Dementia Flashcards
First line treatment for mild-moderate dementia (DRUG CLASS)
Monotherapy with acetylcholinesterase inhibitors
First line treatment for mild-moderate dementia (DRUG NAMES)
Donepezil
Rivastigmine
Galantamine
Specific side effect of donepezil
Neuroleptic malignant syndrome
Donepezil dose
Initially 5mg NOCTE (can increase after 1 month)
Max 10mg NOCTE
Galantamine dose
Initially 8mg OD for 4 weeks
Increased to 16mg OD for 4 weeks
Maintenance dose 16-24mg OD
Galantamine dose hepatic impairment
Initially 8mg MANE on alternate days
Increased to 8mg OD for 4 weeks
Max dose 16mg
Specific side effect of galantamine
Steven-Johnson syndrome
Specific side effect of rivastigmine
GI - reduced if given by transdermal formulation
Rivastigmine transdermal application
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.
Oral rivastigmine dose
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
Treatment for moderate-severe dementia
Add in Memantine
Memantine dose
Initially 5mg OD
Increased in steps of 5mg at weekly intervals
Max 20mg
Memantine dose - renal impairment
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
Common side effects of memantine
Constipation
HTN
Dyspnoea
Headache
Dizziness
Impaired balance
Drowsiness
Drug interactions with memantine
Antimuscarinics - enhanced effects of antimuscarinics
Antipsychotics - reduced effects of antipsychotics
Barbiturates - reduced effects of barbiturates
Dopaminergic - enhanced effects of dopaminergic
Warfarin - enhanced anticoagulant effects
Side effects of acetylcholinesterase inhibitors?
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)
How to manage a patient who is experiencing side effects from acetylcholinesterase inhibitors?
Stop treatment, treat dehydration before reinitiating and amending the dose if needed
Which drugs are to be used with caution in dementia / Interactions
Antimuscarinic drugs - TCA
Antipsychotics - increases risk of neuroleptic malignant syndrome
Beta blockers - bradycardia
Metoclopramide - risk of EPSE
Tramadol or Pethidine
Long-acting benzodiazepines
Chlorphenamine
TRUE OR FLASE
For people with non-Alzheimer’s dementia the use of AChE inhibitors or memantine is unlicensed
TRUE
Treatment of mild-moderate dementia with Lewy bodies
First line: Donepezil or rivastigmine
Second line: Galantamine if first line options are not tolerated
Treatment of severe dementia with Lewy bodies
Donepezil or rivastigmine
Treatment of vascular dementia
AchE inhibitors or memantine are options if the person has suspected comorbid Alzheimer’s disease, PD, or dementia with Lewy bodies
TRUE OR FALSE
People with frontotemporal dementia should be offered AChE inhibitors or memantine.
FALSE
Driving; mild cognitive impairment with no likely driving impairment
Can continue driving
No need to notify DVLA
Driving; mild cognitive impairment where there is possible driving impairment
Subject to medical advice and/or notifying DVLA
Formal driving assessment may be necessary
Symptoms which indicate no fitness to drive
Poor short-term memory
Disorientation
Lack of insight
Lack of judgement
Driving; dementia and impaired cognitive function
Car/Motorcycle - may be able to drive but must notify DVLA
Bus/Lorry - must not drive and must notify DVLA
How is aggravation (non-cognitive symptom) treated in dementia patients?
Benzodiazepines or antipsychotics
When to offer an antipsychotic?
When patient is…
- At risk of harming themselves OR
- Experiencing agitation, hallucinations, or delusions that are causing them severe distress.
Which antipsychotics are licensed for treating non-cognitive symptoms of dementia
Risperidone and haloperidol
How should antipsychotics be initiated?
Lowest effective dose
Shortest time possible
When should a patient be reviewed after initiating antipsychotic in patients with dementia?
Every 6 weeks
Risperidone dose
Initially 0.25mg BD
Increased by 0.25mg BD on alternate days
Optimum dose 0.5mg BD
Can increase to 1mg BD
Haloperidol dose
Initially 0.5mg daily
Increased gradually every 1-3 days to 5mg daily (in 1-2 divided doses)
