Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Management of Disorders > Pharmacological Management of Dementia > Flashcards

Pharmacological Management of Dementia Flashcards

1
Q

What interventions could you offer to someone with mild to moderate dementia to promote cognition, independence and wellbeing?

A

▪️ Cognitive stimulation therapy
▪️ Group reminiscence therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What non-pharmacological interventions should NOT be offered to people with dementia?

A

▪️ Acupuncture
▪️ Vitamins and herbal supplements
▪️ Cognitive TRAINING
▪️ Interpersonal therapies for cognitive symptoms
▪️ Non-invasive brain stimulation (unless an RCT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What medications should NOT be offered to people with AD to slow progression except if part of an RCT?

A

▪️ Diabetes medicine
▪️ Hypertension medicines
▪️ Statins
▪️ NSAIDs, including aspirin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the main class of medication used for symptomatic relief in dementia?

A

Acetylcholinesterase inhibitors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the main acetylcholinesterase inhibitors and what are their mechanisms of action?

A

▪️ Donepezil - selective inhibitor
▪️ Rivastigmine - non-competitive inhibitor
▪️ Galantamine - competitive inhibitor

Increase availability of acetylcholine in synapses
All reversible!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the theory behind the use of acetylcholinesterase inhibitors in AD?

A

The cholinergic deletion theory
▪️ Progressive loss of limbic and neocortical cholinergic innervation
▪️ Acetylcholine metabolism plays key role in cognition and memory processes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Why is galantamine use much less commonly in the UK?

A

Controversies over increased mortality in MCI and increased risk of cardiovascular effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the efficacy of acetylcholinesterase inhibitors?

A

▪️ Essentially all the same with modest benefit
▪️ 1/3 get intermittently better, 1/3 don’t get worse
▪️ Modest benefit on cognitive, functional and global scores (only symptom control)
▪️ For mild-moderate dementia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How does dementia subtype influence response to AChEI treatment?

A

Moderates it
▪️ Best response = PDD and DLB, particularly with rivastigmine
▪️ Less improvement on MMS in AD and VaD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How does AChEI treatment affect neuropsychiatric symptoms?

A

▪️ No short-term benefit
▪️ Potentially less likely to get severe NP symptoms if started early?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What neuropsychiatric symptom can donepezil be considered for?

A

Agitation

BUT not a great effect and should try cognitive, behavioural, and psychological interventions first

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the most common side effects of AChEI and why?

A

▪️ Nausea
▪️ Vomiting
▪️ Dizziness
▪️ Insomnia - can bring REM sleep forward
▪️ Diarrhoea

Usually early on due to excess cholinergic stimulation and increased amounts of acetylcholine in the synaptic cleft - takes time to get used to

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why might rivastigmine be associated with lower risk of adverse effects?

A

▪️ Can be given transdermally
▪️ Can titrate it to get used to it
▪️ Slow titration = reduced plasma peaks
▪️ Also no notable drug interactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which AChEI is associated with more all-cause discontinuation?

A

Rivastigmine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the effect of AChEI on mortality?

A

▪️ Decreased risk by 23%
▪️ BUT are those with higher risk unlikely to be given medication?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What cardiovascular side effect might someone experience on AChEI?

A

▪️ Vagotonic effects on heart rate causing bradycardia
▪️ Dizziness and syncope
▪️ Rare = atrial arrhythmias, MI, angina, seizures

17
Q

What must you be careful of when starting someone of AChEI?

A

Prior conduction disturbances such as AV block, SA block or sick sinus

Ideally get an ECG before starting medications and check pulse routinely

18
Q

What should you do if the patient has a heart rate below 50bpm?

A

Withhold or stop treatment of AChEI and refer on to specialist for underlying cause

If unrelated to drug or fitted with pacemaker, could consider retrial of drug

19
Q

What should you do if someone cannot tolerate the side effects of an acetylcholinesterase inhibitor?

A

▪️ Ideally withdraw slowly, wait for side effects to stop, then start another drug
▪️ Avoid interrupting as may cause loss of benefits

20
Q

What type of medication can be considered in the later stages of dementia and how do they work?

A

NMDA receptor antagonists such as memantine

Reduce glutamate by blocking NMDA-mediated ion flux - ‘calming the brain’

(best benefit in moderate-severe AD)

21
Q

What side effects are associated with memantine?

