Dementia & Alzheimer's Disease

Define dementia

Syndrome characterized by progressive decline in memory and AT LEAST ONE other cognitive domain

Affects daily life in an alert patient

Define delirium

Syndrome of acquired impairment in attention, alertness and perception

How can delirium be distinguished from dementia?

Acute onset with fluctuations in impairment

TEMPORARY whereas dementia is PERMANENT

What medications can impact cognition?

Antidepressants

Antihistamines

Antipsychotics

Atropine

BZDs

Benztropine

Diphenhydramine

Oxybutynin

Sedative hypnotics

Trihexyphenidyl

Define Alzheimer's disease

Progressive, irreversible neurodegenerative disease affecting cognition, behavior and ADLs

Gradual onset and is slowly progressive

Describe the mini mental status exam (MMSE)

Brief neuropsychological screening tool used to assess patient's orientation, attention, calculation, recall and language

Describe the relationship between MMSE score and impairment

INVERSE RELATIONSHIP

Decreased score = increased degree of impairment

Describe the Montreal Cognitive Assessment (MoCA)

A longer test used to assess complex attention, concentration, executive functions, memory, language, conceptual thinking, calculations and orientation

What medications are used for mild-moderate AD?

Acetylcholinesterase inhibitors (AChEI)

What medication is used for moderate-severe AD?

Memantine alone or in combination

Describe pharmacologic treatment for AD

Medications only TEMPORARILY slow progression but cannot reverse memory loss

When should medications for AD be switched?

Switching between AChEI provides therapeutic benefit if previous agent lacked efficacy or tolerability

If no efficacy seen in 3 months on maximum dose, switch

What is the dosing of donepezil for mild-moderate AD?

5, 10 mg QHS

How often should a donepezil patch be applied?

Once weekly

What are notable side effects of donepezil?

Significant GI effects (N/V)

How should donepezil be taken?

Best to take with bedtime snack

How often should rivastigmine patches be applied?

Every 24 hours

How should rivastigmine, galantamine, and benzgalantamine be administered?

With food

What is the dosing of benzgalantamine for mild-moderate AD?

5, 10 mg BID

When are galantamine and benzgalantamine dose adjusted?

Renally and hepatcially dose adjusted

When is galantamine contraindicated?

In severe renal or hepatic impairment

What are warnings/precautions of AChEIs?

PUD, GI bleeding

Asthma, COPD and seizure disorders

AV block or bradycardia

What are safety monitoring parameters while taking AChEIs?

GI bleeding

Weight loss

Heart rate

CV abnormalities

Describe the metabolism of donepezil and galantamine

CYP2D6 and CYP3A4 substrates

What are notable DDIs of AChEIs?

NSAIDs increase risk of bleeding

Medications that decrease HR or cause QTc prolongation

Anticholinergic agents

What is the acronym for cholinergic AEs?

SLUDGE

Sialorrhea

Lacrimation

Urinary

Defecation

GI hyperactivity

Emesis

What is the dosing of memantine?

5, 10 mg BID

How can memantine be administered?

XR caps can be opened and sprinkled on applesauce

When is memantine dose adjusted?

Renally dose adjusted

What are warnings/precautions of memantine?

Seizure disorders

Severe renal or hepatic impairment

What are notable DDIs of memantine?

Drugs that increase urine pH (decreased elimination of memantine)

What are common behavioral changes for patients with Alzheimer's?

Apathy, delusions, aggression/agitation

When could antipsychotics be used in Alzheimer's?

In SEVERE cases of aggression, hallucinations or risk of harm to others/self

What is there a higher risk of when using antipsychotics in elderly patients with dementia?

Stroke, VTE, MI, heart failure

Falls and fractures

Pneumonia and infections

Acute kidney injury