IC17 AD Flashcards
What are the DSM-5 criteria for Major Neurocognitive Disorder (Dementia)?
1) SIGNIFICANT cognitive decline from prior level of performance in one or more cognitive domains: either by observants eg. family members, or documented by standardized neurophysiological testing.
2) The cognitive deficits interfere with independence in everyday activities.
3) The cognitive deficits do not occur exclusively in the context of delirium.
4) The cognitive deficits are not better explained by another mental disorder.
What are the DSM-5 criteria for Minor Neurocognitive Disorder (Dementia)?
1) MODEST cognitive decline from prior level of performance in one or more cognitive domains: either by observants eg. family members, or documented by standardized neurophysiological testing.
2) The cognitive deficits interfere with independence in everyday activities.
3) The cognitive deficits do not occur exclusively in the context of delirium.
4) The cognitive deficits are not better explained by another mental disorder.
What are other manifestations of dementia in earlier stage?
1) Psychological: apathy, depressive symptoms
2) Behavioral: withdrawal from social engagement, disinhibition
3) Sleep: REM behavior disorder
4) Physical: gait impairment
What are other manifestations of dementia in later stage?
1) Psychological: delusions, anosognosia (lack of insight to cognitive problems)
2) Behavioral: aggression, hallucinations, wandering
3) Sleep: altered sleep-wake cycle
4) Physical: repetitive purposeless movements, Parkinsonism, seizures
What are the non-modifiable risk factors for dementia?
Age (>65 yo), Female, Race (Black, Hispanic), Genetics (homozygous APOE4 gene)
What are the modifiable risk factors for dementia?
Comorbidities: HTN, DM, depression, hearing loss
Lifestyle: smoking, binge drinking, sedentary lifestyle, obesity
What is the pathophysiology of Alzheimer’s Disease?
1) Brain atrophy in the neocortex and hippocampus area
2) Senile plaques: beta-amyloid aggregrates
3) Neurofibrillary tangles: hyperphosphorylated tau protein
4) Neurodegeneration: may be related to increased glutamate that causes neuronal death
What are the two class of drugs used for AD tx? List out all drugs in those classes.
Acetylcholinesterase inhibitors and NMDA receptor antagonist
AI: donepezil, rivastigmine, galantamine
NMDA RA: memantine
What are the drugs that are usually used in mild to moderate AD?
Rivastigmine, galantamine, donepezil
What are the drugs usually used in moderate to severe AD?
Donepezil and memantine (monotx or in combination)
What is the general principle of usage of acetylcholinesterase inhibitors?
- Slowly titrate dosing over 4 to 8 weeks to reach target dose and minimize side effects
- If adverse effects encountered, lower dosage temporarily before re-escalating more slowly OR discontinue and try another drug from the same class
What are the monitoring parameters for acetylcholinesterase inhibitors?
Efficacy:
- Improvement in day-to-day life by caregiver
- Routine cognitive tests eg. MoCA
Safety:
- Adverse events
What are the side effects associated with acetylcholinesterase inhibitors?
Nausea/vomiting, increased frequency of bowel movements, vivid dreams, insomnia
What are some cautions and contraindications with acetylcholinesterase inhibitors?
Caution in patients with PUD, respiratory disease, seizure, and urinary tract obstruction
Contraindicated (relative) in patients with bradycardia
What are some side effects associated with memantine?
Constipation, confusion, dizziness, headache
What are some cautions with memantine use?
Caution in CVD, seizure and severe renal/hepatic impairment
What are some other things that pharmacists can do for AD patients with regards to medications?
- Remove meds/supplements that are or may not be needed ie. by evaluating risks vs benefits
- Review meds that may contribute to cognitive impairment eg. anticholinergics, antihistamines
- Simplify the schedule for medications to improve adherence
What are BPSD?
Behavioral and Psychological Symptoms of Dementia: spectrum of NON-COGNITIVE and NON-NEUROLOGICAL symptoms of dementia eg. aggression, agitation, psychosis, depression, apathy, etc.
What are some factors that may be contributing to BPSD?
Medical: delirium, hearing/visual impairment, constipation or urinary retention, untreated pain, depression, anxiety, etc.
Pharmacological: anticholinergic drugs, ASM, steroids, anti-parkinsonian drugs, sedating drugs, etc.
Environmental or social: loneliness, perceived lack of security, unfamiliar environment, lack of privacy, difficulty in finding facilities, etc.
What is the main principle in managing BPSD?
- Treat underlying acute medical problems –> not BPSD
- Use non-pharmacological approaches if behavioral problems returns after treating acute medical problems –> BPSD
- Only consider pharmacological approaches if BPSD are severe and pose risk to the individual or others, and should NOT be continued indefinitely (can slowly withdraw after 3 months of improved symptoms)
What are some pharmacological options for BPSD?
- Acetylcholinesterase inhibitors esp. donepezil
- Memantine
Restlessness and agitation: trazodone
Depression: low dose sertraline, mirtazapine
Agitation and delusion: citalopram
Anxiety: lorazepam
Antipsychotics (may increase risk of stroke, CV events and death):
- risperidone (licensed), olanzapine
- in those with PD: quetiapine, aripiprazole
- if all doesn’t work: amisulpride
- in complex cases: clozapine
What are non-pharm measures for BPSD?
Hallucination: remove triggers, use a night light, remain calm and reassuring
Refusal to bathe: give control, options and flexibility; give privacy; create a soothing environment
Refusal to take meds: use a figure that the person wants to please, crush and mix with food, prioritize important medications, be patient and be on the patient’s eye level
Sundowning: make sure all rooms are well-lit, limit daytime napping
Wandering: disguise doors, place signs to discourage leaving, do not leave keys in plain sight
What is lecanemab and its inclusion/exclusion criteria?
Anti-amyloid monoclonal antibody, for early AD with confirmed brain amyloid pathology (by biomarker) and those who does not have a high bleeding risk (TIA/stroke in past 12 months, on antithrombotics)
What are the adverse effects of lecanemab?
Vasogenic edema and hemorrhage
Higher risk in those with APOE4 homozygotes
What are the benefits of sending AD patients to Dementia Day Care Centers?
- Engage in activities to help slow AD progression
- Caregivers can go to work