A

▪️ Very few - possibly dizziness of headaches
▪️ Can make you drowsy which may be beneficial in late stages
▪️ So beneficial and benign it can be prescribed by GPs
▪️ Consider kidney health as excreted renally

22
Q

What is the efficacy of memantine in other subtypes of dementia?

A

▪️ Small clinical benefit in mild-moderate VaD on cognition, behaviour, and mood
▪️ Limited efficacy in PDD, DLB, FTD, and AIDS-related Dementia Complex

23
Q

What drug should you NOT prescribe alongside acetylcholinesterace inhibitors?

A

Anticholinergic drugs (e.g., clozapine, tricyclic antidepressants, atropine)

24
Q

Why should anticholinergic medications be avoided in dementia?

A

▪️ Directly oppose action of AChEI
▪️ Greater risk of cognitive impairment and decreased physical functioning in elderly
▪️ Possible effects on delirium and mortality in elderly?
▪️ Risk factor for psychosis in AD and faster cognitive decline?

25
Q

What is the Anticholinergic Effect on Cognition scale?

A

A score to advise prescribing, determined by:
▪️ anticholinergic potency
▪️ capacity to cross BBB
▪️ receptor selectivity
▪️ reports of cognitive impairment

0 = safe, 1 = caution, 2-3 = review and withdraw/switch

(Can add scores of multiple medications for total AEC score)

26
Q

How does score on the AEC scale affect mortality and emergency hospitalisation?

A

No effect on either

27
Q

What type of anticholinergic drug was found to be associated with increased emergency hospitalisation and cognitive decline?

A

Those for urinary conditions

28
Q

Which types of anticholinergic drug are associated with increased mortality?

A

▪️ Antidepressants
▪️ Antipsychotics

29
Q

How common are behavioural and psychological symptoms in dementia (BPSD)?

A

50-80%
▪️ More common earlier on in DLB
▪️ More common later in AD?

(50% = self-limiting)

30
Q

What is the first step for treating BPSD?

A

Look for easily treatable cause
▪️ Sensory deficits
▪️ Pain, constipation, infections
▪️ Delirium
▪️ Medication side effects

(Use ABC chart!)

31
Q

According to the Delphi consensus, what are the top 4 recommendations for agitation in dementia?

A
  1. Assessment of underlying cause
  2. Environmental adaptations
  3. Person centred care
  4. Tailored activity

(7 = risperidone)
(Also included citalopram and pain management low down)

32
Q

What side effects are associated with use of antipsychotics in dementia?

A

▪️ Extrapyramidal symptoms
▪️ Gait disturbance
▪️ Somnolence
▪️ Respiratory tract infection
▪️ Fever
▪️ Peripheral oedema
▪️ Increased risk of stroke and death?

33
Q

What is the evidence for antipsychotics in dementia?

A

▪️ Very limited evidence with small effect sizes and purely symptomatic
▪️ Better response in severe cases
▪️ Quick response (discontinue if no benefit in 4-6 weeks)
▪️ Risperidone is likely best
▪️ BUT substantial risk of harm

34
Q

What is the evidence for the use of citalopram in dementia?

A

▪️ Improvements in CGIC, agitation, total NPI and caregiver distress
▪️ No improvement on NPI agitation subscale
▪️ Worsening cognition and QT interval prolongations = increased risk of cardiac issues
▪️ Best for psychosis in dementia - improved delusions, hallucinations, anxiety, and irritability

35
Q

What alternatives to antipsychotics may be considered for agitation in dementia?

A

▪️ Citalopram
▪️ Mirtazapine
▪️ Pimavanserine
▪️ Dextromethorphan/quinidine
▪️ Pain management and analgesics

Cannabinoids - safer alternative?

36
Q

What is the evidence for mirtazapine for agitation in dementia?

A

Agitation improves but no difference in benefit compared to placebo - role of engagement?

37
Q

What might pimavanserine be useful for in dementia and why

A

Psychosis

Shows very good benefit in PD

38
Q

What are the recommended treatments for psychosis in PDD and LBD?

A

▪️ Treat underlying cause or reduce PD medications
▪️ Significant benefit of clozapine
▪️ Possibly quetiapine
▪️ Olanzapine off label BUT associated with worse motor symptoms

39
Q

What are the problems with prescribing clozapine for dementia?

A

▪️ Very anticholinergic
▪️ Associated with severe cardiac AEs such as agranulocytosis
▪️ Needs monitoring and regular blood tests

Management of Disorders (28 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions