Drug Treatment of Dementia

  • Created by: LBCW0502
  • Created on: 26-11-18 17:54
What is dementia?
A syndrome due to disease of the brain - chronic or progressive in nature
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What are the symptoms of dementia?
Cognitive decline (loss of memory, problems with communication/reasoning, orientation). Loss of functional ability (activities of daily living/ADL). Mood changes
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In 2013 how many people in the UK had dementia?
815,000 (1.3% of UK population over age of 65 had dementia) - figure expected to rise to over 1 million by 2025
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What are the risk factors for dementia?
Age, gender (women > men), genetics, high BP/cholesterol/smoking/alcohol, learning disability, query, toxins such as aluminium
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What are the types of dementia?
Alzheimer's disease, vascular dementia, Lewy Body dementias, mixed dementia etc.
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Describe features of Alzheimer's disease
The most common type of dementia. More common in women. Insidious onset with gradual deterioration. Failing memory is first problem. Cognition, language, behaviour, ADL. Profound cholinergic loss
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Describe features of the cholinergic hypothesis
Degeneration of cholinergic neurones. A reduction in the levels of ACh released at the cholinergic synapse. Cognitive decline results
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What are the differences between neurones in a healthy person compared neurones in a patient with AD?
There are neurofibrillary tangles in the cell body of neurones in patients with AD. Also, there are amyloid plaques - (dementia affects language and memory areas in the brain)
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Describe features of vascular dementia
Caused by reduced blood flow to the brain. Believed to be the second most common type of dementia. Abrupt onset, stepwise deterioration. Usually follow a major stroke or multi-infarct. Depression can be common
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What are Lewy bodies?
Presence of abnormal protein deposits which develop inside nerve cells
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What are the clinical features of Lewy body dementia?
Parkinsonism (rigidity, tremor), fluctuation in severity, visual hallucinations, extremely sensitive to antipsychotics
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What is mixed dementia?
Alzheimer's disease and vascular disease occur at the same time
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Describe the diagnosis of dementia
Exclude physical causes. Cognitive assessments e.g. mini mental state examination (psychiatrist/psychologist), ADL functioning (occupational therapists), scans, involve relatives and carers
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What are the three licensed AChE inhibitors available in the UK?
Donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl)
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Describe the mechanism of action for AChE inhibitors
Donepezil/rivastigmine/galantamine inhibit AChE. Rivastigmine also inhibits BChE. Galantamine also modulates nicotinic agonists
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Describe features of AChE inhibitors
They inhibit enzymes responsible for the breakdown of ACh. Leads to increase of ACh in the brain. They are not a cure but stabilise memory for a few months/years. They don't work for everyone. NICE recommends them for mild-moderate AD only
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Can AChE inhibitors be used for vascular or LB dementia?
Not recommended in the NICE guidelines but sometimes used off-licence
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What are the special warnings and precautions for use of AChE inhibitors?
Cardiovascular (bradycardia, sick sinus syndrome), GI (history of ulcer disease), neurological conditions (epilepsy, PD), pulmonary conditions (asthma), genitourinary (urinary outflow obstruction, recovery from bladder surgery), anaesthesia
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Describe features of cholinergic side effects
Generally mild and transient, minimised by taking with or immediately after food, tolerability affected by speed of titration
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Give examples of cholinergic side effects
GI disturbance (nausea, vomiting, diarrhoea). Headache/dizziness, fatigue, muscle cramps, sweating, bradycardia, weight loss, disturbed sleep/nightmares
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Describe features of memantine (Ebixa)
NMDA/glutamate agonist. Moderate-severe AD. 5 mg daily increased by 5 mg every week to 20 mg daily. Adverse effects - constipation, hypertension, headache, dizziness, drowsiness
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What points should be discussed before starting treatment?
Expectations of patient and care, limitations of treatment, end point of treatment, compliance (carer's role), side effects and what to do about them (carer's role), consent for treatment, assessing progress
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Describe features of stopping treatment
Lack of clinical benefit, obvious progression of disease, side effects, reduce dose gradually to withdrawal, deterioration after stopping may require therapy to be restarted
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Give examples of BPSD
Anxiety, agitation, insomnia, hallucinations, delusions, depression, aggression, wandering, vocalisations
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What are the triggering factors of BPSD?
Pain, constipation, infections (UTI, chest infection) - eliminate these potential causes first
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What are the non-pharmacological interventions?
Psychological therapies, music therapy, art therapy, aromatherapy, snoezelen rooms, pet therapy, carer education, respite care
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Describe features of pharmacological management for BPSD
Paracetamol, AChEIs/memantine, antidepressants (SSRIs, trazodone), mood stabilisers (carbamazepine conflicting evidence, valproate ineffective), benzodiazepines (best avoided), antipsychotics
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Describe features of antipsychotic prescribing for BPSD
Over-prescribing of anti-psychotic drugs, inappropriate prescribing, continued for too long (prescribing rate in care homes 24-28%, up to 88% of antipsychotic prescriptions may be inappropriate)
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Describe the regulations for treatments for dementia (1)
FDA determines that BPSD treated with atypical antipsychotics is associated with increased mortality. EMA stated typical antipsychotics are associated with increased risk of death
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Describe the regulations for treatments for dementia (2)
Warning of increased morality has now extended to all antipsychotic drugs both conventional and atypical - (Banerjee report, Cochrane Systematic Review - can remove antipsychotics from dementia treatment)
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What are the adverse effects of antipsychotics?
Hastening of cognitive decline. Lewy body dementia leads to high level of sensitivity to antipsychotics (including death). Stroke, EPSEs, increased agitation, sedation, metabolic side effects
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Which antipsychotic is licensed for short term treatment of moderate-severe AD?
Risperidone (used for up to 6 weeks). Used when patient is unresponsive to non-pharmacological approaches and when there is a risk to harm self/others
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Describe features of pharmaceutical care (1)
When prescribing antipsychotics: exclude physical illness, target symptom requiring treatment, consider non-pharmacological methods first, carry out risk/benefit analysis, discuss treatment options, explain risks to patient and relative/carers
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Describe features of pharmaceutical care (2)
Titrate drug from a low stating dose. Review appropriateness of treatment regularly and monitor benefits. Monitor for side effects. Document clearly treatment choices and discussions with patient, family or carers
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Describe features of adherence
Patients may forget to take medication. Carers are information. Formula. Multi-compartment compliance aids (MCA) may help some patients, not all
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Card 2

Front

What are the symptoms of dementia?

Back

Cognitive decline (loss of memory, problems with communication/reasoning, orientation). Loss of functional ability (activities of daily living/ADL). Mood changes

Card 3

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In 2013 how many people in the UK had dementia?

Back

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Card 4

Front

What are the risk factors for dementia?

Back

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Card 5

Front

What are the types of dementia?

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