Alzheimer's Disease - Summary Slides HL

What is the most common type of dementia?

Alzheimer's (prevalence increases w/ age)

What are the theories of AD etiology/pathophysiology?

1. Beta amyloid plaques and neurofibrillary tangles

2. Shortage of ACh and less NMDA receptors

3. Cholesterol ApoE4 associated plaques

4. Cerebrovascular

What is early onset AD?

< 60 years → stronger genetic link

What is late onset AD?

> 80 years → stronger environmental link

What is the survival timeline of AD?

4-8 years

What are the 3 stages of dementia?

Mild, Moderate, Severe

What are S/S of moderate dementia?

Psychotic symptoms,

Inappropriate or disruptive behavior,

Agitation,

Aggression,

Depression,

Forgetfulness about one's personal hx,

Mood changes,

Confusion about day/time

What are S/S of mild dementia?

Word/name finding difficulty,

Losing or misplacing things,

Increased difficulty in planning and organizing

When do behavioral symptoms of AD emerge?

moderate dementia

True or False: use non-pharm therapy first for moderate dementia S/S

True

What are non-pharm options for moderate dementia?

Use gentle/calm approach,

Give reassurance,

Empathize,

Use distraction/redirection,

Daily routines,

Safe environment,

Daytime activities,

Avoid overstimulation,

Familiar decor,

Bringing abrupt declines in fxn and appearance of new symptoms to professional's attention

What are medication changes used for moderate dementia?

Reduce dose,

Titrate slowly,

Monitor closely,

Document carefully

What are S/S of severe dementia?

24/7 assistance needed,

Loss of physical abilities,

Vulnerability to infection (i.e., pneumonia)

When should therapy be initiated in AD?

ASAP when there's still some fxn to be preserved (i.e., independence)

When should therapy be D/C in AD?

If there's no fxn left to preserve (i.e., total dependence)

#controversial: family plays a large part in the decision

May see rapid decline in patient's condition when therapy is discontinued

True or False: Family members are key to early screening, identification, and treatment for AD

True

When should adjunctive agents be used for behavioral problems?

When non-pharm has failed,

Diagnostic Criteria: depression, psychosis, anxiety (not agitation)

Benefits > risk (i.e., pt danger to self/others, QOL)

How often should monitoring and follow ups occur?

Q3-6M

What tools are used for monitoring and follow ups?

MMSE, clock draw test, subjective information

also consider ADRs of drugs (1 week after initiation then Q3-6M)

What are Anti Amyloid Monoclonal Antibodies?

Lecanemab (Leqembi) & Donanemab (Kisunla)

When are anti amyloids used?

mild cognitive impairment and mild dementia (only useful in early course)

What is the dose of anti amyloids?

Q2-4W

What are ADRs of anti amyloids?

> 10% ARIA (ApoE e4 homozygotes are at greatest risk): Edema, Hemosiderin deposition, Intracerebral hemorrhages

1-10%: Afib, N/V, Rash, Cough

When are cholinesterase inhibitors used?

FIRST LINE for mild, mod, severe AD

Extra Info:

- Have shown benefits over placebo for up to 3 years

- May be beneficial for behavioral problems

What is the dose used for cholinesterase inhibitors?

maximize when possible

What are ADRs of cholinesterase inhibitors?

GI (but usually self limiting, treat with short-term OTCs)

List cholinesterase inhibitors in order of least to most GI ADRs:

Donepezil < Rivastigmine Patch > Galantamine > Rivastigmine PO

When should we D/C and consider alternative to cholinesterase inhibitors?

if GI S/S persist for 4+ weeks

What medication class requires a washout period?

cholinesterase inhibitors (for 1 week if indicated and there's a potential loss of fxn while titrating new drug)

What is an adequate trial of cholinesterase inhibitors?

6 months (+ memantine if needed)

Non-Responders: > 2-4 point decline on MMSE per year

Which meds are cholinesterase inhibitors?

Donepezil,

Galantamine,

Rivastigmine

What is the MOA of memantine?

NMDA receptor antagonist

When is memantine used?

Adjunct therapy for mod - severe AD with AChE inhibitors

OR alternative for patients that can't tolerate AChE inhibitors

How often do you titrate memantine?

weekly (can reduce dizziness and excitability if slower)

When do we adjust memantine dose for CrCl?

if CrCl < 30mL/min

When are antipsychotics used for AD?

benefit > risk (no FDA approval for dementia related to psychosis)

What is the BBW of antipsychotics for dementia patients?

increased risk of death

When are antidepressants used in AD?

depression or sundowning/insomnia

Which class are used for depression?

SSRIs

Which medication is used for sundowning/insomnia?

trazodone

What are ADRs of benzos as anxiolytics in AD?

Impair cognition,

Disinhibition,

Increase risk of falls

True or False: routine use of benzos is approriate

False

What is another agent that can be used for anxiety in AD (other than benzos)?

Buspirone (well tolerated, just limited evidence)

What are nonconventional therapy options?

Vitamine E, NSAIDS, Statins, Ginkgo Biloka, Caprylidene, Healthy Diet, Exercise

Which nonconventional therapy can we recommend?

Gingko Biloba (if no drug interactions), Healthy Diet, and Exercise

What dose of Vitamin E is safe?

< 400 IU (more required for AD benefit)

What is an ADR of NSAID use?

increased risk of bleeding

When are statins recommended for AD?

only if needed for cholesterol

What are ADRs of ginkgo biloba?

drug interactions and increased bleeding

Why don't we recommend caprylidene?

$$$ (medical food)