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Geriatrics > Pharmacological Treatment of Dementia > Flashcards

Pharmacological Treatment of Dementia Flashcards

1
Q

The goal of dementia treatment is to…

A

Improve quality of life for individual and caregivers, maintain optimal function, and provide maximum comfort

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2
Q

The three cholinersterase inhibitors include…

A

Donepezil
Galantamine
Rivastigmine

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3
Q

MOA of cholinesterase inhibitors is to…

A

Prevent the breakdown of acetylcholine - main neurotransmitter involved in learning + memory

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4
Q

Efficacy of cholinesterase inhibitors…

A

Modest benefit - may show small improvements in measures of cognition, and may slow progression by months

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5
Q

Time to benefit for cholinesterase inhibitors is…

A

3-6 months, but long-term benefit is not clear

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6
Q

Common AE’s with cholinesterase inhibitors include…

A

Cholinergic Fx
N/V/D, loss of appetite
Insomnia
Urinary urgency/frequency +/- incontinence

Opposite of anticholinergic

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7
Q

Less common AE’s with cholinesterase inhibitors include…

A

Weight loss
Agitation, behaviour disturbances
Bradycardia, Syncope
Bronchoconstriction
GI bleed
Nightmares

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8
Q

AE’s with cholinesterase inhibitors are ____, but can become tolerable with…

A

Dose-related; slow titration, taking with food, trying anti-emetic

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9
Q

CI’s with cholinesterase inhibtors include…

A

Uncontrolled/severe asthma, or severe COPD (can cause bronchoconstriction)
Cardiac conduction abnormalities, bradycardia (HR < 55 bpm)

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10
Q

Precautions with cholinesterase inhibitors include…

A

Peptic ulcer disease or uncontrolled GERD
Urinary incontinence
Seizure history
Concurrent anticholinergics

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11
Q

The NMDA antagonist that can be used is…

A

Memantine

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12
Q

MOA of NMDA antagonist is…

A

Blocking glutamate at NMDA receptor (thought that persistent activation of NMDA may contribute to symptoms)

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13
Q

Efficacy of NMDA antagonists is…

A

Modest - some evidence of benefit on cognitive testing, minimal clinical benefit in most cases

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14
Q

AE’s of NMDA antagonists include….

A

Dizziness, headache, insomnia
Nausea, constipation
Hypertension
Restlessness, akathisia

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15
Q

NMDA antagonists are cautioned for…

A

CV disease
Seizures

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16
Q

NMDA antagonist differs from cholinesterase inhibitors where the issue is primarily…

A

Lack of efficacy, rather than tolerability

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17
Q

Risk vs. benefit with the dementia medications considers…

A

Small potential improvement with high risk of AE’s, especially with cholinesterase inhibitors

Consider that a small AE can drastically decrease QoL; is it worth a few months of slowed progression?

18
Q

Examples where risk is greater than benefit for dementia medications includes…

A

Adverse effects impeding QoL
Frail + multiple co-morbidities
Problematic urinary incontinence
Pt. experiencing significant weight loss/anorexia
Pt. has significant aggression/agitation
Severe dementia
Adherence concern

Financial restriction

19
Q

Examples where benefit is greater than risk for dementia medications includes…

A

Early-onset dementia in a relatively healthy individual (few co-morbidities, no CI)
Early on in disease progression
Few AE’s once started
No concerns about adherence or management of AE’s

20
Q

General consesus of when to discontinue dementia treatment with cholinesterase inhibitors + NMDA antagonist, is…

A

Loss of ability to perform ADL’s independently (dementia progressed to stage where there would be no meaningful benefit remaining)
Any situation where risk > benefit

21
Q

When discontinuing NMDA antagonist or cholinesterase inhibitor, we should…

A

Taper carefully over 2-4 weeks
Monitor for worsening of cognitive symptoms or BPSD

