- dementia disgnosed, legally required to inform DVLA - can still drive in early dementia - may need annual review/formal driving assessment

dementia in practice Flashcards by Sarah Ramsbottom

diseases included in dementia

Alzheimer's
Lewy body dementia
vascular dementia
mixed dementia
Parkinson's dementia
frontotemporal dementia

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pharmacists role in dementia

public health- support, campaigns, reviews, eg. alcohol, smoking, DM, obesity RF for cognitive impairment
ID dementia signs/referral
med reviews - reduce inappropriate polypharmacy of meds that casue cognitive impairment
supporting QoL - communication, dementia friendly pharmacies, signposting
proactive meds menagement - ordering, adherance support

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dementia friendly pharmacies

quality payment scheme if 80% of staff are ‘dementia friends’

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other casues of cognitive impairment

drug related
- anticholinergics
- BDZs
- opioids
- anti-psychotics
- alcohol
physical health problem
- infection (confusion eg. UTI)
- hypothyroidism (impaired conc, memory)
- sensory impairment (sight, hearing loss)
- hypoglycaemia
depression (lack of conc, poor ST memory)

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What to do if dementia suspected?

refer to specialist/memory clinic

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DVLA and dementia

dementia disgnosed, legally required to inform DVLA
can still drive in early dementia
may need annual review/formal driving assessment

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aim of pharmacological Tx for dementia

improve symptoms

delay further decline

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drug clases used for dementia

AChE inhibitors

NMDA receptor antagonists

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examples of AChE inhibitors

donepezil
galantamine
rivastigmine

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examples of NMDA receptor antagonists

memantine

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When are AChE used?

mild/moderate dementia

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When is memantine used?

mod-severe dementia

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What drugs are used for dementia with lewy bodies

donepezil

rivastigmine

(galantamine/memantine are alternatives)

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What meds are used for vascular dementia?

no licenced drug Tx

main aim is to reduce risk of ischaemic attacks/stroke

drugs used if patient has combination dementia

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What drugs are used for parkinson’s dementia?

all drugs used but they’re not licenced

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Who initiates dementia meds?

specialist

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cautions with AChE inhibitors

GI ulcer risk
asthma/COPD (can inc bronchoconstriction)
supraventricular cardiac conduction conditions - SA/AV block (can cause bradycardia, block)
urinary retention
low body weight

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s/e with AChE inhibitors

GI: nausea (esp initiation), vomiting, anorexia, diarrhoea, GI upset, ulceration

alertness, agitation, hallucinations

dizziness, seizures

insomina

heart: bradycardia, SA or AV block

urinary incontinence

pain, headache, muscle cramps

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interactions with AChE inhibitors

antimuscarinic drugs - antagonise effects

antipsychotic Tx - inc risk of neuroleptic malignant syndrome (NMS)

CYP3A4 inducers/inhibitors

drugs with adverse CV effets - bradycardia

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formulations of donepezil

tabs
orodispersible tabs
oral solution

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How to take donepezil?

take at bedtime

becauase it can cause dizziness

-> can switch to OM if bad dreams/interfering with sleep

dose of donepezil

initially 5mg and continue for at least a month before clinical assessment

then can titrate up to 10mg (max)

nausea and donepezil

nausea usually improves

monitoring with donepezil

HR - can casue bradycardia

-> avoid co-prescription with drugs that reduce HR or monitor

forms of galantamine

oral capsule MR tabs IR liquid IR

How to take galantamine?

with/aftter food

dose of galantamine

8mg daily inc every 4 weeks to max of 24mg if needed/tolerated BD dosing if IR

contraindications for galantamine

severe liver impairment - reduce dose in moderate hepatic impairment

rare serious s/e with galantamine

skin reaction -> discontinue

monitornig for galantamine

monitor appetite - can dec appetite

most common drug for PD dementia

rivastigmine

forms of rivastigmine

oral capsule | transdermal patch

How to take rivastigmine?

with/after food (oral)

dose of rivastigmine

oral: - 1.5mg BD with/after food - titrate up in 2 week intervals - to max 6mg BD if tolerated patch - 4.6mg daily - inc to max of 13.3mg daily if tolerated

counselling for rivastigmine patch

rotate patch site becasue it can cause rash

monitoring for rivastigmine

body weight - reduced appetite, anorexia

When might you need to discontinue AChE?

- stopping/swapping - poor compliance - poor tolerance, s/e - co-morbidity - no benefit

progression of dementia and AChE

as disease progresses the amount of ACh produced will be less than the start patient performance will decline eventually to a stage where the drug will have little clinical effect

forms of memantine

tablet oral drops

dose of memantine

5mg daily titrated up to max 20mg daily

s/e of memantine

``` hallucinations dizziness constipation headache tiredness ```

When to adjust dose with memantine?

renal impairment

BPSD

behavioural and psychological symptoms of dementia 90% of pts will have these symptoms

symptoms in BPSD

delusions hallucinations agitation aggression

Why aren't antipsychotics used for BPSD symptoms?

inc risk of cerebrovascular events contribute to cognitive decline inc mortality risk

drug used for BPSD

risperidone licenced for ST use of BPSD

non-pharmacological approaches to BPSD

- identify behaviour triggers - conforting routines - info from family/carers - altered sense of reality - forget me not card - engage patinet in activities - include and involve pt in conversations - sleep hygiene - time orientation

causes of delirium that would not be dementia symptoms

``` pain infection nutrition - poor blood sugar control constipation hydration meds alcohol withdrawal environment - noise, over stimulating, lighting, changes? ```

pharmacological approaches to BPSD

- stop inappropriate meds - treat infection - constipation - pain - paracetamol - underlying depression - sertraline, mirtazepine (less likely to prolong QT than citalopram) - antipsychotics last resort (worsen cognitive fx, stroke risk, mortality risk) - > start low, titrate if needes, withdraw gradually

meds optimisaiton for dementia

- supporting patients to live well - dossette boxes - home delivery - proactively contacting about repeat Rx - printed lists of meds - do patient/carers understand how new meds should be taken - ask about OTC meds - flagging potentially inappropriate prescribing

adherence with dementia

- changes in presentation of tabs (size, shape, colour) canlead to confusion and non-adherance eg. new brand - non-adherance to Tx for co-morbid conditions can worsen that condition (eg. not taking BP meds can lead to worsening of dementia symptoms)

med review for dementia

- appropriate titration of dementia meds - check for s/e (N&V, GI) - compliance issues - repeat Rx issues - simplifying drug regimens - swallowing difficulties (with progression of dementia), alert, may need to change to liquid - lifestyle changes - palliative care - rationalise meds and reduce unnecessary meds (reduce polypharmacy can reduce falls risk) - DM review, avoid hypoglycaemia - min drugs with high anticholinergic burden (inc cognitive decline, inc mortality, additive effect, alternatives)