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Chapter 4 - Nervous System > Dementia > Flashcards

Dementia Flashcards

1
Q

Define Dementia

A

Umbrella term for a progressive and irreversible syndrome of widespread impairment of mental function

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2
Q

What are the various types of Dementia? Define each of these (3)

A

Alzheimers Disease
Vascular Dementia
Dementia with Lewy bodies

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3
Q

What are the COGNITIVE symptoms of dementia? (4)

A

Memory loss
Language impairment
Poor concentration
Disorientation/Confusion

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4
Q

What are the NON-COGNITIVE symptoms of dementia? (4)

A

Anxiety
Depression
Sleep disturbances
Delusion

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5
Q

What drug treatments are available for cognitive symptoms? 1st line and 2nd?

A

1st line - Acetylcholinesterase inhibitors e.g. Donepezil hydrochloride, Galantamine, Rivastigmine

2nd line - Memantine Hydrochloride

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6
Q

When is Memantine hydrochloride used?

A

It is used as an alternative when Acetylcholinesterase inhibitors are contra-indicated or not tolerated.

1st line choice for severe Alzheimer’s disease.

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7
Q

In which type of dementia is pharmaceutical treatment not recommended for cognitive symptoms?

A

Vascular dementia

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8
Q

What is the treatment of choice for non-cognitive symptoms (unless severe)?

A

Non-pharmalogical treatments such as multi-sensory stimulation or aromatherapy
Counselling

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9
Q

Anti-psychotics are reserved only for severe symptoms. What is the MHRA advice on their use in dementia patients?

A

MHRA states that there is increased risk of stroke and a small increased risk of death when anti-psychotics used in elderly with dementia.

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10
Q

How should antipsychotic treatment be started?

A

Lowest effective dose and slowly titrated upwards with regular review every 6 weeks

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11
Q

What can be used in severe aggression, violence and extreme agitation apart from anti-psychotics?

A

Benzodiazepines
e.g. haloperidol, lorzepam, olanzapine.

Diazepam and chlorpromazine are not recommended.

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12
Q

What is the drug class and the mechanism of action of Donepezil hydrochloride ?

A

Acetylcholinesterase (AChE) inhibitor.

Reversible inhibitor of acetylcholinesterase.

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13
Q

What is the dose of donepezil hydrochloride for mild/moderate dementia in Alzheimer disease?

A

Initially 5mg ON for a month and then can be increased to upto 10mg daily if needed.

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14
Q

Why should donepezil hydrochloride be given for at least one month?

A

To allow earliest clinical response to treatment to be assessed & allow steady state concentration to be achieved.

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15
Q

Is donepezil hydrochloride suitable for

  1. 18 and under
  2. Renal impairment
  3. Hepatic impairment
  4. Pregnancy
  5. Breastfeeding
A
  1. No
  2. Yes - as clearance of donepezil is not affected by renal impairment.
  3. Depends on patient’s tolerability - due to possible increased exposure in mild/moderate hepatic impairment. No results in severe.
  4. No data. Should not be used unless clearly necessary
  5. Should NOT be used. No studies.
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16
Q

V. common (3) & common(10) side effects on donepezil?

A

V. common:
Diarrhoea, Nausea, Headache,

Common:
Common cold, Aggression, Agitation, Vomiting, Dizziness, GI disorders, Muscle cramp, Fatigue, Insomnia, Hallucination

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17
Q

Cautions to using Donepezil? (3)

A
  1. Respiratory - Asthma, COPD - due to chol
  2. Cardiovascular - Sick Sinus Syndrome/ Supraventricular conduction (Sinoatrial/Atrioventricular block) This is because cholinesterase inhibitors may have vagotonic effects on heart rate (bradycardia/slower)
  3. GI conditions - increased risk of peptic ulcers (e.g. concurrent NSAID use, history of peptic ulcer = monitoring)
18
Q

Notable interactions with donezepil
Reduce (4)
Increase (2)

A 
Reduce levels of Donepezil :
Enzyme inducers such as Rifampicin
Phenytoin
Carbamazepine
Alcohol

Increase levels:

Enzyme inhibitors such as:
Ketoconazole
Quinidine

19
Q

What is the indication and mechanism of action of Galantamine ?

A

Mild to moderately severe dementia of the Alzheimer type

Reverisible inhibitor of acetylcholinesterase

20
Q

Dosing schedule of Galantamine?

Immediate release and prolonged release

A

Immediate release:
4mg BD for 4 weeks
then increased to 8mg BD for at least 4 weeks
Maintenance dose = 8-12mg BD

Prolonged release:
8mg OD for 4 weeks, increased to 16mg OD for at least 4 weeks.
Maintenance = 16-24mg OD

21
Q

Is galantamine suitable for:

  1. 18 and under
  2. Renal impairment
  3. Hepatic impairment
  4. Pregnancy
  5. Breastfeeding
A
  1. No
  2. Avoid if eGFR less than 9ml/min/1.73m (Galantamine plasma concentrations may be increased in pts with moderate to severe renal impairment )
  3. Galantamine plasma concentrations may be increased in moderate to severe hepatic impairment

moderately impaired hepatic function (Child-Pugh score 7-9), dosing should begin with 8 mg PR capsule once every other day (in morning) for one week. Thereafter, should proceed with 8 mg once-daily for four weeks. daily dose max 16 mg.

