CNS: Dementia and Parkinsonism Flashcards by arike f

What is dementia?

a progressive, irreversible clinical syndrome with a range of cognitive and behavioural symptoms

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What are some cognitive symptoms of dementia? (2)

Memory loss

Issues with reasoning/communication

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What are some behavioural symptoms of dementia? (2)

Inability to carry out basic tasks

Change in personality

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What is the most common type of dementia?

Alzheimer’s dementia

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What are some common types of dementia (5)?

Alzheimer's 
Lewy-body dementia
Vascular dementia
Mixed dementia
Frontotemporal dementia

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Which commonly prescribed drug classes should be avoided in patients with dementia? (4)

Drugs with antimuscarinic effects, e.g.

Antidepressants, antihistamines, antipsychotics, antispasmodics

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What drug class is first line for treatment for Alzheimer’s disease?

Acetylcholinesterase inhibitors (AChEIs)

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What are the three AChEIs used as first line treatment for mild to moderate Alzheimer’s?

Donepezil
Galantamine
Rivastigmine

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What is the STOPP criteria for all AChEIs? (4)

Heart block
Unexplained syncope
Persistent bradycardia
Concurrent treatment with drugs that reduce heart rate

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What can be used in patients with moderate Alzheimer’s if AChEIs are not tolerated or contraindicated?

Memantine

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What is the first line treatment for patients with severe Alzheimer’s?

Memantine

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If patients on an AChEI for mild Alzheimer’s deteriorate, what drug can be added?

Memantine

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Can medicines for dementia be prescribed in primary care/by a non-specialist?

Yes - addition of memantine to patient already on AChEIs

No - newly diagnosed patients

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Why shouldn’t AChEIs be discontinued in patients with moderate Alzheimer’s?

Doing so can worsen cognitive function substantially

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What are the first line drugs for mild, moderate and severe lewy-body dementia? (2)

Donepezil

Rivastigmine

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When should galantamine be considered in lewy-body dementia?

When treatment with donepezil or rivastigmine is not tolerated

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When should memantine be considered for use in lewy-body dementia?

When AChEIs are contraindicated or not tolerated

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When should drug treatment be considered for patients with vascular dementia?

When they also have another form of dementia (Alzheimer’s, Parkinson’s or lewy-body)

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What treatment is available for patients with frontotemporal dementia or cognitive impairment caused by MS?

None at the moment - AChEIs and memantine are not recommended in this group

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What are some cholinergic side effects? (8)

Remember: DUMBBELS

Diarrhoea
Urination
Muscle weakness/cramps
Bronchospasm
Bradycardia
Emesis (vomiting)
Lacrimation (teary eyes)
Salivation/sweating

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When should antipsychotics be offered to patients with dementia? (2)

If they are at risk of harming themselves/others

If they are severely distressed due to hallucinations, delusions or agitation

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What did an MHRA report conclude about elderly dementia patients on antipsychotics? (2)

There is an increased risk of stroke and a small increase in risk of death

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How should antipsychotics in dementia patients be prescribed? (3)

Starting with the lowest effective dose
For the shortest time possible
With 6-weekly reviews

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What is important to consider in Parkinson’s and lewy-body dementia patients re: antipsychotics?

Antipsychotics can worsen motor features

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What four psychological treatments can be considered in dementia patients suffering with depression/anxiety?

CBT Multisensory stimulation Relaxation Animal-assisted therapies

What should be offered to dementia patients with sleep disturbances? (3)

Sleep hygiene education Exposure to daylight Increasing exercise

What is the mechanism of action for memantine?

It is an NMDA glutamate receptor antagonist - limiting Ca2+ influx into the cell

What role does glutamate play in Alzheimer's dementia?

Glutamate plays a role in membrane excitability and synaptic transmission too much glutamate → too much Ca2+ being let into the post-synaptic nerve → cell bursts and dies

What are three main points for donepezil?

Take at bedtime There is a rare risk of neuroleptic malignant syndrome (increased risk when taken with antipsychotics) It is long acting, so usually only given once a day

What are two main points for rivastigmine?

Monitor body weight | Interrupt treatment if dehydration (due to D+V) occurs

How does galantamine differ from rivastigmine and donepezil?

It has nicotinic receptor agonist effects, as well as being an AChEI

What should patients on galantamine be warned of?

Serious skin reactions (e.g. SJS) - patients should stop taking and seek medical advice immediately

What is Parkinson's disease?

A progressive, neurodegenerative condition caused by death of dopaminergic cells in the substantia nigra

What are some motor symptoms of Parkinson's? (5)

``` Hypokinesia (less movement) Bradykinesia (slow movement) Rigidity Tremor at rest Postural instability ```

What are some non-motor symptoms of Parkinson's? (6)

``` Dementia Sleep disturbances Changes in speech and language Swallowing issues Weight loss Bladder/bowel dysfunction ```

How often should patients with Parkinson's be reviewed?

