Dementia Medications

Question 1

donepezil (Aricept)

Answer 1

Indication: Alzheimer’s Dementia

Dose: Start 5mg QAM and increase to 10mg after 4-6 weeks (mild to moderate); increase to 23mg after three months or more (severe) (manufacturer recommends bedtime dosing, but AM dosing prevents vivid dreams and insomnia)

Monitoring: No routine monitoring required

Mechanism: acetylcholinesterase inhibitor

Advantages: lower side effect profile than most

ADEs: dose-related diarrhea; nausea; weight loss (especially at higher doses); anorexia; insomnia; vivid dreams; vagotonic effects (i.e., bradycardia and syncope)

Off-Label: mild cognitive impairment; memory disorders

Fun Facts: comes as a combination pill with memantine (Namzaric)

Question 2

galantamine (Razadyne; Razadyne ER)

Answer 2

Indication: Alzheimer’s Dementia (mild to moderate)

Dose: Start 4mg BID (or 8mg QAM in XR); increase by 8mg/d in monthly increments; MAX=24mg/d

Monitoring: No routine monitoring required

Mechanism: acetylcholinesterase inhibitor AND cholinergic nicotinic receptor modulator

Advantages: dual cholinergic actions (but actual utility of this is lacking)

ADEs: diarrhea; nausea; weight loss; anorexia; insomnia; abnormal dreams; vagotonic effects (i.e., bradycardia and syncope)

Off-Label: mild cognitive impairment; memory disorders

Question 3

memantine (Namenda; Namenda XR)

Answer 3

Indication: Alzheimer’s Dementia (moderate to severe)

Dose: IR: Start 5mg QD x 1 week; then 5mg BID x 1 week; then 10mg-5mg x 1 week; then 10mg BID
XR: Start 7mg QD increase by 7mg increments weekly to 28mg/d

Monitoring: No routine monitoring required

Mechanism: N-methyl-D-aspartate (NMDA) receptor antagonist

Advantages: can be opened and sprinkled on food

ADEs: dizziness; transient confusion; headache; diarrhea; constipation; sedation

Off-Label: mild AD; mild cognitive impairment; memory disorders; chronic pain

Question 4

rivastigmine (Exelon)

Answer 4

Indication: Alzheimer’s Dementia; Dementia associated with Parkinson’s Disease

Dose: Start 1.5mg BID with meals x 4 weeks, then increase by 1.5mg BID incremeents every 4 weeks; MAX=6mg BID
Patch: Start 4.6mg/24hr patch; increase to 9.5mg patch after for weeks; for severe dementia, may continue to 13.3mg patch

Monitoring: No routine monitoring required

Mechanism: acetylcholinesterase inhibitor AND butyrylcholinesterase inhibitor

Advantages: patch option; only CI with indication for Parkinson’s related dementia

ADEs: dizziness; headache; diarrhea; anorexia; nausea; skin reactions (patch); vagotonic effects (i.e., bradycardia and syncope)

Off-Label: mild cognitive impairment; memory disorders