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PHA333 > dementia in practice > Flashcards

dementia in practice Flashcards

1
Q

diseases included in dementia

A 
Alzheimer's
Lewy body dementia
vascular dementia
mixed dementia
Parkinson's dementia
frontotemporal dementia
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2
Q

pharmacists role in dementia

A
  1. public health- support, campaigns, reviews, eg. alcohol, smoking, DM, obesity RF for cognitive impairment
  2. ID dementia signs/referral
  3. med reviews - reduce inappropriate polypharmacy of meds that casue cognitive impairment
  4. supporting QoL - communication, dementia friendly pharmacies, signposting
  5. proactive meds menagement - ordering, adherance support
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3
Q

dementia friendly pharmacies

A

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

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4
Q

other casues of cognitive impairment

A
  1. drug related
    - anticholinergics
    - BDZs
    - opioids
    - anti-psychotics
    - alcohol
  2. physical health problem
    - infection (confusion eg. UTI)
    - hypothyroidism (impaired conc, memory)
    - sensory impairment (sight, hearing loss)
    - hypoglycaemia
  3. depression (lack of conc, poor ST memory)
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5
Q

What to do if dementia suspected?

A

refer to specialist/memory clinic

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6
Q

DVLA and dementia

A
  • dementia disgnosed, legally required to inform DVLA
  • can still drive in early dementia
  • may need annual review/formal driving assessment
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7
Q

aim of pharmacological Tx for dementia

A

improve symptoms

delay further decline

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8
Q

drug clases used for dementia

A

AChE inhibitors

NMDA receptor antagonists

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9
Q

examples of AChE inhibitors

A

donepezil
galantamine
rivastigmine

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10
Q

examples of NMDA receptor antagonists

A

memantine

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11
Q

When are AChE used?

A

mild/moderate dementia

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12
Q

When is memantine used?

A

mod-severe dementia

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13
Q

What drugs are used for dementia with lewy bodies

A

donepezil

rivastigmine

(galantamine/memantine are alternatives)

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14
Q

What meds are used for vascular dementia?

A

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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15
Q

What drugs are used for parkinson’s dementia?

A

all drugs used but they’re not licenced

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16
Q

Who initiates dementia meds?

A

specialist

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17
Q

cautions with AChE inhibitors

A

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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18
Q

s/e with AChE inhibitors

A

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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19
Q

interactions with AChE inhibitors

A

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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20
Q

formulations of donepezil

A

tabs
orodispersible tabs
oral solution

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21
Q

How to take donepezil?

A

take at bedtime

becauase it can cause dizziness

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

22
Q

dose of donepezil

A

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

then can titrate up to 10mg (max)

23
Q

nausea and donepezil

A

nausea usually improves

24
Q

monitoring with donepezil

A

HR - can casue bradycardia

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

25
Q

forms of galantamine

A

oral capsule MR
tabs IR
liquid IR

26
Q

How to take galantamine?

A

with/aftter food

27
Q

dose of galantamine

A

8mg daily

inc every 4 weeks to max of 24mg if needed/tolerated

BD dosing if IR

28
Q

contraindications for galantamine

A

severe liver impairment

  • reduce dose in moderate hepatic impairment
29
Q

rare serious s/e with galantamine

A

skin reaction

-> discontinue

30
Q

monitornig for galantamine

A

monitor appetite - can dec appetite

31
Q

most common drug for PD dementia

A

rivastigmine

32
Q

forms of rivastigmine

A

oral capsule

transdermal patch

33
Q

How to take rivastigmine?

A

with/after food (oral)

34
Q

dose of rivastigmine

A

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
35
Q

counselling for rivastigmine patch

A

rotate patch site becasue it can cause rash

36
Q

monitoring for rivastigmine

A

body weight - reduced appetite, anorexia

37
Q

When might you need to discontinue AChE?

A
  • stopping/swapping
  • poor compliance
  • poor tolerance, s/e
  • co-morbidity
  • no benefit
38
Q

progression of dementia and AChE

A

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

39
Q

forms of memantine

A

tablet

oral drops

40
Q

dose of memantine

A

5mg daily

titrated up to max 20mg daily

41
Q

s/e of memantine

A 
hallucinations
dizziness
constipation
headache
tiredness
42
Q

When to adjust dose with memantine?

A

renal impairment

43
Q

BPSD

A

behavioural and psychological symptoms of dementia

90% of pts will have these symptoms

44
Q

symptoms in BPSD

A

delusions
hallucinations
agitation
aggression

45
Q

Why aren’t antipsychotics used for BPSD symptoms?

A

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

46
Q

drug used for BPSD

A

risperidone

licenced for ST use of BPSD

47
Q

non-pharmacological approaches to BPSD

A
  • 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
48
Q

causes of delirium that would not be dementia symptoms

A 
pain
infection
nutrition - poor blood sugar control
constipation
hydration
meds
alcohol withdrawal
environment - noise, over stimulating, lighting, changes?
49
Q

pharmacological approaches to BPSD

A
  • 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
50
Q

meds optimisaiton for dementia

A
  • 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
51
Q

adherence with dementia

A
  • 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)
52
Q

med review for dementia

A
  • 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)

PHA333 (27 decks)

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