Every 6-12 months

Who should Parkinson's patients inform about their diagnosis? (2)

The DVLA and their car insurer

What non-pharmacological treatment should be offered to patients with Parkinson's? (3)

Physiotherapy Speech and language therapy Occupational therapy

What is the first line treatment for motor symptoms that affect quality of life in Parkinson's?

Levodopa with carbidopa (co-careldopa) OR with benserazide (co-beneldopa)

Why does levodopa need to be given either either carbidopa or benserazide?

Carbidopa and benserazide inhibit peripheral metabolism of levodopa, increasing its chances of reaching the brain

What are the first line treatment options for motor symptoms that DO NOT affect quality of life in Parkinson's? (3)

Levodopa Non-ergot derived dopamine receptor antagonists MOA-B inhibitors

How do non-ergot derived dopamine receptor agonists work?

They mimic dopamine and directly stimulate dopamine receptors

What are three examples of non-ergot derived dopamine receptor antagonists?

Ropinirole Pramipexole Rotigotine

How do MOA-B inhibitors work?

They inhibit the breakdown of dopamine in the synaptic cleft

What are two examples of MAO-B inhibitors?

Selegiline | Rasagiline

What ADRs should Parkinson's patients be warned about before treatment? (3)

Excessive sleepiness/sudden onset of sleep Psychotic symptoms Impulse control disorders (more common with non-ergot derived dopamine receptor antagonists)

Which Parkinson's medication is associated with more motor complications?

Levodopa - response fluctuations and dyskinesia (on and off periods)

Which drug class is more effective in improving overall motor performance?

Levodopa > non-ergot derived dopamine receptor antagonists

Why should abrupt withdrawal of antiparkinsonian drugs be avoided? (2)

Abrupt withdrawal may increase the risk of acute akinesia or neuroleptic malignant syndrome

What antiemetic medication can be given to patients with Parkinson's and why?

Domperidone (does not cross BBB ∴ does not cause extrapyramidal side effects)

What should happen when a patient with Parkinson's develops dyskinesia or motor fluctuations? (2)

Specialist advice should be sought before changing their therapy Adjunct therapy is considered

What can be given to patients with Parkinson's who require adjunct therapy with levodopa?

``` Non-ergot dopamine receptor agonists (e.g. ropinirole) MOA-B inhibitors (e.g. rasagiline) COMT inhibitors (-capone) ```

When should ergot-derived dopamine receptors be considered as adjunct therapy?

Only when symptoms are not adequately controlled with a NON-ergotic dopamine receptor antagonist

Why aren't ergot-derived dopamine receptor agonists preferred over non-ergot derived?

They cause fibrotic reactions (patients should be warned of pulmonary, retroperitoneal and pericardial side effects)

What is an example of a ergot-derived dopamine receptor antagonist?

Bromocriptine

When should amantadine be considered?

When dyskinesia is not adequately managed by modifying existing therapy

What drug can be offered to patients with advanced Parkinson's?

Apomorphine (with domperidone started 2 days and discontinued ASAP)

What advice is given by the MHRA to patients on apomorphine and domperidone?

Assess cardiac risk factors and monitor ECG (can cause QT prolongation)

What are four important side effects of dopaminergic drugs?

Excessive daytime sleepiness Impulse control disorders Motor complications End-of-dose deterioration

Which drug class of antiparkinsonian medication is more likely to cause side effects?

Dopamine receptor agonists

Have you taken a break today?

Don't ignore the question - you won't remember anything if you don't take regular breaks 🥺

What foods are thought to cause hypertension when taken with MAO-B inhibitors?

Tyramine-rich foods (e.g. mature cheese, fermented food)

What drugs should be avoided by patients who are taking MAO-B inhibitors?

Anything that can cause hypertension

What are two examples of COMT inhibitors?

Entacapone | Tolcapone

How do COMT inhibitors work?

By inhibiting COMT they limit the metabolism of dopamine/levodopa

What should patients who use tolcapone be made aware of?

Signs of liver toxicity e.g. dark urine, pruritus, N&V | it's hepatotoxic

What should patients using entacapone be made aware of?

It can make the colour of urine reddish-brown

What is co-careldopa gel indicated for? | How is it administered?

Advanced Parkinson's with severe motor fluctuations and hyper- or dyskinesia Via a portable pump directly to the duodenum or upper jejunum

What should happen if a patient develops a problematic impulse control disorder? (2)

Dopamine receptor agonist therapy should be reduced and stopped Patients should be monitored for symptoms of dopamine agonist withdrawal

What are some examples of impulsive control disorders? (4)

Hypersexuality Gambling Excessive spending Binge eating