week 4- Medication Used In Dementia and Medicine Optimisation Flashcards
what are the 3 stages for giving medication in dementia?
To prevent dementia
At the onset of dementia
During the later stages of dementia
what are the different types of medication that can be used for medication?
Acetylcholinesterase inhibitors (AChEIs), e.g. Donepezil, Rivastigmine, Galantamine NMDA antagonists, e.g. Memantine Antioxidants, e.g. Ginkgo Anti-inflammatories, e.g. Ibuprofen Neurotrophic factors, e.g. Oestrogen Antiamyloid agents, e.g. Tramiprosate
is it useful to take acetylcholine esterase before a diagnosis?
no it isn’t
wont prevent the patient from progressing to Alzheimer disease
is it useful to take NSAIDs before a diagnosis?
if started early they could help
is it useful to take anti-hypertensives(ACE I, DIURETICS) before a diagnosis?
CAN DELAY PROGRESS AND HELP
is it useful to take beer before a diagnosis?
can help
is it useful to take oestrogen, lithium, statins,fish and vitamins before a diagnosis?
can help
what are some of the agents that have an effect on onset of dementia?
- ginseng
- folic acid
- omega 3
what is aducanumab?
- anti-amyloid antibody
- designed to target amyloid plaques in early stages of alzhemiers
when will disease modifying treatment work?
will only work if taken early enough, maybe
decades before diagnosis of dementia.
Disease modifying treatment is expected to yield more dramatic benefits than
treatment of established dementia.
what medication is used for onset of dementia? type, function
- they are acetylcholinesterase inhibitors
- only for mild to mid Alzheimer but rivastigmine used in parkinsons
- not cures but slow down progression of symptoms
- donepezil 5-10mg OD ON
- galantamine 4-12mg BD
- rivastigmine 1.5-6mg BD
do acetylcholinesterase inhibitors work? outcomes?
The three possible outcomes of AChEIs : Improvement Non-decline No response Each of these in equal proportions in the population
-about 1/3 will show improvement on daily activity can last 6-2yrs then decline will continue
The progressive decline in functioning that would otherwise have occurred
can be delayed for several months or years
This reduces carer burden
This delays the need for transfer to a dementia-care home or hospital
what happenes if the AChEI’s dont work?
Failure to benefit from one AChEI does not necessarily mean that someone
will not respond to another.
Also, poor tolerance to one AChEI does not rule out good tolerance to another
how do you ensure the patient gets the best benefit and unwanted effects what should be done?
Slow titration is recommended
Rivastigmine patches are better tolerated than capsules
Rivastigmine is best choice for patients taking multiple medications, and also
licensed in Parkinson’s disease
what does the NICE guidance say for treatment?
• Use the least expensive one first
• alternative AChE inhibitor could be prescribed if it is considered appropriate
when taking into account adverse event profile, expectations about
adherence, medical comorbidity, possibility of drug interactions and dosing
profiles
• Rivastigmine can be used in dementia associated with Parkinson’s disease
what are the adverse effects of AchEIs?
When they start to work, the AchEIs cause cholinergic stimulation of the body
too:
Common side-effects: Nausea, Vomiting, Diarrhoea, Loss of appetite, Sleep
disturbance, Abnormal dreams, Headache, Incontinence, Fatigue, Agitation
Bradycardia (dangerous in certain heart diseases, or if taking heart-slowing drugs,
e.g. Digoxin, beta-blockers, calcium-channel blockers)
what is the problem with commonly prescribed medicines and AchEIs?
Some commonly prescribed medicines are associated with increased anticholinergic burden, and
therefore cognitive impairment
what are some medication that can cause cognitive impairment?
EXAMPLES (List not Exhaustive) Antihistamines e.g Diphenhydramine Tricyclic Antidepressants Antipsychotics- e.g Quetiapine Drugs used in Urinary Incontinence- e.g Solfenacin Hyoscine Pain Killers- e.g Morphine Some Asthma and COPD meds
what is the tool that can be used to assess anticholinergic burden
There are validated tools for assessing anticholinergic burden- e.g. the Anticholinergic Cognitive
Burden Scale
how can medicines be optimised? routines?
Donepezil can cause sleep disturbance and nightmares – give dose in the
morning.
• Rivastigmine patches can cause a rash. If mild, an emollient cream can be
used to soothe it. If severe then prescriber should be informed. Rotation of
the application site helps.
• Nausea is a common side-effect. This may be minimised by taking doses after
food.
• Bradycardia may occur. Check pulse every few months and seek advice if less
than 50 bpm.
what medication is used during the later stages of dementia? drug, dose, side effects?
-memantine
- Licenced for moderate to severe Dementia in Alzheimer’s Disease
Monotherapy is recommended for managing moderate Alzheimer’s disease who are intolerant
of or have a contraindication to AChE inhibitors or severe Alzheimer’s disease
NMDA receptor Antagonist that maybe neuroprotective and thus disease modifying
Usually started at 5 mg daily for one week and then increased by 5 mg per week,until 20 mg
daily is reached. Some practitioners do titrate faster than this in some cases.
Common side-effects: Headache, Constipation, Dizziness, Hypertension, Dyspnoea
what treatment is given to patents that have dementia other than alzhemiers?
UNLICENCED USE
Offer donepezil or rivastigmine to people with mild to moderate dementia with
Lewy bodies.
Only consider galantamine for people with mild to moderate dementia with Lewy
bodies if donepezil and rivastigmine are not tolerated.
Consider donepezil or rivastigmine for people with severe dementia with Lewy
bodies.
Only consider AChE inhibitors or memantine for people with vascular dementia if
they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or
dementia with Lewy bodies.
