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Pharmacist Revision > Dementia > Flashcards

Dementia Flashcards

1
Q

What are the different types of Dementia?

A
  • Alzheimer’s Disease
  • Mixed Dementia
  • Vascular Dementia (due to cerebrovascular disease)
  • Dementia with Lewy Bodies
  • Frontotempeoral Dementia
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2
Q

What types of medications can increase cognitive impairment and their use should be minimised in patients with Dementia?

A
  • Antimuscarinics
  • Antidepressants (Amitriptyline, Paroxetine)
  • Antihistamines (Chlorphenamine, Promethazine)
  • Antipsychotics ( Olanzapine, Quetiapine)
  • Urinary Antispasmodics (Solifenacin, Tolterodine)
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3
Q

What is the 1st line treatment for mild to moderate Alzheimer’s Disease?

A

Monotherapy of Donepizil or Galantamine or Rivastigmine
(should only be initiated under the advice of a specialist clinician)

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4
Q

What are class are Donepizil Galantamine and Rivastigmine?

A

They are Acetylcholinesterase inhibitors.

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5
Q

What is a suitable alternative for moderate Alzheimer’s Disease if Acetylcholinesterase inhibitors are not tolerated or contraindicated?

A

Memantine

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6
Q

What is 1st Line for severe Alzheimer’s Disease?

A

Memantine

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7
Q

If Alzheimer’s progresses to a moderate or severe state what medications can be given concurrently with Acetylcholinesterase inhibitors?

A

Memantine (can be initiated in primary care)

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8
Q

What medications in mild to moderate Dementia with Lewy Bodies should be given?

A

Donepezil (unlicensed use) or Rivastigmine (unlicensed use)

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9
Q

What medications in mild to moderate Dementia with Lewy Bodies should be given if Donepezil and Rivastigmine are not tolerated?

A

Galantamine (unlicensed use)

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10
Q

If all Acetylcholinesterase inhibitors are not tolerated or contraindicated in Dementia with Lewy Bodies what medication can be given as an alternative?

A

Memantine (unlicensed use)

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11
Q

When should Acetylcholinesterase inhibitors or Memantine be considered in Vascular Dementia?

A

If patient with vascular dementia have suspected co-morbid Alzheimer’s disease, Parkinson’s Disease Dementia or Dementia with Lewy Bodies.

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12
Q

When is Acetylcholinesterase inhibitors or Memantine NOT to be given in dementia?

A

In patients with Frontotemporal Dementia or when they have cognitive impairment caused by Multiple Sclerosis.

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13
Q

What MHRA warning is reported regarding Dementia patients and Anti-Psychotics medications?

A

Increased risk of Stroke and small increased risk of death in elderly patients using anti-psychotics that also have dementia

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14
Q

If an anti-psychotic is to be given to patients with Dementia what is overall guidance?

A

Anti-psychotics drugs should be used at the lowest effective dose and patient should be regularly review at least every 6 weeks.

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15
Q

What sort of Dementia can Anti-Psychotics worsen motor features and in some cases cause severe antipsychotics sensitivity reaction

A

Dementia with Lewy Bodies and Parkinson’s Disease Dementia

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16
Q

What dose of Donepezil should be given?

A

Initially 5 mg once daily at bedtime, increased if tolerated and necessary after 1 month to a maximum of 10 mg daily.

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17
Q

What dose of Galantamine should be given for dementia?

A

Initially 8 mg capsule once daily for 4 weeks, then increased to 16 mg once daily for at least 4 weeks; maintenance dose is 16–24 mg once daily.

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18
Q

What dose of Galantamine should be given for dementia in patients with moderate Hepatic Impairment?

A

Initially 8 mg on alternate days, preferably taken in the morning, for 7 days. Thereafter, 8 mg once daily for 4 weeks. Daily doses should not exceed 16 mg.

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19
Q

What dose of Rivastigmine should be given for Dementia?

A

By Mouth: Initially, 1.5 mg twice daily, increased in steps of 1.5 mg twice daily at intervals of at least 2 weeks.
Maximum dose per day is 6mg BD

By Patch: Initially, the 4.6 mg/24 hours patch should be applied for at least 4 weeks.
Increase to 9.5mg/24hr for a further 6 months.
Can increase to 13.3mg/24hr if tolerated.
Caution in patients with bodyweight less than 50kg.

If treatment was interrupted for more than 3 days, retitrate from 4.6mg/24hrs.

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20
Q

What is the dose conversion for Rivastigmine oral to patch?

A

Orally: 3–6 mg = 4.6 mg/24 hours patch

Orally: 9 mg = 9.5 mg/24 hours patch if oral dose stable and well tolerated; if oral dose not stable or well tolerated, patients should switch to 4.6 mg/24 hours patch, then titrate as above.

Orally: 12 mg = 9.5 mg/24 hours patch.

