Dementia Flashcards
Dementia is a progressive clinical syndrome characterised by a range of cognitive and behavioural symptoms that can include ___________ loss, problems with ____________ and __________, a change in ____________, and a reduced ability to _______________
memory loss
reasoning and communication
personality
carry out daily activities such as washing or dressing
What are the types of dementia? (5)
- Alzheimer’s (most common)
- Vascular
- Lewy Body dementia
- Mixed
- Frontotemporal
What are the aims of treatment in the management of dementia? (3)
- Promote independence
- Maintain function
- Manage symptoms
What are the non-drug treatment options in the management of mild-moderate dementia presenting with COGNITIVE symptoms? (4)
- Opportunity to participate in group cognitive stimulation program
- Group reminiscence therapy (use of life stories to improve psychological well-being)
- Cognitive rehabilitation
- Occupational therapy
Which drugs should be avoided in patients with dementia? (4)
Drugs that are associated with an increased antimuscarinic (anticholinergic) burden and therefore cognitive impairment
- Some antidepressants (TCAs)
- Antihistamines (chlorphenamine, promethazine)
- Antipsychotics (olanzapine, quetiapine)
- Urinary antispasmodics (solifenacin succinate, tolterodine)
In patients with mild-moderate Alzheimer’s, monotherapy with which drugs is first line? (3)
Acetylcholinesterase inhibitors:
- Donepezil
- Galantamine
- Rivastigmine
**In newly diagnosed patients, drug treatment should only be initiated under the advice of a specialist clinician experienced in the management of Alzheimer’s disease
In patients with moderate Alzheimer’s in whom acetylcholinesterase inhibitors are not tolerated or contraindicated, what drug may be used as an alternative?
Memantine
What is the drug of choice for patients with severe Alzheimer’s?
Memantine
In patients already receiving an acetylcholinesterase inhibitor to treat Alzheimer’s disease, the addition of _______________ should be considered if they develop moderate or severe disease
memantine
In this case, memantine can be initiated in primary care without the advice of a specialist clinician
Can acetylcholinesterase inhibitor treatment be discontinued in patients with moderate Alzheimer’s disease if disease severity improves?
Treatment discontinuation should not be based on disease severity alone;
In patients with moderate Alzheimer’s disease, discontinuing acetylcholinesterase inhibitor treatment can cause a substantial worsening in cognitive function
What drugs should be given to patients with mild-moderate Lewy body dementia? (2)
(Both unlicensed)
- Donepezil
- Rivastigmine
*galantamine (unlicensed) can be considered ONLY if treatment with the other two is not tolerated
Which 2 drugs may be considered for the management of severe Lewy Body dementia?
- Donepezil
- Rivastigmine
Both unlicensed
What drug may be considered as an alternative in patients with Lewy Body dementia in whom acetylcholinesterase inhibitors are contra-indicated or not tolerated?
Memantine (unlicensed)
Acetylcholinesterase inhibitors [unlicensed indication] or memantine hydrochloride [unlicensed indication] should only be considered in patients with vascular dementia if…?
they have suspected co-morbid:
- Alzheimer’s disease
- Parkinson’s disease dementia
- dementia with Lewy bodies
In which two groups of patients are acetylcholinesterase inhibitors and memantine hydrochloride NOT recommended?
- Frontotemporal dementia
2. Cognitive impairment caused by MS
What is the mechanism of action of memantine?
Glutamate receptor antagonist (blocks NMDA receptors)
Patients with dementia should be offered psychosocial and environmental interventions such as ____________ and management of __________ and __________ to reduce distress
Counseling
Pain
Delirium
What is the role of antipsychotics in the management of dementia?
Antipsychotic drugs should only be offered to patients with dementia if they are either at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress
Antipsychotic drugs should only be offered to patients with dementia if they are…? (2)
- at risk of harming themselves or others
2. experiencing agitation, hallucinations or delusions that are causing them severe distress
The CHM/MHRA has reported (2009) an increased risk of ________ and a small increased risk of ________ when antipsychotic drugs are used in elderly patients with dementia.
Stroke
death
The balance of risks and benefits should be carefully assessed, including any previous history of stroke or transient ischaemic attack and any risk factors for cerebrovascular disease such as hypertension, diabetes, smoking, and atrial fibrillation
In the management of dementia, antipsychotic drugs should be used at the lowest effective dose and for the shortest time possible, with a regular review at least every ___ weeks
6
Antipsychotics can worsen which two subtypes of dementia?
