Neurological disorders Flashcards
T/F: 30-40% of delirium is preventable
True
T/F: Delirium is abrupt onset as opposed to insidious progression like dementia (alzheimers)
True
What are some pharmacological triggers for delirium?
Agents with anticholinergic effects:
Antihistamines: H1 and H2
Antidepressants: paroxetine, TCAs
Antipsychotics: typical > atypical
Antispasmodics and muscle relaxants
Antiparkinson: tihexyphenidyl, benztropine
Benzos, meperideine, steroids
*meperidine has metabolite that can affect pts with renal impairment
Withdrawal syndromes with alcohol, sedative hypnotics, and barbituates
T/F: There are 3 subtypes of delirium
T: hyperactive, mixed, hypoactive
Hypoactive seen more in older adults (quietly confused, disoriented, apathetic, sluggishness, lethargic)
*Often misdiagnosed as depression
What is The CAM assessment tool?
Common Assessment Method: for screening and diagnosis and sometimes monitoring of delirium
T/F: there is no medication to PREVENT delirium
True. Medications used to reduce delirium duration
T/F: The approach in managing delirium is to identify cause and remove offending agent and if needed treat pharmacologically for severe agitation with low dose antipsychotics like haloperidol, olanzapine, risperidone, quetiapine
True
T/F: Dementia is a major neurocognitive disorder
True: sig cognitive decline from a previous level of performance in one or more cognitive domains (more than just memory)
*Decline interferes with functioning in Instrumental activities of daily living (IADL): driving, managing check book AND activities of daily living (ADL): dressing, eating, etc
What are the vitamin deficiencies associated with antiseizure medications like phenytoin, carbamazepine, phenobarbital, and primidone?
B12 and folic acid
What vitamin deficiencies are associated with dementia?
B-12
Folic acid
B-1 (Thiamine)
What are the assessment tools used for cognition?
MMSE: mini mental state exam
MoCA: montreal concentration assessment
BOMC: blessed orientation memory concentration
SLUMS: st louis university mental status
What are some assessment tools for depression?
Patient health questionaire-9 (PHQ-9)
Geriatric depression scale-15 (GDS-15)
> =5: depression
What is the pathological hallmark of Alzheimer’s disease?
extracellular beta-amyloid plaques and intracellular neurofibrillary tangles
What are the three classes of medications used to treat dementia?
Acetylcholinesterase inhibitors
NMDA antagonist
Anti-amyloid monoclonal antibody
What are the acetylcholinersterase inhinotors?
Donepezil, rivastigmine, galantamine
What is the only disease modifying therapy for dementia?
Amyloid beta-directed antibody (Aduhelm: aducanumab)
*used of early disease, mild cognitive impairment
T/F: Memantine is not used to treat mild to moderate dementia
True. Memantine used to treat only moderate to severe dementia
What allele is associated with dementia?
APOE4
What are the major side effects of the Ach inhibitors, NMDA antagonists like donepezil and memantine respectively?
*Opposite of Anticholinergic medications: diarrhea, nausea, vomiting, anorexia, weight loss
CNS: dizziness, headache, insomnia
Donepezil
GI side effects and insomnia.
If GI take at night
If insomnia take in morning
Rivastigmine comes in patch formulation that has less GI side effects but $$$
Why does rivastigmine interact with anticholinergics?
Anticholinergics can cause confusion and blunt effects of acetylcholinesterase inhibtors
*acetylcholinesterase breakdown acetylcholine
*anticholinergics block the transmission of acetylcholine in the central and peripheral nervous systems
*acetylcholinerase inhibitors allow for more availability of acetylcholine transmission
What is the only NMDA antagonist used in dementia?
Memantine
Used only in mod to severe disease
CNS side effects
Dose adjust with renal impairment
Why is Aduhelm typically not used for dementia?
Very expensive, IV admin q4 weeks, MRI monitoring
Not much data of benefit to justify expense. Clinically impact not clear for use currently.
*Patients on anticoagulants where excluded due to risk of bleeding
What is huperzine A?
Herbal supplement with MOA similar to ACHE Inhibitors
*active ingredient from chinese club moss, half compound and acts like ACHEI
*May be used to help slow cognitive decline in elderly
What is mechanism of NMDA antagonists?
Blocks Ca influx on receptors
Too much Ca excites cells too much and cell dies
Reduces excitatory state and attempt to save cells from dying
T/F: Efficacy of with ACHEIs should be assessed after 12 weeks of therapy
True. Further assessments on a 6 month basis.
