Lec 14- Dementia II

Question 1

Cognitive Enhancers

Answer 1

• Refer to earlier lecture
• Donepezil, memantine- Improve care symptoms, impaired cognition
• Follow NICE guidelines
• Advise on locally shared care guidance
  
  • Agreement between primary and secondary on prescribing reponsibilities
  • Usually started by secondary
  • When patient stable prescribing transferred to primary care
• Adverse events not well recognised education and training- advise to carers including care homes

Question 2

BPSD

Answer 2

• Refer to the previous lecture
• Ensure appropriate guidelines followed- Alzheimer’s society, DoH, National Dementia Strategy
• Audit of usage medication of BPSD
• Need to consider all psychotropics e.g. BZs
• Supporting Care Homes
• the role for Pharmacy-led medication review
  
  • Collaborative medication review linking primary and secondary care
  • Staff training- help care home manage BPSD
• Research article: A pharmacy led the program to review anti-psychotic prescribing fro people with dementia

Question 3

Supporting Carers

Answer 3

• People with dementia unable self-advocate
• Reason’s model: error causation barrier removed
• Increased cognitive impairment => carer-controlled med man

Question 4

Carers and medication managment

Answer 4

• Conduct up to 10 med man activities- Noticing & managing side-effects, deciding administer medication
• Key role safe medication use
• Family carers not equipped & responsibility significant burden
• Greater No med related activities => Increase social function & family carer stress burden

Question 5

Impact of carer burden

Answer 5

• Carer burden linked collapse current care arrangement
• Polypharmacy => carer burden & use residential care
• Very little research in dementia
• Perspectives of carers on medication management in dementia: lessons from collaboratively developing a research proposal

Question 6

Medication review

Answer 6

• Adherance review- type II
• Support appropriate adherence
• Full clinical review- type III

Question 7

Type II- Improving adherence

Answer 7

• Memory aids e.g. alarm clocks
• Paitent education
  
  • Repeat information immediately once or twice
  • Concentration important & ignore less important
  • Use both verbal and written
• Carer education
• Keep it simple
• Compliance aid

Question 8

Compliance Aids

Answer 8

• Nurses abuse compliance
• Limited space doses
• Stability issues- not airtight, less protection, less moisture
• Lack data on stability
• Not stable- venlafaxine; valporate
• Bacterial cross-contamination

Question 9

Use of compliance Aids in dementia

Answer 9

• How do people with dementia and their informal carers manage their medication in the community: mixed studies review
• Funded by pharmacy research UK
• Published in BMC geriatrics
• May help in early stages of dementia
• Less likely to help when disease more advanced

Question 10

Medication review

Answer 10

• Review medication impairs cognition
• Sedative compounds
  
  • BZs; H2 antagonists; anti-psychotics
• Medication anti-cholinergic activity
  
  • Psychotropics
  • OTCs- H2 antagonists, anti-histamines
    
    • Physical drugs e.g. furosemide, digoxin, warfarin, prednisolone

Question 11

Medication appropriateness

Answer 11

• Evidence medicines inappropriately older people
• Cross-sectional study 2707 patient 65+
  
  • 19.8% prescribed >1 inappropriate medication
• Analysis anti-psychotics 2.5 million nursing home residents
  
  • 58.2% outside guidelines
  • 17.2% doses > recommended levels
• Holistic approach- time to benefit
  
  • Must exceed the life expectancy
  • Example- statins time benefit >5 years
  • Work outside guidelines otherwise polypharmacy

Question 12

Pharmacist medicines review

Answer 12

• Pharmacist reduce inappropriate med use
  
  • Improving outcomes e.g. Decrease admissions rates problematic
• 203 patients 70+ pharm. care vs usual care
• MAI (Medication Approp. Index) signific improve intervention group
  
  • Odds ration 9.1 (85% CI= 2.2-17.0)
  • No significant effect on mortality, re-admission rates
• Negative study- Homer study
• Pharmacist intervention increased admissions rate
  
  • 234 vs 178

Question 13

Case illustration

Answer 13

• 55 downs syndrome
  
  • Lives independently- daily social service visit
• Epilepsy, hypothyroidism, increased ChE- Na Val 500mg TDS; Thyroxine 50mcg OM; Simva 20mg ON
• Presenting increase cognitive impairment
  
  • Difficulty medication => residential care
• Simplify OD coincide visit
  
  • Simva => 6pm = Check ChE
  • Na Val => 1500mg SR= monitor epilepsy
  • Thyroxine => 6pm check TSH