centrally-acting anticholinergic effects can cause acute cognitive impairment and, occasionally, psychosis and hallucinations.
- Centrally acting anticholinergics should be avoided in the elderly
- Beers criteria
-If a drug is used to treat incontinence, the reduction in symptoms should be evaluated at six weeks. If there is a lack of improvement, the drug should be discontinued.
Natural products with possible benefit
- Vitamin E (2,000 IU daily)
- Ginkgo
Both Increase bleeding risk and should be stopped if pt has high risk of bleeding and before an elective surgery - Acetyl L Carnitine –> acts as acetylcholine precursor
- Vinpocetine
- Vitamin D
NON-DRUG TREATMENT
The vascular health of the blood vessels in the brain is vital for cognitive function.
■ Keep blood glucose, blood pressure and cholesterol well- controlled.
■ Engage in “thinking” activities and regular physical activity (in all age groups, physical activity enhances the growth and survival of brain cells).
■ Eat a healthy diet, with fruits, vegetables, nuts, fish and with a low intake of red meat and alcohol.
Drug ttmt
- Acetylcholinesterase inhibitors (e.g., donepezil) are the mainstay of treatment.
- They are used alone or with memantine in more advanced stages of the disease
- If nausea is present, administration in the evening can help. Donepezil is taken at bedtime for this reason. If insomnia is a concern, the patient can take the dose in the morning.
- Memantine (Namenda) is approved for use alone or with donepezil for moderate-to-severe disease. - Namzaric is a combination of donepezil and memantine. Patients stabilized on donepezil 10 mg can be switched to Namzaric.
- Antidepressants (e.g., sertraline, citalopram, escitalopram) can be used to treat related depression and anxiety.
- Antipsychotics are used off-label for delusions and agitation, but there is an increased risk of death in elderly patients
Donepezil
(Aricept)
Acetylcholinesterase inhibitors
- Start: 5 mg QHS, can increase to 10 mg QHS after 4-6 weeks
- Moderate-to-severe disease: can increase to 23 mg QHS after 2:3 months of 10 mg QHS
- Donepezil is dosed QHS to help ! nausea
- Exelonpatch and donepezil ODT have less GI side effects
Donepezil + Memantin
Namzaric
Acetylcholinesterase inhibitors + NMDA blocker
If stable on donepezil 10 mg, can switch to Namzaric (memantine I7 mg/donepezil 10 mg QHS) and titrate weekly (minimally)
Rivastlgmine
Exelon
Acetylcholinesterase inhibitors
Dose:
- Capsule: start 1.5 mg BID, can increase every 2 weeks to 6 mg BID
- Patch: start with 4.6 mg/24 hrs, can increase every 4 weeks to 13.3 mg/24 hrs (patch is changed daily)
- Hepatic impairment: max patch dose is
4.6 mg/24 hrs
- Exelon patch and donepezil ODT have less GI side effects
- Exelon patch: apply first patch the day after last oral dose; rotate sites - do not use same site for 14 days.
- Does not contain metal (i.e., will not burn skin in MRI)
- Exelon capsules and galantamine IR should be taken with breakfast and dinner
