Dementia

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What is Alzheimer's disease?
It is clinically characterised by a gradual and progressive decline in intellectual functions such as deficits of recent memory and language, associated with visuospatial and attention problems.
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What are the symptoms?
Loss of language, visospatial skills, attention and orientation. Loss of memory
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What are non-cognitive symptoms of dementia?
Non-cognitive symptoms including hallucinations, delusions, anxiety, marked agitation and associated aggressive behaviour.
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How is this caused?
Tau tangling, B-amyloid plaques and micro tubule disintegration in neuronal axons.
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What does this cause?
Decreased activity of the enzymes, mainly choline acetyltransferase (CAT).
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How is AD treated?
Acetylcholinesterase inhibitors, NMDA receptor blockers (memantine). Drugs for incontinence, depression, anxiety and sleep disorder.
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What is the MoA of donepizil/galantamine/rivastigmine?
Inhibit acetylcholinesterase, the enzyme primarly responsible for Ach breakdown; thereby augmenting cholinergic function.
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What are the side effects?
Diarrhoea, fatigue, muscle cramps, N & V, urinary incontience and insomnia
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Rare side effects?
syncope, SA/AV block and bradycardia.
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What formulations are available?
Don - Tablets only. Galan - Capsules or suspension. Rivastig - Patches, Capsules and Oral solution
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Which ACEI should be started first?
The drug with the lowest acquisition cost; taking into account pts daily dosage. More expensive treatments may be used if clinically justified
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What about potential for cross-sensitivity?
Each drug has a different chemical structure: Donepezil – piperidine derivative, Galantamine – phenanthrene derivative, Rivastigmine – carbamate derivative. So if pt has reaction i.e. rash try another AchEI
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When is memantine added?
Only for patients with mod-sev AD when AchEI are C/I or not tolerated.
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When to use shared care guidelines?
When Rxing is initiated in memory clinic.
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How do AchEI cause incontinence?
AchEI are not specific to their site of action. Ach muscarinic receptors stimulated by parasympathetic neurones control the baldder detrusor contraction. Thereby inhibiting Ach breakdown, increases risk of incontinence.
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How is this managed?
Oxybutynin, Tolterodine or Trospium
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What is the problem with these drugs?
None are specific to the bladder therefore may have an antagonistic effect to the AchEI.
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What are the side effects of these drugs?
Constipation, tachycardia, and CNS adverse effects such as agitation or hallucination. Also blurred vision and dry mouth.
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Which are least likely to cause these CNS effects?
Tolterodine as it is 30x less lipophilic therefore less likely to cross the BBB or trospium which seems less likely again to cross the BBB.
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Should these drugs be used to treat incontinence?
Not an absolute C/I and should be used if incontinence is causing the patient distress. Consider the side FX when monitoring the pt.
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AchEI and CVD?
Side effects of bradycardia and arrhytmia. Caution in patients with sick sinus or CVD.
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AchEI and Respiratory disease?
SPCs states “AChEIs should be used with caution in patients with a history of asthma or COPD” appears to be based on the theoretical risk that cholinomimetics can cause bronchoconstriction and bronchospasm, rather than actual reports of problems
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How is this managed?
Lower starting doses and slower titration could be used in patients with severe or poorly controlled respiratory disease.
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AchEI and Sleep disturbence?
NEVER BENZO - hang over effect, confusion, agitation and falls risk. Short course Z-drug. Melatonin (offliscence)
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Is there a benzo exception?
a short course of a drug with a short half life i.e. lorazepam
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Non-pharmacological management of sleep disturbance?
Lavender oil, lowering lights, warm milky drinks and hot baths before bed.
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When are anti psychotics incorporated into a dementia patients care?
Antipsychotics should NOT be a first-line treatment except in circumstances of extreme risk and harm
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Which is recommended?
Risperidone 1-2mg for 6 weeks only.
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Antidepressants?
DO NOT USE TCA'S. Sertraline or mirtazipine
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Card 2

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What are the symptoms?

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Loss of language, visospatial skills, attention and orientation. Loss of memory

Card 3

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What are non-cognitive symptoms of dementia?

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Card 4

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How is this caused?

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Card 5

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What does this cause?

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