Dementia

Question 1

First line treatment for mild-moderate dementia (DRUG CLASS)

Answer 1

Monotherapy with acetylcholinesterase inhibitors

Question 2

First line treatment for mild-moderate dementia (DRUG NAMES)

Answer 2

Donepezil
Rivastigmine
Galantamine

Question 3

Specific side effect of donepezil

Answer 3

Neuroleptic malignant syndrome

Question 4

Donepezil dose

Answer 4

Initially 5mg NOCTE (can increase after 1 month)
Max 10mg NOCTE

Question 5

Galantamine dose

Answer 5

Initially 8mg OD for 4 weeks
Increased to 16mg OD for 4 weeks
Maintenance dose 16-24mg OD

Question 6

Galantamine dose hepatic impairment

Answer 6

Initially 8mg MANE on alternate days
Increased to 8mg OD for 4 weeks
Max dose 16mg

Question 7

Specific side effect of galantamine

Answer 7

Steven-Johnson syndrome

Question 8

Specific side effect of rivastigmine

Answer 8

GI - reduced if given by transdermal formulation

Question 9

Rivastigmine transdermal application

Answer 9

Risk of fatal overdose with patch administration errors.

Initially 4.6 mg/24 hours patch - removed after 24 hours and a replacement patch applied on a different area
Increased to 9.5mg/24 hours patch daily after 4 weeks (USUAL MAINTENANCE DOSE)
Increased to 13.3mg/24 hours daily after 6 months (CAUTION IN PATIENTS <50kg)

Avoid using the same area for 14 days
If treatment is interrupted for more than 3 days, transdermal rivastigmine should be re-titrated from a 4.6 mg/24 hours patch.

Question 10

Oral rivastigmine dose

Answer 10

Initially 1.5mg BD
Increased in steps of 1.5mg BD at intervals of 2 weeks
Max 6mg BD
Re-titration is necessary if treatment is interrupted for more than several days

Question 11

Treatment for moderate-severe dementia

Answer 11

Add in Memantine

Question 12

Memantine dose

Answer 12

Initially 5mg OD
Increased in steps of 5mg at weekly intervals
Max 20mg

Question 13

Memantine dose - renal impairment

Answer 13

eGFR 30-49ml/min - 10mg daily (if tolerated can increase in steps to 20mg daily)
eGFR 5-29ml/min - 10mg daily
eGFR <5ml/min - avoid

Question 14

Common side effects of memantine

Answer 14

Constipation
HTN
Dyspnoea
Headache
Dizziness
Impaired balance
Drowsiness

Question 15

Drug interactions with memantine

Answer 15

Antimuscarinics - enhanced effects of antimuscarinics
Antipsychotics - reduced effects of antipsychotics
Barbiturates - reduced effects of barbiturates
Dopaminergic - enhanced effects of dopaminergic
Warfarin - enhanced anticoagulant effects

Question 16

Side effects of acetylcholinesterase inhibitors?

Answer 16

REST AND DIGEST

o Diarrhoea (digest)
o Urinary incontinence (digest)
o Muscle Weakness (rest)
o Bradycardia (rest)
o Bronchospasms (rest)
o Emesis (digest)
o Lacrimation (digest)
o Salivation (digest)

Question 17

How to manage a patient who is experiencing side effects from acetylcholinesterase inhibitors?

Answer 17

Stop treatment, treat dehydration before reinitiating and amending the dose if needed

Question 18

Which drugs are to be used with caution in dementia / Interactions

Answer 18

Antimuscarinic drugs - TCA
Antipsychotics - increases risk of neuroleptic malignant syndrome
Beta blockers - bradycardia
Metoclopramide - risk of EPSE
Tramadol or Pethidine
Long-acting benzodiazepines
Chlorphenamine

Question 19

TRUE OR FLASE

For people with non-Alzheimer’s dementia the use of AChE inhibitors or memantine is unlicensed

Answer 19

TRUE

Question 20

Treatment of mild-moderate dementia with Lewy bodies

Answer 20

First line: Donepezil or rivastigmine
Second line: Galantamine if first line options are not tolerated

Question 21

Treatment of severe dementia with Lewy bodies

Answer 21

Donepezil or rivastigmine

Question 22

Treatment of vascular dementia

Answer 22

AchE inhibitors or memantine are options if the person has suspected comorbid Alzheimer’s disease, PD, or dementia with Lewy bodies

Question 23

TRUE OR FALSE

People with frontotemporal dementia should be offered AChE inhibitors or memantine.

Answer 23

FALSE

Question 24

Driving; mild cognitive impairment with no likely driving impairment

Answer 24

Can continue driving
No need to notify DVLA

Question 25

Driving; mild cognitive impairment where there is possible driving impairment

Answer 25

Subject to medical advice and/or notifying DVLA

Formal driving assessment may be necessary

Question 26

Symptoms which indicate no fitness to drive

Answer 26

Poor short-term memory
Disorientation
Lack of insight
Lack of judgement

Question 27

Driving; dementia and impaired cognitive function

Answer 27

Car/Motorcycle - may be able to drive but must notify DVLA
Bus/Lorry - must not drive and must notify DVLA

Question 28

How is aggravation (non-cognitive symptom) treated in dementia patients?

Answer 28

Benzodiazepines or antipsychotics

Question 29

When to offer an antipsychotic?

Answer 29

When patient is…
- At risk of harming themselves OR
- Experiencing agitation, hallucinations, or delusions that are causing them severe distress.

Question 30

Which antipsychotics are licensed for treating non-cognitive symptoms of dementia

Answer 30

Risperidone and haloperidol

Question 31

How should antipsychotics be initiated?

Answer 31

Lowest effective dose
Shortest time possible

Question 32

When should a patient be reviewed after initiating antipsychotic in patients with dementia?

Answer 32

Every 6 weeks

Question 33

Risperidone dose

Answer 33

Initially 0.25mg BD
Increased by 0.25mg BD on alternate days
Optimum dose 0.5mg BD
Can increase to 1mg BD

Question 34

Haloperidol dose

Answer 34

Initially 0.5mg daily
Increased gradually every 1-3 days to 5mg daily (in 1-2 divided doses)