Wk 30 - Dementia in Practice Flashcards
Outline the different types of dementia
- Alzheimers
- Lewy body
- Vascular
- Mixed
- Parkinsons
- Frontotemporal
What are the drugs related to cognitive impairment?
- Anticholinergics
- Benzodiazepine
- Opioids
- Anti-psychotics
- Alcohols
Give examples of physical health problems that causes cognitive impairment
- Infection (confusion)
- Hyperthyroidism (impaired conc/memory)
- Sensory impairment eg. sight/hearing loss, hypoglycaemia
- Depression (lack of conc + poor ST memory)
What happens when dementia is diagnosed?
- Legally required to inform DVLA
- Early dementia, where sufficient skills are retained + progression slow, license may be issued subject to annual review - formal driving assessment necessary
What are the different groups of pharmacological managements?
- AChE inhibitors: donepezil, galantamine, rivastigmine
- NMDA receptor antagonist memantine
When are AChE inhibitors usually used for?
Mild-mod disease
When is memantine usually used for?
Mod-severe disease
Which medication are used for lewy body?
Donepezil or rivastigmine
Which medications are used for parkinson’s?
All the above
What is the drug treatment for vascular dementia?
No licensed drug - mainstay to red risk of ischaemic attacks + stroke
Which drug group is dose-dependent activity?
AChE inhibitors
What are the cautions for AChE inhibtors?
- GI ulcer risk
- Asthma/COPD
- Supraventricular cardiac conduction conditions eg. SA/VA block
- Urinary retention
- Low body weight
What are the side effects of AChE inhibitors?
- Nausea, anorexia, vom
- Diarrhoea, GI upset, ulceration
- Alertness + agitation, hallucinations
- Bradycardia
What are the interactions of AChE inhibitors?
- Antimuscarinic drugs
- Concurrent antipsychotic can inc risk of neuroleptic malignant syndrome
- CYP3A4 inducer/inhibitors
- Drugs w/ adverse CV effects eg. bradycardia
Donepezil
- Take orally at bedtime (cause dizziness, switch OM if interfering sleeping)
- 5mg for at least a month before assessment then titrate to 10mg
- Well tolerated
- Asses HR bc bradycardia + avoid co-prescription of drugs that red HR
Galantamine
- W/after food
- 8mg daily, inc every 4 wks to max 24mg if needed/tolerated (BD if IR)
- C/Im in severe liver impairment (dose red in mod hepatic)
- Rarely serious skin reaction (discontinue)
- Can dec appetite - monitor
Rivastigmine
- For alzheimers + parkinsons
- W/after food
- Oral: 1.5mg BD + titrate in 2 wk intervals to max 6mg BD
- Patch: 4.6mg daily, inc 13.3mg daily (rotate to avoid rash)
- Monitor body weight (red appetite/anorexia)
When should you discontinue the drug medication?
- Poor compliance
- Poor tolerance
- Co-morbidity
- No evidence of benefit
Memantine
- Monotherapy
- Combination w/ AChE
- 5mg daily, titrate to 20mg daily
- Hallucinations, dizziness, constipation, headache, tiredness common
- Dose mod in renal impairment
What is BPSD?
- Symptoms: delusions, hallucinations, agitation, aggression
- 90% display in late stage
- Antipsychotics discouraged bc inc risk cerebrovascular events (cognitive decline, inc mortality)
- Risperidone for ST use
What is used as a first line to BPSD?
Non-pharmacological approach:
- Identify behaviour triggers
- Comforting routines
- Altered reality sense + communicating on this level
- Information from carers/relatives
- Forget me not card
- Engage patient in activities meaningful to them
- Include and involve patient in conversations at every opportunity
- Sleep hygiene
- Time orientation
Outline the pharmacological approach to BPSD
- Stop inappropriate meds, treat infection, constipation
- Unrecognised pain: paracetamol
- Underlying depression: sertraline, mirtazapine less likely to prolong QT interval that citalopram
- Antipsychotic + benzodiazepines last resort bc worsen cognitive function, stroke risk + mortality risk
