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Which color is

missing?

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Guess who’s who?

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Impressive!Scoreboard:• Dr. A• Dr. G• Dr. S• Dr. T

By the way, what is today’s date?

Memory is powerful.

but not until we lose it that we fully realize its significance

AgingBeautifully:Visions & Realities

Part III: Dementia

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By Christine HortillosaPharm.D. 2013 CandidateUniversity of Texas at Austin College of Pharmacy5. 9. 2013

DeliriumDementia

Acute

Two of the following:

• Misinterpretation, illusions, hallucinations• Incoherent speech• Disturbance in sleep-wake cycle• Change in psychomotor activity

Related to medical illness + medications

Reversible

Progressive

Marked by memory impairment

Not a normal part of aging

Irreversible

Most common form of dementia is…

Alzheimer’s disease

mild

moderate

severe

20-24

Short-term memory loss; word-finding problems

Loss of IADLs

10-19 Disorientation to time, place, inability to engage in activities

Needs assistance with ADLs

<10 Loss of speech and ambulation, incontinence of bowel and bladder

Dependency in basic ADLs; often requires around-the-clock care

*ADLS= activities of daily living (bathing, dressing); IADLS= instrumental activities of daily living (housekeeping); MMSE= Mini-Mental Status Examination

MMSE Examples of cognitive loss

Examples of functional loss

Stages

Drugs for Treatment of Alzheimer’s

Donepezil

Rivastigmine

Galantamine

Memantine

Donepezil

Starting Dose 5 mg/day; No dose change for renal impairment

Maintenance Dose 10mg/day May also increase to 23mg/day

Properties Cholinesterase inh; partly metabolized by CYP 2D6 and 3A4

Indication For all stages of Alzheimer’s

Adverse Effects Bradycardia, syncope, weight loss, N/V/D, Insomnia

DDI Anticholinergics, Antipsychotics, Beta-blockers, Alcohol

Administration At bedtime without regard to food

Starting Dose 1.5mg BID; No dosage change for renal impairment

Maintenance Dose 3-6mg BID

Properties Cholinesterase inh

Indication For mild to moderate Alzheimer’s and mild-to moderate dementia with Parkinson’s

Adverse Effects Has most intense cholinergic (N/V/D) ADE, bradycardia, syncope, dizziness, EPS

DDI Anticholinergics, Antipsychotics, Beta-blockers, Alcohol

Administration With meals; for patch (avoid application to same spot for 14 days)

Rivastigmine

Starting Dose 4 mg BID; Use not reco’d for CrCl <9ml/min

Maintenance Dose 8-12mg BID or 8-24mg ER Qday

Properties Cholinesterase inh and nicotine receptor modulator; partly metabolized by CYP 2D6 and 3A4

Indication For mild-to-moderate Alzheimer’s

Adverse Effects Bradycardia, syncope, weight loss, N/V/D

DDI Anticholinergics, Antipsychotics, Beta-blockers, Alcohol

Administration With meals; if therapy is interrupted for 3+ days, restart at lower dose and increase to current dose

Galantamine

Memantine

Starting Dose 5 mg/day (max dose of 20mg for CrCl 30-49 and max dose 5mg for CrCl 5-29)

Maintenance Dose 10mg BID

Properties Blocks glutamate transmission

Indication For moderate to severe Alzheimers; may be used in combination with donepezil

Adverse Effects Hypertension, confusion

DDI Sodium bicarbonate, Trimethoprim

Administration Without regard to food

Star t wi th chol inesterase inhib i torsCaution: statistically significant difference ≠ clinical meaningful improvement

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How long should the therapy be?• Evaluation at 3-6 months for prevention of decline

or improvement• Conflicting evidence in unresponsive patients• Taper upon discontinuation

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Pharmacists are critical in effective alzheimer’s disease management.

With your help,I can preserve my memories a little

bit longer.

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Discussion.