The first patch should be applied on the day following the last oral dose.

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21
Q

When is Donepezil contraindicated?

A

Pregnancy and breastfeeding

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22
Q

When is Galantamine contraindicated|?

A
  • Severe renal impairment (eGFR: 9 mL/minute/1.73 m2).
  • Severe hepatic impairment (Child-Pugh score greater than 9).
  • Significant renal and hepatic dysfunction.
  • Urinary outflow obstruction.
  • Gastrointestinal obstruction.
  • During recovery from bladder or gastrointestinal surgery.
  • Pregnancy and breastfeeding.
23
Q

When is Rivastigmine contraindicated?

A

Pregnancy and breastfeeding

24
Q

What are the cautions of Donepezil?

A
  • Sick sinus syndrome or other supraventricular conduction abnormalities.
  • Susceptibility to peptic ulcers including concurrent nonsteroidal anti-inflammatory (NSAID) use.
  • Asthma and chronic obstructive pulmonary disease (COPD).
  • Hepatic impairment.
  • Concomitant antipsychotic treatment — increased risk of neuroleptic malignant syndrome (NMS).
25
Q

What is Neuroleptic Malignant Syndrome and when can it occur?

A

Potentially life-threatening condition characterized by hyperthermia, muscle rigidity, autonomic instability, and fluctuating consciousness. Additional signs may include myoglobinuria (rhabdomyolysis) and acute renal failure.

Increased risk in people receiving concomitant antipsychotics with Donepezil.

If a person develops signs and symptoms of NMS, or presents with unexplained high fever without additional clinical manifestations of NMS, donepezil treatment should be discontinued.

26
Q

What are the cautions with Galantamine?

A
  • Renal and hepatic impairment.
  • Cardiac disease (including sick sinus syndrome or other supraventricular conduction abnormalities, post-myocardial infarction, unstable angina, new onset atrial fibrillation, second degree heart block or greater, and congestive heart failure) or in those who use medicinal products that significantly reduce heart rate concomitantly, such as digoxin and beta blockers.
  • QTc interval prolongation or taking drugs that prolong the QTc interval.
  • Electrolyte disturbances (such as hyperkalaemia or hypokalaemia).
  • Susceptibility to peptic ulcers including concomitant use of NSAIDs.
  • History of severe asthma, COPD, or pulmonary infection.
  • History of seizures.
27
Q

What are the cautions with Rivastigmine?

A
  • Hepatic impairment.
  • Renal impairment.
  • Gastric or duodenal ulcers (or susceptibility to ulcers).
  • Sick sinus syndrome or conduction abnormalities.
  • History of asthma or COPD.
  • History of seizures.
  • Bladder outflow obstruction.
28
Q

When should Galantamine be discontinued?

A

First appearance of a skin rash.

29
Q

What are the ADR to Donepezil?

A

Commonly: nausea, vomiting, anorexia, diarrhoea, fatigue, insomnia, headache, dizziness, syncope, abnormal dreams, hallucinations, agitation, aggression, muscle cramps, urinary incontinence, rash, and pruritus.

Rarely: extrapyramidal symptoms, sinoatrial block, atrioventricular (AV) block, liver dysfunction (including hepatitis), and neuroleptic malignant syndrome (NMS).

30
Q

What are the ADR to Galantamine?

A

Vomiting, nausea, abdominal pain, diarrhoea, dyspepsia, decreased appetite, weight loss (monitor the person’s weight during treatment with galantamine), bradycardia, hypertension, syncope, hallucinations, depression, dizziness, tremor, headache, fatigue, malaise, and muscle spasm.

31
Q

What warning should be made to patients taking Galantamine?

A

Serious skin reactions (including Stevens-Johnson syndrome, erythema multiforme, and acute generalized exanthematous pustulosis).

32
Q

What should you monitor in patients taking Galantamine?

A

The patient’s weight

33
Q

What are the ADR to Rivastigmine?

A

Nausea, vomiting, diarrhoea, dyspepsia, anorexia, weight loss, abdominal pain, bradycardia, dizziness, headache, drowsiness, gait abnormalities, fall, malaise, agitation, anxiety, tremor, confusion, insomnia, parkinsonism, syncope, skin reactions, urinary tract infection, urinary incontinence, and sweating.

34
Q

What advice regarding Rivastigmine does its manufacturers make?

A

That treatment with transdermal rivastigmine should be temporarily stopped if gastrointestinal adverse effects occur.

35
Q

What are the caution for all Acetylcholinesterase inhibitors?

A
  • History of bradycardia,
  • heart block,
  • recurrent unexplained syncope.
  • Concurrent treatment with drugs that reduce heart rate
36
Q

What effects can Acetylcholinesterase inhibitors have regarding driving and what are the appropriate monitoring?

