Pharm - Stroke, Parkinsons, Dementia

Question 1

What is the primary recommendation to avoid stroke?

Answer 1

Decrease BP to 140/90 or less (old numbers) or 130/80 or less (new numbers)

Question 2

First-line agents (which class) for dyslipidemia? (Goal is stroke prevention)

Answer 2

Statins

Question 3

Should ASA be used as antiplatelet therapy for everyone?

Answer 3

No - only those with a high risk of CV events or stroke.

Question 4

What’s an Rx antiplatelet therapy other than aspirin?

Answer 4

Cilostazol

Question 5

In a lacunar stroke, what is blocking the flow?

Answer 5

An atherosclerotic plaque

Question 6

In an embolic stroke, what is blocking the flow?

Answer 6

An embolism

Question 7

In an atherothrombotic stroke, what is blocking the flow?

Answer 7

Plaque and embolus together

Question 8

Alteplase: 
MOA
Risks
Route
Monitoring

Answer 8

(aka tPA)
MOA: fibrinolytic: converts plasminogen to plasmin, breaking up clots.

Risk of hemorrhagic transformation
Must administer within 3-4.5 hrs of onset

IV administration: bolus plus infusion
Must monitor BP regularly during infusion

Question 9

Secondary stroke prevention - what does this mean and what is it?

Answer 9

After a stroke, HTN is still the most important goal: 140/90 or 130/90 for lacunar strokes.

diuretics and ACEis for HTN management.

Question 10

Lipids and secondary stroke prevention: recommendations?

Answer 10

High intensity statins if stroke/TIA was related to atherosclerosis.

Question 11

Diabetes and secondary stroke prevention: recommendations?

Answer 11

Screen for DM2 after a stroke… using HbA1C

Question 12

Sleep apnea and secondary stroke prevention?

Answer 12

Provide a CPAP

Question 13

Lifestyle changes after a stroke?

Answer 13

Quit smoking, decrease heavy alcohol consumption.

Question 14

Antithrombotic Therapy options for noncardioembolic stroke or TIA

Answer 14

ASA 50-325mg monotherapy

ASA 25/Dipyridamole 200

Clopidogrel 75mg monotherapy

ASA+Clopidogrel for 21 days after stroke

Question 15

Parkinson’s: What does SOAP stand for?

Answer 15

Sleep disturbances
Other misc (fatigue, nausea, speech, pain, vision)
Autonomic symptoms (drooling, constipation, sexual dysfunction, dysphasia)
Psychological symptoms (anxiety, psychosis, depression, cognitive impairment)

Question 16

Carbidopa/Levodopa for Parkinson’s motor symptoms: what happens over time? Tx?

Answer 16

Will become less effective over time

Can have wearing-off problems (take more frequently or add other drugs - MAO, COMT inhibitor, or apomorphine (dopamine agonist))

Can have peak dose dyskinesia (reduce levodopa dose, add amantadine)

Can have delayed or no “on” response (take on empty stomach or add apomorphine)

Can have ‘freezing” (use PT, increase dose, add apomorphine or MAO inhibitor)

Question 17

Difference between:

• Lewy body dementia
• Alzheimer’s dementia
• Vascular dementia

Answer 17

Can all occur together, or separately, but…

Lewy body dementia: similar disease process to Parkinson’s.
Vascular dementia: d/t TBI, stroke, etc.
Alzheimer’s dementia: most common - default diagnosis when the type is unknown.

Question 18

Apraxia (define)

Answer 18

Loss of ability to execute learned, purposeful movements

Question 19

Agnosia (define)

Answer 19

Loss of ability to recognize objects)

Question 20

Wandering, repetitive speech, motor hyperactivity, psychosis, depression, combativeness are all symptoms of…

Answer 20

Dementia

Question 21

Alzheimer’s pathology is characterized (physiologically) by

Answer 21

B-amyloid plaques and tangles
Acetylcholine shortage
Dysregulated glutamate activity
Cholesterol
Estrogen

Question 22

Life expectancy after Alzheimer’s diagnosis?

Answer 22

Usually 4-8 years, but can live up to 20 years.

Question 23

How does the treatment focus change for vascular dementia?

Answer 23

Goal is to reduce cardiovascular risks

Question 24

How to evaluate where the patient is in their dementia? Does it matter what type?

Answer 24

MMSE
Doesn’t matter what kind of dementia. This evaluates all cognitive function.
The lower the score, the worse the impairment. (Severe is 9 or less. Mild is 18-26).

Question 25

What are cholinesterase inhibitors for? SEs? MOA? Names (DGR)?

Answer 25

To slow the progress of dementia.
MOA: increases ACH availability at the synapse

Donepezil, Galantamine, Rivastigmine

GI upset is common.
Diarrhea, cholinergic effects.

Stop treatment if: lack of improvement, poor adherence or tolerance.

Question 26

What is Memantine? MOA? When would you start it? SEs?

Answer 26

NMDA receptor antagonist. Protects neurons from excessive glutamate. Only blocks glutamate when there are excessive amounts.

Start it in Moderate to Severe AD. Available as a liquid, too.

Constipation, Confusion, Dizziness, HA.

Question 27

What should be addressed first when you see neurobehavioral symptoms in dementia patients?

Answer 27

Pain
Nicotine withdrawal
Alcohol use
Medication SEs
Environmental problems

Question 28

When should you use medications with dementia?

Answer 28

Caregiver or patient distress
Dementia is causing a disability or interferes with necessary care (baths, insulin, exams)
Patients are becoming a danger to themselves or others.