dementia in practice

Question 1

what are the different types of dementia?

Answer 1

• Alzheimer’s disease
• Lewy Body dementia
• Vascular dementia
• Mixed dementia
• Parkinson’s dementia
• Frontotemporal dementia
• Others

Question 2

what are the different dementia friendly teams/environments?

Answer 2

Dementia-friendly pharmacies
–Framework which includes looking at the
environment/public health info/training/support etc
•Quality Payments scheme
–community pharmacies can claim a monetary award if
80% of all patient-facing staff are “Dementia Friends

Question 3

what drugs could cuase alterations of cognitive impairment?

Answer 3

–Anticholinergics
–Benzodiazepines 
–Opioids 
–Anti-psychotics 
–Alcohol.

Question 4

what physical health problems could cause alterations of cognitive impairment?

Answer 4

.g. infection (confusion), hypothyroidism (impaired concentration/memory), sensory impairment e.g. sight or
hearing loss, hypoglycaemia.

Question 5

what would you use to assess initial cognitive testing?

Answer 5

•Lots of brief validated tools available such as: 
–GPCOG
–AMTS 
–10-CS
–6CIT
–6-item screener 
–MIS
–Mini-Cog
–TYM

Question 6

when is a patient legally required to tell the DVLA ?

Answer 6

When dementia is diagnosed, the person is

legally required to inform the DVLA

Question 7

when may a formal driving assessment be necessary?

Answer 7

In early dementia, where sufficient skills are
retained and progression is slow, a license
(car/motorcycle) may be issued subject to
annual review.

Question 8

what is use dto treat mild-mod AD?

Answer 8

AChE- donepezil, galantamine, rivastigmine

Question 9

what is used to treat mod-severe AD?

Answer 9

Memantine

Question 10

what do you treat dementia with lewy bodies with?

Answer 10

donepezil or rivastigmine

galantamine/memantine alternatives

Question 11

what do you treat dementia with parkinsons with?

Answer 11

ache inhibitors and memantine

Question 12

what is used to treat vascular dementia?

Answer 12

no licensed treatments

Question 13

what are the cautions with AChE?

Answer 13

GI ulcer risk, asthma/COPD, supraventricular cardiac conduction conditions e.g. SA or AV block, urinary retention, low body weight

Question 14

what are the side effects of AChE?

Answer 14

–Nausea (esp on initiation), anorexia, vomiting
–Diarrhoea, GI upset, ulceration
–Alertness and agitation, hallucination, dizziness, insomnia, seizures, bradycardia and SA or AV block, urinary incontinence,
pain, headache, muscle cramps.

Question 15

what interactions occur with AChE inhibitors?

Answer 15

antimuscarinic drugs (antagonise effects), concurrent antipsychotic tx can increase risk of neuroleptic malignant syndrome (NMS), CYP3A4 inducers/inhibitors, drugs with adverse CV effects eg bradycardia

Question 16

when do you take donepezil?

Answer 16

Take orally at bedtime

–(ON as can cause dizziness- can switch to OM if bad dreams/interfering with sleep)

Question 17

how do you initiate and maintain donepezil?

Answer 17

Start at 5mg and continue for at least a month before clinical assessment then can titrate dose
up to 10mg

Question 18

what should you assess when on donepezil?

Answer 18

Assess heart rate as can cause bradycardia and
avoid co-prescription of drugs that can reduce
HR/monitor

Question 19

how should you initiate and maintain galantamine?

Answer 19

8mg daily, increasing every 4 weeks to max of
24mg daily if needed/tolerated. (BD dosing if
IR)

Question 20

how should you take galantamine?

Answer 20

with/after food

Question 21

who is galantamine c/i in?

Answer 21

C/I in severe liver impairment (dose reduce in

moderate hepatic imp)

Question 22

when should you discontinue galantamine?

Answer 22

•Rarely serious skin reaction (discontinue)

Question 23

when is rivastigmine used?

Answer 23

•Licensed in Alzheimer’s, Parkinson’s dementia

Question 24

how do you take rivastigmine?

Answer 24

with/after food

Question 25

how do you initiate and maintain rivastigmine?

Answer 25

•Oral 1.5mg BD with/after food and titrate up in 2 week intervals to max 6mg BD if tolerated
•Patches 4.6mg daily, increasing to max of 13.3mg daily
if tolerated.
–Rotate patch site as can cause rash

Question 26

what should you monitor when checking?

Answer 26

Monitor body weight (reduced appetite/anorexia)

Question 27

when should you discontinue dementia medication?

Answer 27

Stopping or swapping 
•Poor compliance
•Poor tolerance SE
•Co-morbidity
•No evidence of benefit

Question 28

how should you give memantine?

Answer 28

• Monotherapy
• Can also use in combination with AChE
• 5mg daily, titrated up to max 20mg daily

Question 29

what are the side effects of memantine?

Answer 29

Hallucinations, dizziness, constipation,

headache, tiredness common

Question 30

when would you need a dose modification for memantine?

Answer 30

Dose modifications in renal impairment

Question 31

what do you assess when youre not sure if the patients symptoms are dementia or delerium?

Answer 31

–Pain?
–Infection?
–Nutrition? Poor blood sugar control?
–Constipation?
–Hydration?
–Medication? Alcohol withdrawal?
–Environment? Noise? Over-stimulation? Lighting? 
Changes?

Question 32

what are some non-pharmacological approaches to BPSD?

Answer 32

–Identify behaviour triggers
–Comforting routines
–Altered reality sense and communicating on this level
–Information from carers/relatives
–Forget me not card
–Engage patient in activities meaningful to them
–Include and involve patient in conversations at every opportunity
–Sleep hygiene
–Time orientation

Question 33

what would you give if the patient had underlying depression?

Answer 33

Sertraline, mirtazapine may be more appropriate and less

likely to prolong QT interval than citalopram

Question 34

why would you only use antipsychotics as a last resort?

Answer 34

they can worsen cognitive function, stroke risk and

mortality risk

Question 35

what would you check when doing a medication review?

Answer 35

Appropriate titration of dementia medications
•Check for side effects – nausea, vomiting, GI
•Compliance issues and repeat prescribing issues
•Simplifying drug regimens
•With progression of dementia, may experience
swallowing difficulties, ask carer, be alert may
need change to liquid
•Lifestyle changes to keep healthy
•Palliative care (end stage)

Question 36

why would you minimise drugs with an anticholinergic burden?

Answer 36

–These are associated with increased cognitive decline
and increased mortality
–Additive effect of multiple meds
–Is there a more appropriate alternative?