Immediate release - 4mg OD for 7 days. then 4mg BD for 4 weeks. Max 8mg BD

Severe hepatic impairment (Child-Pugh score greater than 9), the use of galantamine is contraindicated

No dosage adjustment in mild hepatic impairment

  1. Use with caution - toxicity in animal
  2. Avoid - no info
22
Q

What serious skin reaction should patients be made aware of with galantamine?

A

Stevens-Johnson syndrome (red man syndrome) - stop using it at first sign of skin rash or reaction

23
Q

Cautions with Galantamine? (4)

A

Cardiac disorder (same with donepezil) - sick sinus syndrome, supraventricular cardiac disturbances or those on medicines which reduce heart rate e.g. digoxin and beta blockers, or pts with uncorrected electrolyte disturbances e.g. hyperkalaemia, hypokalaemia.

GI disturbances - peptic ulcers. Not used in those with GI blockages or recovering from GI surgery.

Resp - asthma, COPD

Urinary/Renal - should NOT be used in those with urinary outflow obstruction or recovering from bladder surgery.

24
Q

Most common side effects of galantamine? (7)

A

Nausea
Vomiting

Fatigue
Bradycardia
Hypertension
Abdominal pain
Diarrhoea
25
Q

Indication and MoA of rivastigmine

A

Mild/Moderate dementia in Alzheimer’s disease & Parkinson’s disease

Reversible non-competitive inhibitor of acetylcholinesterases.

26
Q

What is the dosing schedules of Rivastigmine for Alzheimer and Parkinsons

A

A.D & P.D
ORAL- Initially 1.5mg BD then can be increased every 2 weeks depending on tolerance.
Usual dose 3-6mg BD
Max dose 6mg BD

If treatment interrupted for several days - needs retitrate from 1.5mg BD

PATCH
4.6mg/24hr daily for at least 4 weeks, increased to 9.5mg/24hr for 6 months, then if necessary to 13.3mg/24hr

Need to retitrate from 4.6mg if treatment stopped for more than 3 days.

27
Q

Use Rivastigmine with caution in patients with a body weight less of…

A

50kg.

28
Q

What is the dose equivalence if you wanted to switch from oral rivastigmine to patch?

A

3-6mg orally = 4.6mg/24hr
9mg orally = 9.5mg/24hr
12mg orally = 9.5mg/24hr

If not tolerated titrate up from 4.6mg patch. First patch should be applied the day after last oral dose.

29
Q

Is rivastigmine suitable for:

  1. 18 and under
  2. Renal impairment
  3. Hepatic impairment
  4. Pregnancy
  5. Breastfeeding
A
  1. No
  2. Yes - no adjustments req.
  3. Titrate depending on individual tolerability.
  4. No - unless clearly necessary
  5. No
30
Q

Specific side effects of Rivastigmine?
(6)
Rare (2)

A 
Oral:
Confusion
Hallucinations
Gait abnormal 
Malaise
Parkinsonism
Sleep disorder 
Rare: 
Angina pectoris (chest pain due to CHD), GI disorder/haemorrhage
31
Q

What should be monitored with Rivastigmine? and in Alzheimer’s disease in general.

A

Weight

32
Q

Risk of transdermal patches of Rivastigmine?

A

Fatal overdose

33
Q

What is the drug class, MOA and indication of Memantine hydrochloride?

A

Drug class: NMDA receptor antagonists

MoA: glutamate receptor antagonist

Indication: moderate to severe dementia in Alzheimer’s disease

34
Q

What is the dose of memantine?

A

Start at 5mg OD then increased in steps of 5mg every week.

Usual & max dose 20mg OD

It is titrated up to reduce risk of adverse effects.

35
Q

Is memantine hydrochloride suitable for

  1. 18 and under
  2. Renal impairment
  3. Hepatic impairment
  4. Pregnancy
  5. Breastfeeding
A
  1. No
  2. Avoid in severe renal impairment less than 5ml/min

eGFR 5-29ml/min daily dose 10mg.

eGFR 30-49ml/min dose should be 10mg per day and if well tolerted after at least 7 days then can be increased to 20mg following titration

  1. Yes, no dose adjustment required in mild/moderate heaptic. Severe - no data.
  2. Avoid in preg
  3. Avoid
36
Q

Common side effects of Memantine? (7)

A 
Balance impaired 
Constipation
Dizziness
Dyspnoea
Headache
Hypersensitivity
Hypertension
37
Q

Cautions with memantine? (3)

A

Epilepsy
History of convulsions
Risk factors for epilepsy

38
Q

NICE guidelines on the prescribing of donepezil, galantamine, rivastigmine and memantine? (3)

A
  1. Treatment should be initiated on advice of a specialist
  2. ensure local arrangements for prescribing follow guidelines
  3. treatment should continue only if it is considered to have a worthwhile effect on cognitive, global function or behavioural symptoms
39
Q

Directions for administration of Rivastigmine (Exelon) patches?

A

Apply patches to clean, dry non-hairy non-irritated skin on back, upper arm, or chest, removing after 24 hours.

Make sure to remove previous patch before new one is put on a different area avoid using same area for 14 days.

40
Q

Acetylcholinesterase inhibitors may have STOPP criteria in elderly - which categories may they be inappropriate?

A
  1. Pts with a known history of persistent bradycardia (heart rate less than 60 beats per minute)
  2. Heart block
  3. Recurrent unexplained syncope
  4. Concurrent treatment with drugs that reduce heart rate

Chapter 4 - Nervous System (15 decks)

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