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| Alzheimer's disease (
go to quick treatment table) |
| Overview |
 | Most common cause of dementia in the elderly |
| Prevalence: 10% over age 65, 47% over age 84 |
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| Diagnostic criteria for
Probable Alzheimer's dementia |
| Abnormal clinical exam and Mini Mental status Exam |
| Deficits in 2 or more areas of cognition |
| Progressive worsening |
| No disturbance of consciousness |
| Absence of systemic or other brain disease to account for symptoms |
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| Proposed Risk Factors for Alzheimer's |
| Family History of Alzheimer's disease |
| APO Genotype (epislon4): for late onset familial and sporadic forms,
those who inherit one or more alleles are at greater risk. |
| Aging and estrogen deficiency |
| Head injury |
| Low education |
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| Features that make AD less likely |
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| Psychotic & Affective
disturbance |
| Delusions: (false beliefs) affect 30-70% of patients. Usually simple
delusions, such as
 | persecution (somebody is trying to kill me) |
| theft (things got stolen) |
| phantom boarder (intruder in house) |
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| Hallucinations: not common. If present usually visual. |
| Depression is very common
| frequency is debated due to difficulty in applying formal diagnostic
criteria to demented patient. |
| Suicide is rare. |
| Severe depression more common in vascular dementia. |
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| Behavior problems |
| Personality change: apathetic or more impulsive |
| Anxiety: apprehension over upcoming events |
| Aggression: physical or verbal |
| Wandering: can be dangerous, medications not effective, provide a
"sheltered freedom". Example: Cover door knob with shoe boxes. |
| Screaming: very disturbing, may be related to pain, delusion or
Neuroleptic induced akathisia. ? background music may be helpful. |
| Sleep disruption & Sundowning: very common |
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| Guideline for the Treatment of Agitation
in Dementia (Alexopoulos, Silver, Kahn, et al., 1998): |
| Structure and routine.
| Follow regular, predictable routines |
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| Pleasant activities
| that the person knows and
enjoys:
 | listening to music, watching TV, watching a movie or sporting event, sorting coins, playing simple card games, walking the dog,
dancing. |
| Ask family to list activities that
patient has enjoyed in the past. |
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| Keep things simple.
| Break down complex tasks into many small, simple steps that the person can handle |
| Folding towels while one is doing the
laundry. |
| Allow time for frequent rests. |
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| Redirect.
| Get the person to do something else as a substitute. |
| A person who is restless and fidgety can be asked to sweep, dust, rake, fold clothes, or take a walk or a car ride with the caregiver. |
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| Distract.
| Offer a snack |
| Put on a favorite videotape or some familiar music |
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| Be flexible.
| Know when to back away from a task- a bath or dressing and reapproach later |
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| Soothe.
| When agitated, do simple, repetitive activities such as massage, hair brushing, or giving a manicure. |
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| Reassure.
| Let the person know that you are there and will keep him or her safe. |
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| Symptom Treatment |
| Attempt to use monotherapy |
| Sleep and Anxiety
| Nonpharmacologic: Daytime stimulation, adequate supervision, avoidance of
napping. |
| Pharmacologic:
| Chloral hydrate, 500 to 1000 mg prn (up to 2/d or 10/wk) |
| Zolpidem (Ambien), 5 to 10 mg hs prn |
| Lorazepam (Ativan), 0.5 to 1 mg prn (up to 2/d or 10/wk) |
| Buspirone (Buspar), 5 to 10 mg tid for short-term (few weeks) |
| Trazodone (Desyrel), 50 mg hs, may increase gradually to 50 mg bid or tid |
| Possibly melatonin, 1 to 2 mg hs prn (investigational) |
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| Neuroleptics: may be helpful for delusion and agitation. 20% may get
worse.
| Neuroleptic
may worsen cognitive function - BMJ - Jan 1997 |
| Haldol 0.25 mg qd to 2 mg bid, avoid anticholinergic med, if there is sign of
parkinson, swtich to other agent. |
| Thioridazine 25 mg qd to bid, may cause hypotension. |
| Trifluoperazine (Stelazine), molindone (Moban), perphenazine (Trilafon),
and loxapine (Loxitane): 2.5-5 mg/day; Max: 10-20 mg/day (qhs or bid).
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| Risperidone 1 mg qd to bid, EPS may occur at 2 mg.