Do not offer
what is the evidence that has come from key trials for medicines for Alzheimer?
• Reduced carer burden with galantamine
• Adverse drug reactions more frequent with rivastigmine
• No significant difference in cognitive function between AChE inhibitors
• Significant delay in worsening symptoms with memantine (compared with
placebo)
what are some behavioural symptoms of dementia from observation?
-Physical Aggression -Screaming
-Wandering
-Culturally inappropriate
behaviour
-Sexual Disinhibition
-Swearing
what are some psychological symptoms of dementia from interview?
- Anxiety
- Depression
- Hallucinations
- Delusions
how does BPSD (Behavioural
and Psychological Symptoms
of Dementia) progress over the stages?
mild- depression
moderate-physical aggression, hallucinations, screaming, swearing, wandering
severe-some symptoms disappear but depression hallucinations, paranoia, screaming
what are some other causes that can be due to non-dementia causes THAT CAUSE SYMPTOMS?
- stressed
- hungry
- anxiety
- pain
- thirst
- hypoxia
- infection
- medication induced
- constipation
what are some other causes that can be die to non-dementia causes that cause physical aggression?
-Medicines (anticholinergic / sedatives) -alcohol withdrawal -loss of dignity -unfamiliar environment -pain -anger -inability to speak -exhaustion -being rushed
how are patients managed for BPSD?
FIRST LINE - non drugs
Modification of behaviour of the carer may:
•reduce the occurrence of BPSD
•remove the need to treat the BPSD
-many symptoms may natural resolve themselves after 4-6 weeks
what are some non-drug treatment principles?
- Identify what symptom(s) cause most concern
- Describe each symptom in detail
- The ABC approach, antiseedants what happened before, behaviour, the consequence what happened after
what is pain like for patients with dementia? how to manage
Under-reported by patient in both frequency and intensity, but they are still in pain
- could go undetected or under-dosed
- non vocals- facial expressions, point at face on chart, using abbey pain scale
what are the princles of psychiatric drug treatment for BPSD?
Discuss risks and benefits of treatment
Check that symptoms have:
-no physical cause e.g. infection
-no iatrogenic cause e.g. medication
-no environmental
cause e.g. room being too hot or too cold
-no response to(or not treatable by)non-drug interventions
how are psychiatric medicines introduced?
prescribing should involved:
- the pateint kowing their capacity and medicine plan
- informed concsent
- use slow and cautious dose titrations to avoid side effects
- use cautious dose regimes
how are psychiatric medicine monitored in BPSD?
- psychiatric medicines should be reviewed every 3 month and antipsychotic medicines should be reviewed every 6 weeks
- review symptoms and behaviour
- review any side effects and stop medication if no response or risk higher than benefit
what are the benefits of combination medication?
use medicines that address several different symptoms to avoid unnecessary polyprescribing
-sedating antidepressants help with agitation, depressants and sleep disturbance
how is management with psychiatric medicines done for dementia?
- 50% of patients with dementia also experience depression
- use of AChEI to improve symptoms of apathy
what are some non-antipsychotics medicines for BPSD?
- AChEI like rivastimine, galantamine, Donepezil
- memantine
when is it appropriate to use antipsychotics in the management of BPSD?
IF THE PATIENT HAS:
- persistent aggression
- Risk of harm to self or others
- Unresponsive to non-drug approaches
- Moderate to severe Alzheimer’s dementia
how can antipsychotics help with dementia symptoms?
-can help people with hallucinaions that 50% of patients get
what are the 5 types of delusions that patent with BPSD?
- PEOPLE STEALING FROM THEM
- spouse or care givers are imposters
- abandonment
- spouse being unfaithful
- misidentification in the mirror
what are the 4 types of misidentification a patient with BPSD can have?
- presence of persons in the patient’s own house (the ‘phantom boarder’ syndrome)
- cannot identify own self in mirror
- cannot identify others
- Television / photographs are seen as “real”
what are some major adverse outcomes with antipsychotics in bpsd?
- can cause over sedation and dehydration that can lead to stroke and infections
- can double chances to falls and fractures
what re some major adverse side effects ?
- sedation
- parkinsonism symptoms
- dehydration
- chest infections
- confusion
- movement problems e.g. tremors
- agitation
- dry mouth
what is risperidone used for in BPSD?
- SHORT TERM UP TO 6 WEEKS FOR PEOPLE WITH mild-moderate Alzheimer’s dementia that are unrepsonsve to other medication where they are a harm to themselves or others
- Superior to placebo for aggression and psychosis in dementia
- Others are ineffective or have harmful side-effects
- Greater cognitive decline with quetiapine when compared to placebo
what is the dose and regime for prescribing risperidone?
- starting at 0.25mg BD
- Adjust by increments of 0.25 mg twice daily, not more frequently than every other day, if needed
- Optimum dose is 0.5 mg twice daily for most patients
- Some patients need 1 mg twice daily
- Maximum 6 weeks
Evaluate frequently and regularly
Reassess the need for continuing treatment reassessed
how does discontinuation of antipsychotics work?
- Many patients can stop antipsychotics for BPSD safely without worsening of symptoms
- monitoring may be carried out by healthcare profession
- may remove them after 6 weeks not all are discontented
- never discontinuation if they have schizophrenia
why shouldnt benzodiazepines in people with BPSD?
-AS BENZODIAZEPINES INCREASE THE CHANCE OF FALLS BY X8
what the first line treatment for BPSD?
- Non-drug psychosocial interventions
- Most BPSD resolve after 4 - 6 weeks
- Assessment and appropriate treatment of medical conditions, e.g. pain, infection, depression
- in servere aggression in demetnia only prescribe risperidone