Taper to prevent anticholinergic rebound with cholinesterase

22
Q

Currently, for prevention of dementia…

A

There is no evidence of pharmacological help to prevent cognitive decline or dementia

Mostly non-pharm (CV risk reduction), education/social engagement, exercise, diet

23
Q

New monoclonal antibodies are disease modifying for alzheimer’s, where they…

A

Reduce beta-amyloid plaques in the brain

24
Q

So far, efficacy of monoclonal antibodies shows that…

A

Clinical significance is unclear - may slow progression of amyloid pathology
ONLY indicated for Alzheimer’s
Significant AE’s, administration challenges

25
Q

Before starting pharmacotherapy for BPSD, we should consider…

A

Treating any medical/medication causes or contributors (similar to delirium)
Explore and minimize psychological + environmental triggers

26
Q

Pharmacotherapy should only be initiatied for BPSD if…

A

Behaviour is causing harm/significant distress to individual, caregiver, and others
AND
Is persistent or recurrent

27
Q

Assessing for and treating medical causes of BPSD may involve…

A

Taper/stop any medications that may be contributing to cognitive decline (think of delirium)
Look for + manage any underlying medical issues - infection, endocrine, electrolytes, urinary retention, pain

Offer food/drink for hunger/thirst
Manage constipation proactively

28
Q

If we are using drugs for managing BPSD, we should re-evaluate drug regimen every…

A

3 months

29
Q

Ways that we can help manage psychological triggers of BPSD include…

A

Avoid social isolation
Allow individual to make decisions - simple, clear choices, simple instructions
Warm, kind, mannerisms
Do not argue

30
Q

Ways that we can help manage environmental triggers include…

A

Encourage use of glasses, hearing aids
Provide regular, structured routine in familiar environment
Avoid overstimulation
Engaging activities + social opportunities
Bright light exposure in the day, dark at evening

31
Q

Antidepressants may be given for BPSD if…

A

It is found that depression or anxiety is the root trigger of behaviour - once daily

Try and find ones that might help with co-morbid conditions (duloxetine for neuropathic pain, mirtazapine for sleep)

32
Q

These AD’s should be avoided…

A

TCA’s, paroxetine - anticholinergics
Fluoxetine - more DI’s, long half-life

33
Q

We should avoid benzodiazepines for anxiety/sedation because…

A

Worsen cognitive impairment
Increase fall risk
Worsen disinhibition

Occasionally may be used following stressful event or preventatively before dental work

34
Q

AP’s should only be given if…

A

Behaviour is causing harm and/or has not responded to non-pharmacological methods

35
Q

These AP’s are preferred due to…

A

Atypical - decreased risk of EPS

36
Q

A black box warning of AP’s with dementia is ____ - therefore, we should…

A

Increased risk of mortality - try to taper and stop q3months

37
Q

With AP usage, we need to watch for…

A

Weight gain, orthostatic hypotension
Anticholinergic effects, sedation, falls, EPS
Tardive dyskinesia, urinary retention

TITRATE SLOW

NEEDS to be monitored

38
Q

Olanzapine should be…

A

Avoided - very anticholinergic and sedating

39
Q

For acute delirium, we could give…

A

Haloperidol PRN

NOT for parkinson’s due to EPS

40
Q

Stimulants for BPSD is…

A

Unfavorable - AE’s usually outweigh any potential benefit (increased BP, decreased appetite, dizziness, insomnia, agitation)

External activity + environmental stimulation is more effective

OCCASIONALLY used to treat apathy, loss of motivation

41
Q

Sedatives may potentially be considered for BPSD when…

A

Behaviour is thought to be directly correlated with lack of sleep OR behaviours are during the night - but consider risks of dependence, tolerance, increased delirium + falls

42
Q

Analgesics for BPSD are…

A

Warranted when pain is thought to be the cause of behaviour - trial of acetaminophen is often overlooked

QoL !!

Geriatrics (8 decks)

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