Pharmaceutical treatment of Dementia

Question 1

What are interventions to promote cognition, independence and wellbeing in dementia?

Answer 1

• Offer cognitive stimulation therapy to people with mild to moderate dementia
• Consider group reminiscence therapy for people with moderate dementia

Question 2

What not to offer in dementia treatment?

Answer 2

• Acupuncture
• Ginseng, Vitamin E supplements, herbal formulations
• Cognitive training to treat mild to moderate AD
• Interpersonal therapies to treat symptoms of mild to moderate AD
• non-invasive brain stimulation to treat mild to moderate AD

Question 3

Do not offer folloing meds to slow down progress of AD:

Answer 3

• diabetes meds
• hypertension meds
• statins
• non-steroidal anti-inflammatory drugs (including aspirin)

Question 4

What are proven effective Acetylcholinesterase inhibitors?

Answer 4

• Donepezil
• Rivastigmine
• Galantamine

Question 5

What is the efficacy of AChEI?

Answer 5

-Modest benefit
- 1/3rd (intermittently better), 1/3 dont get worse, 1/3 no benefits

• Benefit seen in mild to moderate AD and dementia with Lewy bodies

Question 6

What can AChEI do and what not?

Answer 6

• Cannot cure, modify or reverse disease
• symptom control only
• modest benefit to cogntive, functional and global score

Question 7

Efficacy with dementia subtype as moderator for AChEI treatment effect showed…

Answer 7

2x high effect in Parkinson diesease dementia/dementia with lewy bodies vs AD/vascular dementia

Question 8

Side effects of AChEI

Answer 8

Excess cholinergic stimulation causes nausea, vomiting, dizziness, insomnia, diarrhoea

! Cardiovascular events in people with prior problems

Question 9

How to minimise AChEI adverse affects?

Answer 9

Speed of titration affects plasma peaks therefore…
- patches are better
- slow titration is better

Question 10

Which drugs showed slight benefits in moderate to severe AD

Answer 10

NMDA receptor antagonist Memantine

Question 11

What drug interactions can be seen with Donepezil? (With what drug?)

Answer 11

• azoles, erythromycin, fluoxetine, paroxetine (levels increasing)
• Rifampicin, phenytoin, carbamazepine, EtOH (levels decreased)

Question 12

Which drug shows not relevant drug interaction?

Answer 12

Rivastigmine (non-hepatic)

Question 13

What drug interaction effects memantine (non-hepatic) shows?

Answer 13

Cimetadine, ranitidine, trimethoprim, nicotine (increasing levels)

Question 14

What not to prescribe with AChEI and why?

Answer 14

Anticholinergic drugs do the opposite to AChEI

Question 15

What risks does Anticholinergic medication have for dementia patients?

Answer 15

• directly oppose the action of AChEI
• in older population can cause risk of incident cogntive impairment and decline, delirium, mortality
• Risk factor for psychosis in dementia

Question 16

What are examples for anticholinergic drug types?

Answer 16

antidepressants & antipsychotics

Question 17

How to address BPSD?

Answer 17

• correct sensory deficits
• treat pain
• treat constipation
• treat infection
• look for delirium
• look for side effects of medication

Question 18

Recommendations to treat dementia agitation:

Answer 18

1. Thorough assessment and management of underlying causes
2. Caregiver problem - solving/information/education
3. Environmental adaptation/approaches
4. Person-centred care
5. Tailored activity programme
6. Citalopram
7. Treat pain - paracetamol/analgesia
8. Risperidone

Question 19

Recommendations to treat psychosis

Answer 19

1. Thorough assessment and management of underlying causes
2. Risperidone with Pimavanserin and Citalopram as potential emerging treatments

Question 20

Principles of pharmacological treatment of dementia

Answer 20

• target symptoms
• low doses
• regularly
• monitor for side effects
• review

Question 21

Risks of antipsychotics

Answer 21

increase mortality,
cerebrovascular events

Question 22

What drug has shown to be safe and effective for psychosis in AD, PD and PD dementia?

Answer 22

Pimavanserin