A

AChE inhibitors can cause fatigue, dizziness, somnolence and muscle cramps, and can induce syncope or delirium. They have a minor or moderate influence on the ability to drive, especially during the first weeks after initiation of treatment or dose increases. Routinely assess the person’s ability to drive.

37
Q

What are the drug interactions with Acetylcholinesterase inhibitors?

A
  • Antimuscarinic drugs (e.g.TCAs) — these antagonize the effects of donepezil, galantamine, and rivastigmine.
    Concomitant use of two or more such drugs can increase adverse effects such as dry mouth, urine retention, confusion and constipation.
  • Antipsychotics (such as olanzapine) — concurrent use increases the risk of neuroleptic malignant syndrome (NMS).
  • Beta-blockers (such as atenolol) or other bradycardia agents (such as class III antiarrhythmics, calcium channel blockers) — if concurrent use is necessary, be alert for bradycardia.

-

38
Q

What is the interaction with metoclopramide?

A

concurrent use of rivastigmine and metoclopramide might increase the risk of extrapyramidal adverse effects. Be alert for movement disorders and signs of NMS.

39
Q

What drugs can increase plasma conc. of Galantamine?

A
  • CYP3A4 inhibitors (such as ketoconazole and erythromycin)
  • CYP2D6 inhibitors (such as paroxetine and fluoxetine
40
Q

What drugs can increase plasma conc. of Donepezil?

A
  • CP450 enzyme and CYP3A4 inhibitors (such as ketoconazole and possibly itraconazole and erythromycin) and CYP2D6 inhibitors (such as quinidine and possibly fluoxetine)
41
Q

What drugs can decrease plasma conc. of Donepezil?

A

Liver enzyme inducers — enzyme inducers such as rifampicin, phenytoin, carbamazepine, and alcohol)

42
Q

What is the dose for memantine?

A

Initially 5 mg once daily, increased in steps of 5 mg at weekly intervals to a maximum of 20 mg daily.

43
Q

What dose changes should be made in memantine for patients with renal impairment?

A

-eGFR <50 = 10mg daily and if well tolerated for at least 7 days then dose can increase in steps to 20mg daily

  • eGFR <30 = 10mg daily
  • eGFR <5 = Avoid
44
Q

What are the contraindications and cautions for Memantine?

A

Contraindicated:
- Rare hereditary problems of galactose intolerance, the Lapp lactase deficiency, or glucose-galactose malabsorption.
- Severe hepatic impairment.
- Severe renal impairment — eGFR <5

Cautions:
History of convulsions or predisposing factors for epilepsy.

45
Q

What are the ADR to Memantine?

A

constipation, hypertension, dyspnoea, headache, dizziness, impaired balance, and drowsiness.

46
Q

What are the drug interactions with Memantine?

A
  • Antimuscarinics — memantine possibly enhances effects of antimuscarinics.
    Concomitant use of two or more such drugs can increase adverse effects such as dry mouth, urine retention, and constipation.
  • Antipsychotics — memantine possibly reduces effects of antipsychotics.
  • Barbiturates — memantine may reduce the effect of barbiturates.
  • Baclofen and dantrolene — memantine possibly modifies the effects of these drugs. A dose adjustment may be necessary.
  • Dopaminergics — memantine possibly enhances effects of dopaminergic drugs such as cabergoline.
    N-methyl-D-aspartate (NMDA)-antagonists (such as amantadine, ketamine, or dextromethorphan) — there is an increased risk of central nervous system toxicity with memantine. Avoid concomitant use.
  • Warfarin — memantine possibly enhances anticoagulant effect of warfarin. Monitor international normalized ratio (INR) closely during concurrent use.
47
Q

What type of medications should be avoided for concomitant use with Memantine and why?

A
  • Dopaminergics- cabergoline,
  • N-methyl-D-aspartate (NMDA)-antagonists (such as amantadine, ketamine, or dextromethorphan.

An increased risk of central nervous system toxicity

48
Q

What is the mnemonics to remember the Cholinergic side effects ( Parasympathetic)

A

D- Diarrhoea
U - Urination
M - Muscles cramps, Muscle weaknesses, Miosis
B - Bradycardia

B - Bronchospasm
E - Emesis
L - Lacrimation (teary eyed)
S - Salivation/ Sweating

49
Q

What is agnosia?

A

Loss of the ability to identify objects using one or more senses.

50
Q

What is aphasia?

A

A comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain (usually the left side).

51
Q

What is apraxia?

A

Apraxia is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex or corpus callosum ) which causes difficulty with motor planning to perform tasks or movements.

52
Q

What is graphesthesia?

A

Graphesthesia is the ability to recognize writing on the skin purely by the sensation of touch.

53
Q

what is agraphesthesia?

A

Agraphesthesia is a disorder of directional cutaneous kinesthesia or a disorientation of the skin’s sensation across its space. It is a difficulty recognizing a written number or letter traced on the skin after parietal damage

Pharmacist Revision (22 decks)

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