- Lewy body dementia
- Parkinson’s disease dementia
May cause severe antipsychotic sensitivity reactions in some cases
What is the role of antidepressants in the management of dementia?
antidepressants should be reserved for pre-existing severe mental health problems
What are the preferred interventions for the management of mild-moderate depression and anxiety associated with mild-moderate dementia? (4)
Psychological treatments:
- CBT
- Multi sensory stimulation
- Relaxation
- Animal-assisted therapies
*antidepressants should be reserved for pre-existing severe mental health problems
What is the recommended management of sleep disturbances associated with dementia? (3)
Patients should be offered non-drug treatment approaches:
- Sleep hygiene education
- Exposure to daylight
- Increasing exercise and activity
List the main acetylcholinesterase inhibitors (6)
- Rivastigmine
- Physostigmine
- Pyridostigmine
- Neostigmine
Also
- Donepezil (reversible)
- Galantamine (reversible; also has nicotine receptor agonist properties)
Which acetylcholinesterase inhibitors do NOT cross the BBB? (2)
- Neostigmine
2. Pyridostigmine
Donepezil should be prescribed with caution in which patients? (5)
- Asthma
- COPD
- Sick sinus syndrome
- Supraventricular conduction abnormalities
- Susceptibility to peptic ulcers
What are the common of very common side effects of Donepezil? (16)
- Aggression
- Agitation
- Decreased appetite
- Common cold
- GI disturbances (diarrhea, N/V)
- Dizziness
- Fatigue
- Hallucinations
- Headache
- Injury
- Muscle cramps
- Pain
- Skin reactions
- Sleep disorders
- Syncope
- Urinary incontinence
What are the uncommon/rare but dangerous side effects of Donepezil? (5)
- GI hemorrhage
- Seizure
- Cardiac conduction disorders
- NMS and extrapyramidal symptoms
- Rhabdomyolysis
Memantine monotherapy is recommended as an option for managing Alzheimer’s disease for people with (2)
- Moderate AD who are intolerant of or have a contraindication to other AChE inhibitors
- Severe AD
What 3 AChE inhibitors are recommended as monotherapies for the management of mild-moderate AD?
- Donepezil
- Galantamine
- Rivastigmine
What cautions should be used when prescribing galantamine? (5)
- Avoid in GI obstruction and whilst recovering from GI surgery
- Avoid in urinary outflow obstruction and whilst recovering from bladder surgery
- Cardiac disease including CHF, sick sinus syndrome, unstable angina
- COPD and severe asthma
- History of seizures
What are the common or very common side effects of galantamine? (14)
- Decreased appetite, weight loss
- Arrhythmias
- Asthenia
- Depression
- GI discomfort, diarrhea, N/V
- Dizziness and drowsiness
- Falls
- Hallucinations
- Headache
- HTN
- Muscle spasms
- Skin reactions
- Syncope
- Tremor
Caution is advised when prescribing Rivastigmine in which patients? (6)
- Bladder outflow obstruction
- Conduction abnormalities or sick sinus syndrome
- Duodenal or gastric ulcers
- History of asthma or COPD
- History of seizures
- Risk of fatal overdose with patch administration errors
What are the common or very common side effects of Rivastigmine? (17)
- Psychological: Anxiety, depression, hallucinations, sleep disorders, confusion, nightmares
- Decreased appetite and weight loss
- Arrhythmias
- Asthenia
- Dehydration
- Dizziness, falls, drowsiness
- GI discomfort, N/V
- Headache
- Hyperhyrdosis and hypersalivation
- Skin reactions
- Movement disorders and Parkinsonism
- HTN or hypotension (with oral use)
- Tremor
- Syncope
- Urinary incontinence
- UTIs
- Gastric ulcer (with transdermal use)
What are the rare but significant side effects of Rivastigmine? (5)
- AV block
- Pancreatitis
- Seizure
- Hepatitis
- GI hemorrhage (with oral use)
What preparation of Rivastigmine is less likely to cause side effects?
Transdermal
What are the monitoring requirements for Rivastigmine?
Monitor body weight
Memantine should be prescribed with caution in which patients?
Patients with epilepsy, history of convulsions, or risk factors for epilepsy
What are the common or very common side effects of memantine? (7)
- Impaired balance
- Constipation
- Dizziness and drowsiness
- Dyspnea
- Headache
- Hypersensitivity
- HTN
What are the uncommon but important side effects of memantine? (6)
- VTE
- Seizure
- Pancreatitis
- Hepatitis
- Psychotic disorder
- HF
Which two drugs should not be co-prescribed with memantine due to increased risk of CNS toxicity? (2)
- Amantadine
2. Ketamine