Monitor for AE throughout therapy
T/F: donepezil available in patch form
True. just approved, transdermal 5 or 10mg once a WEEK
T/F: verapamil, diltiazem, lancosamide, beta-blockers inc risk for bradycardia and heart block (PR interval prolongation) when used with AChEI
True
T/F: NSAIDS not recommended use with AChEI due to inc risk for dyspepsia, peptic ulcer disease, gastric bleeding
True
T/F: AChEI interact with CYP2D6 inhibitors and CYP3A4 inducers
True:
CYP2D6 inhibitors: dc tolerability, buproprion, duloxetine, paroxetine, quinidine, cimetidine (dec tolerability)
CYP3A4 inducers: carbamazepine, phenytoin, primidone, rifampin, st johns wort (dec efficacy)
What is NUPLAZID (pimavanserin)?
Used to treat dementia related behavior
FDA indicated for hallucinations/delusions associated with parkinson/s disease related psychosis
When do you stop AChEis and memantine?
consensus lacking but:
non adherence
continued deterioration
terminally ill or serious comorbidity
patient or caregiver choice
What are some well documented risk for using benzos in older population?
*falls
*cog worsening
*paradoxical disinhibition, worsens behavior
*modest inc in risk of development of pneumonia (sedation leading to hypoventilation, reduction in pressure in the lower esophageal sphincter leading to reflux and aspiration
T/F: FDA warning on ALL antipyscotics in AD
True. if used in AD dementia = off-label!!
*primary cause of mortality with use of Antipsycotics = HF, sudden death, pneuomia
black box warning of inc risk of death
T/F: Parkinson’s is diagnosed by motor symptoms
True
Resting tremor
Bradykinesia/akinesia
Rigidity
What are medications that can cause sub-acute development of parkinsonian symptoms?
AP: haloperidol, fluphenazine
Antiemetics: metoclopramide, prochlorperazine
*usually bilateral onset (weeks to months from initiation)
T/F: Parkinson/s disease is shortage of dopamine in the brain
True
T/F: Selegeline IR is goes through first pass metabolism into amphetamine and methamphetamine and can cause insomnia
True.
*BID dosing and recommended to take 2nd dose of the day earlier in day to prevent insomnia (by 2pm)
*selegeline ODT bypasses first pass metabolism (buccal)
T/F: Safinamide only approved for management of “off” period in PD treatment
True. Cannot be used as monotherapy, adjunct only
T/F: DHIVY is newly approved formulation of carbidopa/levodopa (25mg/100mg)
True. nothing too different, IR formulation.
The different is fractional tablet, can break off lil fragments if dose too high, etc.
T/F: Rytary is extended release CD/LD
True. capsule with different release or IR and ER inside
Provides more consistent levels, no high peaks
Can be sprinkled for pts with trouble swallowing.
T/F: intestinal gel of CD/LD is called DUOPA
True. infused during 16 hr period in daytime (J-tube), provides continuous stimulation bypassing stomach
T/F: COMT inhibitors are not to be used as monotherapy
True. Adjunct only
T/F: New medication for adjunct to CD/LD for PD istradefylline (Nourianz)
True. once daily dosing
*dose adjusted to higher dose for smokers
*strong 3A4 inhibitors, lower dose
*strong 3A4 inducers, like carbamazepine —> avoid use
*similar adverse effects as other dopaminergic meds except does NOT cause orthostatic hypotension
T/F: INbrija (Levodopa) used for rescue medications for “off period” in PD
True. Inhalation, onset 15 min, last up to 60 min
*up to 5 doses per day
T/F: To manage REM sleep behavior disorder (RBD), use melatonin 3-15 mg 1 hr before sleep and if that does not work: clonazepam 0.5-2mg before sleep
True. RBD (screaming, reenacting dreams, etc)
What are the main medications in older adults that would lower the seziure threshold?
Diphenhydramine
Tramadol
Buproprion
Meperidine
Clozapine
Haloperidol
___
stimulants
lithium
TCA
theophylline
Imipenem
excessive PCN or Cephalosporin use
what is seizures
seizures is loss of consciousness for a brief period of time
What are common target levels of antiepileptic medications?
total PHT 10-20
free PHT 1-2
CBZ 4-12
VPA 50-100
LMT 4-18
T/F: More than 909% of PHT is bound to protein
True
T/F: Phenytoin has the ability to induce many hepatic enzymes
True
CYP3A4: lurasidone, quetiapine, pimavanserin, donepezil, galantamine, apixaban, methadone, fentanyl, statins, vit D, macrolides, verapamil, diltiazem protease inhibitors, cyclopsorine,
CYP2D6: codeine, morphine, tamoxifen, tramadol, haloperidol, bb blockers, TCAs, donepezil, galantamine
CYP2C9: warfarin, PHT, glipizide
CYP1A2: clozapine, olanzapine, rasagiline, ropinorole
CYP2C19: PPIs, diazepam,PHT
UGTs: LMT, VPA
