Therapeutics - Alzheimers Flashcards
true or false
all dementia is alzhemiers disease
false
vascular dementia (multi-infarct) treatment
prevention is the best treatment! control HTN, lower cholesterol, stop smoking, use aspirin
in what type of demention is a shunt placed to relieve pressure and can help to decrease progression
normal pressure hydrocephalus
“dementia with lewy bodies”
parkinsonian symptoms
cognitive decline happens faster than alzhemiers
what agents are used for dementia with lewy bodies
not levodopa - minimal response
atypical agents, SSRIs, trazodone, ACHE inhibitors
what is pseudodementia
depression – NOT DEMENTIA
what is mild cognitive impairment and what is the treatment
may be early marker for alzheimers
no definite tx - but potential benefit with ache inhibitors
what drugs can cause dementia
CNS depressants, anticholinergics
true or false
patients can get alzhemiers “overnight”
FALSE
progressive cognitive decline and slow onset
true or false
the labs and tests of an alzhemiers patient will appear normal
TRUE
they’re awake and seem healthy, just not oriented
do we have any drugs that actually modify alzhemier’s?
no
symptomatic effect of cholinesterase inhibitors in alzhemier’s patients over time
drug will work at first, but then will stop working and the patient declines
which 2 types of drugs are old drugs and should NOT BE USED in alzhemiers patients
cerebral vasodilators
ergoloid mesylates
if anything they made it worse
which ACHE inhibitor is not used in AD because it has too much peripheral action
physostigmine
name 4 ACHE inhibitors that can be used in alzheimers
donepezil
rivastigmine
galantamine
benzgalantamine
the ACHE inhibitors are approved for MILD-MODERATE AD
which 2 are also approved for severe AD
donepezil and rivastigmine patch
ACHE inhibitors tend to show more benefit in AD when started when?
early in the disease
true or false
there is a clear time period when we should stop ACHE inhibitors
FALSE - unclear when to stop
**ADRS of acetylcholinesterase inhibitors
bradycardia leading to syncope (if also on BB or CCB - be very cautious!!!)
SLUDG (salivation, lacrimation, urination, defecation, GI upset/emesis)
how often is donepezil administered
QD
big AE of rivastigmine
high GI effects - often not well tolerated
if treatment of rivastigmine is interrupted for longer than 3 days, what must we do and why
RESTART the dosing at 1.5mg BID and titrate back up
otherwise they will throw up
1.5mg isnt even an effective dose - it’s just to taper them up to avoid GI side effects
counseling point rivastigmine
take w meals to avoid GI upset
AE of galantamine vs rivastigmine
galantamine has less GI side effects
same counseling tho to take w meals
also if treatment interrupted for 3 or more days - restart dosing at lowest
prodrug of galantamine
why is it a lil beneficial over galantamine
benzgalantamine
less GI effects bc converts to galantamine after GI absorption
memantine MOA and why was it designed to work like this
NMDA antagonist
bc overstimulation of NMDA receptors by glutamate may be a cause of neurodegenerative disorders
can memantine be used in combo with other drugs?
usually it’s used in combo with an ACHE inhibitor
however, pts may also use as monotherapy if they cant tolerate the AE of ACHE inhibitors
true or false
memantine is usually well tolerated
true
true or false
ACHE I + memantine has shown improvement in outcomes and is well tolerated
true
true or false
the results of studies of ACHEI with or without memantine are both statistically and clinically significant
FALSE - statistically significant but not really clinically.
they decline eventually, also studies are mostly less than a year so long term effect is unknowns
name 3 monoclonals for AD
which isn’t on the market anymore?
are these used a lot and why?
aducanumab (not on market)
lecanemab
donanemab
very expensive. have been shown to reduce amyloid plaques, BUT MINIMAL CLINICAL EFFICACY
big issue with the monoclonals for AD
they reduce amyloid plaques
however, created ARIAs (amyloid-related imaging abnormalities)
maybe test for certain alleles beforehand
ARIA-H = microhemorrhage
ARIA-E - brain edema
for the monoclonals the patient should confirm what first
the patient should get a PET scan or LP (lumbar puncture) 1st to confirm that the AD patho is amyloid-related
bc thats how they work
5 misc agents for AD
vitamin E
NSAIDS
estrogen
statins
gingko biloba
chemical name of vitamin E
alpha-tocopherol
role of vitamin E in AD
may have benefit, but high dose vitamin E can kill you
AE of vitamin E
increased fall risk
dental effects
increased bleeding with warfarin
true or false
NSAIDS are NOT HELPFUL in patients with established AD OR with advanced preclinical AD pathology
true
more studies may be needed,,, but as of now not beneficial
true or false
estrogen has clinically been shown to decrease AD symptoms
false
true or false
statins have clinically been shown to prevent dementia
FALSE
MAY BE A POTENTIAL LINK, BUT NOT RN
ginkgo biloba in AD patients
not effective
AE - increased risk of spontaneous bleeding! has an effect on platelet aggregation
name some things that HAVE been shown to prevent/slow cognitive decline
-physical activity
-control BP
-cognitive training
-manage obesity, diabetes
exercise!
which type of exercise has the most favorable effect on delaying a decline in cognitive function
aerobic - take a walk! :)
which drugs should be AVOIDED when treating symptoms of AD, due to memory loss and falls
benzodiazepines
what drugs can be used to treat the delusions, paranoia, and hallucinations of an AD patient
atypical antipsychotics like risperidone, olanzapine, quetiapine, abilify
low dose!
what should be used to treat the depression of an AD patient
SSRI
what may be used to treat the aggression of an AD patient
potentially valproic acid
what is the 1 antipsychotic that is FDA approved for agitation associated with dementia due to alzheimers?
rexulti (brexpiiprazole)
used SHORT TERM
if pt doesnt get significant response after 4 weeks, dicontinue
what can be used for sleep for AD patient
low dose trazodone
what 2 drugs can potentiall be used for aggression and agitation of an AD patient
buspirone or citalopram
AE citalopram
decreased cognition and prolonged QT
BBW of antipsychotic use in dementia
increased risk of death in patients with dementia - for both atypical agents AND conventional
therefore, should really try to avoid antipsychotics if we can
only one approved is rexulti!
nonpharm interventions for AD patients
set environment - make it feel homey, have soft colors
mild activities - music, pets, dolls, exercise
respite care - relive burden on caregivers
concern with ACHEI dosing
complicated titration
