Pharm: Dementia

Question 1

Which 4 AChE inhibitors are preferred for Dementia?

Answer 1

• Donepezil
• Rivastigmine
• Galantamine
• Physostigmine

Question 2

AChE inhibitors will prolong the blockade of which non-depolarizing neuromuscular blocking agent?

Answer 2

Mivacurium –> metabolized by plasma AChE

Question 3

AChE inhibitors may enhance which effects of beta-blockers?

Answer 3

Bradycardic effects

Question 4

Which sx’s are noted initially from acute intoxication of AChE after ingestion vs. percutaneous absorption?

Answer 4

• Ingestion: GI sx’s occur earliest
• Percutaneous absorption: localized sweating and muscle fasciculations

Question 5

What is the MOA of Memantine used in dementia?

Answer 5

- Antagonist of the NMDA type of glutamate receptors

• Binds the intra-pore Mg²⁺ site, functioning as an effective receptor blocker only under conditions of excessive stimulation

Question 6

What are some non-pharmacologic options for patients with advanced dementia?

Answer 6

• Use evidence-based medicine and shared decision making to form formal advanced directives and health care proxies
• Focus on comfort care/hospice

Question 7

What four things should be focused on during advanced dementia care?

Answer 7

1. Hand feed as long as possible (avoid feeding tubes)
2. avoid missuse of Abx; frequent recurrent infections
3. Avoid hospitalizations
4. D/C chronic meds when no longer benefiting pt

Question 8

How can the neuropsychiatric sx of dementia be managed?

Answer 8

• Try non pharm approach first
• Titrate pain meds slowly
• SSRIs (citalopram) and avoid tricyclics
• Avoid antipsychotics (may use low dose in DLB)
• Avoid physical restraints
• Try cholinesterase inhibitor, antidepressant or methylphenidate for apathy
• Use good sleep hygiene

Question 9

When AD is mild, treat with what drug?

As it progresses, what should be added?

If an ACHEi is not improving sx or is not tolerated, what should be tried?

Answer 9

ACHEi

Memantine

Another ACHEi

Question 10

What are some of the toxic concerns with Memantine?

Answer 10

confusion/dizziness, headache

skin HSN

avoid abrupt D/C which can cause neuropsych issues

Question 11

What is the MOA of donepezil?

What are the toxicities?

Answer 11

ACHEi

• Altered cardiac conduction, prolonged QT and Torsades
• GI upset
• Abrupt D/c can cause neuropsych issues
• Can worsen ulcer, asthma/copd, BOO