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| Antidepressant: may help agitated behaviors, apathetic personality,
anxiety, depression
| Trazadone 25 mg hs, increase as tolerated, sedating, but low
anticholinergic effect |
| Prozac 10-20 mg qam |
| Sertraline 25-100 mg qam |
| Desipramine 25-100 mg qhs |
| Nortriptyline 10-100 mg qhs |
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| Anxiolytics: for short term use, long term use may worsen cognitive
function
| Lorazepam 0.5 - 2 mg |
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| Anticonvulsant: use is becoming more common, may help mood fluctuations,
impulsiveness
| Carbamazepine 100 mg bid, titrate |
| Depakene 125 mg bid, titrate |
| Beta blockers: ?behavioral outbursts |
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| Hints for using
Acetylcholinesterase inhibitors (AChE-I) |
| Establish a diagnosis of probable AD. |
| Discontinue agents with anticholinergic effects. |
| Start Vit E 1000 mg bid |
| Initiate AChE-I and monitor for side effects. |
| Reduce dosage or discontinue if side effects are intolerable. |
| Monitor efficacy by caregiver report, quantified mental status examination, effects on activities of daily living, or effects on behavior. |
| Continue for 6-12 months if any of the efficacy measures indicate
benefit or there is stabilization in functional, cognitive, or behavioral deterioration. |
| Continue AChE-I therapy until there is evidence of ongoing cognitive decline. |
| If there is evidence of continuing cognitive decline, reduce the
dosage and monitor to determine if there is an acceleration of deterioration. |
| If deterioration is accelerated, reintroduce AChE-I. |
| Discontinue AChE-I therapy for patients requiring general anesthesia. |
|
Galantamine
(Reminyl)
Razadyne ER (slow release form) |
| Start at 4 mg BID (8 mg/day) for at
least 4 weeks, then 8 mg bid |
| Available in 4 mg, 8 mg, and 12 mg
tablets |
| Most frequent adverse events that
occurred with placebo, REMINYL 16 mg/day, and REMINYL 24 mg/day,
respectively, were nausea (5%, 13%, 17%), vomiting (1%, 6%, 10%),
diarrhea (6%, 12%, 6%), anorexia (3%, 7%, 9%), and weight decrease
(1%, 5%, 5%). |
| Razadyne ER: start with 8 mg qd, then 16 mg qd,
then 24 mg qd. |
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| Rivastigmine (Exelon) |
| Benefits:
| Improved activities of daily living, including
eating, dressing, and household chores. |
| Reduce behavioral symptoms, such as delusions
and agitation. |
| Improved cognitive function |
| Reduced use of psychotropic medications. |
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| Dose: titrate dosage to achieve optimal effect.
| Usual dose: 6 to 12 mg/day given BID. Start
1.5 mg bid, increase by 3 mg every 2 weeks. |
| Available
in capsule doses of 1.5, 3, 4.5, 6 mg. |
| Half life: 2 hours |
| Few interactions with other drugs |
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| Side effects:
| No hepatotoxicity |
| GI disturbances, occur mainly during dose
adjustment. |
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| Novartis
Pharmaceuticals U.S., Exelon®
package insert. |
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| Aricept (Donepezil) |
| Indicated for mild to moderate Alzheimer's dementia |
| More selective for acetylcholinesterase, the cholinesterase common in the
brain, believed to account for the low incidence of GI side effects |
| 5 mg qd for 4 to 6 wk, if tolerate increase to 10 mg qd |
| Pharmacology:
| Half life: 72-hour |
| Steady states are achieved in 15 days. |
| 94% protein-bound |
| metabolized by the hepatic P450 enzyme system,
but few drug interactions have been identified. |
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| Adverse effect:
| nausea, vomiting, gastrointestinal cramping,
diarrhea and muscle cramping. |
| Does not have hepatoxicity. |
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| Namenda
(Nemantine) |
| More information,
visit Namenda website |
| Action: NMDA receptor agonist |
| May be used alone or in combination with AchI |
| Dose: start at 5 mg qd, titrate weekly to 5 mg bid, then 5 mg am and
10 mg pm, then 10 mg bid. |
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| Alpha-tocopherol
(vitamin E) & Selegiline |
| Alpha-tocopherol (vitamin E) and selegiline have been shown to slow the
progression of AD (Sano et al, 1997). |
| However, a later multicenter trial of selegiline in 400 patients with mild to moderate stage disease showed no benefits over a l year trial. |
| Dose used in study: vitamin E 2000 I.U. daily and
Selegiline 5 mg am, 5 mg noon. |
| Side effects:
| Selegiline: insomnia, confusion, and
psychosis. |
| Vitamin E: Can potentially cause a prolonged prothrombin time for pateints on
coumadin |
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| Further reading |
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| Family Resources |
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Differentiate Pseudodementia & Dementia
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