Term
|
Definition
| most common form of dementing illness in older adults; a progressive, degenerative disorder; more common in females; prevalence increases with each decade of life; 5th leading cause of death due to associated complications: sepsis, pneumonia, choking, nutritional deficiencies, trauma |
|
|
Term
| Environmental Risk Factors for AD |
|
Definition
| head trauma, low educational level, reduced mental & physical activity in late life |
|
|
Term
|
Definition
beta-amyloid plaques --> inflammatory response --> neuronal dysfuction;
neurofibrillary tangles (NFTs) --> abnormal tau protein --> microtubular collapse --> increased density of NFTs --> increased dementia severity;
Loss of cholinergic neurons in cortex & hippocampus --> deficit of ACh;
Increased intracellular Ca accumulation due to increased glutamate activity --> neuronal cell toxicity |
|
|
Term
|
Definition
| progresses through stages as nerve cell damage spreads; memory loss, loss of independence, psychological & behavioral problems |
|
|
Term
|
Definition
| Pt experience NO SUBJECTIVE or OBJECTIVE change in intellectual functioning |
|
|
Term
|
Definition
Pt complains of LOSING THINGS or FORGETTING FAMILIAR WORDs;
Problems DO NOT INTERFERE with job or social functioning |
|
|
Term
| Stage 3 - Early Confusion |
|
Definition
Pts have DIFFICULTY finding RIGHT WORD in conversation;
Pts have DIFFICULTY with RECALL or RETAINING new material;
PERFORMANCE ISSUES in social or work setting are NOTICEABLE |
|
|
Term
| Stage 4 - Late Confusion - Early AD - MMSE > or = 21 |
|
Definition
Pts need ASSISTANCE w/ IADLs (housework, food prep, managing money, shopping);
Pts have DIFFICULTY REMEMBERING RECENT EVENTs;
Pts have IMPAIRED ABILITY to perform CALCULATIONS;
Pts have DECREASED ABILITY to perform COMPLEX tasks; |
|
|
Term
| Stage 5 - Early Dementia - Moderate AD - MMSE = 10-20 |
|
Definition
Pts are FREQUENTLY DISORIENTED with regard to TIME;
Pts need HELP SELECTING PROPER CLOTHING;
Pts RECALL for RECENT events or DETAILS of PAST LIFE is IMPAIRED |
|
|
Term
| Stage 6 - Middle Dementia - Moderate-Severe AD - MMSE < or = 9 |
|
Definition
Pts need ASSISTANCE with ADLs (eating, dressing, toileting, bathing, grooming);
Pts OCCASIONALLY FORGET NAMES of FAMILY & caregivers;
Pts experience PERSONALITY CHANGES & BEHAVIORAL symptoms |
|
|
Term
| Stage 7 - Late Dementia - Severe AD - MMSE < or = 9 |
|
Definition
Pts LOSE CAPACITY for RECOGNIZABLE speech;
Pts LOSE ABILITY to SIT & WALK without support;
Pts LOSE ability to FEED SELF & SWALLOWING is IMPAIRED;
Pts need help with TOILETING & INCONTINENCE is a PROBLEM |
|
|
Term
| Noncognitive Signs/Symptoms of Advanced AD |
|
Definition
Psychological: hallucinations, delusions, anxiety, depressed mood;
Behavioral:
physically aggressive (pushing, biting, spitting)
physically non-aggressive (wandering, pacing, intruding on other's rooms)
Verbally Aggressive (yelling, screaming, cursing)
Verbally non-aggressive (complaining, repetitive questioning or calling out) |
|
|
Term
| When to Screen for Dementia |
|
Definition
| If pt has: cognitive changes, psychiatric symptoms, personality changes, behavior problems, functional changes |
|
|
Term
| When to screen for Delirium |
|
Definition
| In pts: relative acute onset; disorientation, inattention, altered level of consciousness, reversible etiologies (dehydration, electrolyte imbalance, medications) |
|
|
Term
| DSM-IV-TR Criteria for Dementia of Alzheimer's |
|
Definition
A. development of multiple cognitive deficits manifested by both: memory impairment & one or more of following - aphasia, apraxia, agnosia, or disturbance in executive functioning;
B) Cognitive Disturbances each cause SIGNIFICANT IMPAIRMENT;
C) Characterized by GRADUAL ONSET & CONTINUING DECLINE;
D) NOT DUE TO FOLLOWING: other CNS conditions, systemic conditions known to cause dementia, or substance induced;
E) Deficits DO NOT occur exclusively during course of delirium;
F) Disturbance is not better accounted for by another Axis 1 disorder; |
|
|
Term
| Acetylcholinesterase Inhibitors - donepezil [Aricept], rivastigmine [Exelon], galantamine [Razadyne, Razadyne ER] |
|
Definition
first-line tx of mild-moderate Alzheimer's (MMSE of 10-26);
MoA: increases ACh through inhibition of AChE;
ADRs:
N/V, diarrhea, insomnia, HA, dizziness, fatigue, muscle cramps
Warnings:
exaggerated succinylcholine-type relaxation during anesthesia;
increased gastric acid secretion;
vagotonic effect on SA & AV nodes;
May cause bladder outflow obstruction or convulsions;
Effects MAY be seen as IMPROVEMENT, STABILIZATION, or REDUCTION in rate of decline |
|
|
Term
|
Definition
AChE inhibitor;
1st line tx for mild, moderate AND severe AD;
Dosing:
Initial - 5 mg QHS
Titration - 4-6 wks
Effective - 5-10 mg qHS
Take in evening before bed, with OR without food, allow ODT to dissolve in tongue;
Forms: 5 mg & 10 mg tablets, 5 mg & 10 mg ODTs, 1 mg/mL oral solution (300 mL);
96% protein bound;
T1/2 = 70 hrs; Hepatic CYP450 glucuronidation;
Eliminated via kidneys |
|
|
Term
|
Definition
AChE inhbitor; for mild-moderate AD;
Dosing: has activity as butyrylcholinesterase inhibitor
Initial - 1.5 mg BID
Titration - 2 wks
Effective dose - 3-6 mg BID
Take in AM & PM, WITH FOOD, swallow oral solution directly from syringe OR mix w/ glass of water, cold fruit juice, or soda;
Forms: 1.5 mg, 3 mg, 4.5 mg, & 6 mg caps; 2 mg/mL oral solution; 4.6 mg/24 hrs, 9.6 mg/24 hrs patch;
PKs:
40% protein bound;
T1/2 = 1.5 hrs
Cholinesterase-mediated hydrolysis;
Eliminated renally |
|
|
Term
|
Definition
AChE inhibitor; 1st line for mild-moderate AD; has activity at nicotinic receptor modulator;
Dosing:
Initial - 4 mg BID
Titration - 4 wks
Effective Dose - 8-12 mg BID;
Take in AM & HS; WITH FOOD; MAX dose = 16 mg/day with moderate hepatic/renal impairment; Avoid use w/ severe hepatic or renal impairment (CrCL < 9 mL/min);
Forms: 4 mg, 8 mg, & 12 mg tabs; 4 mg/mL oral solution (100 mL);
PKs:
18% protein bound;
T1/2 = 5-7 hrs;
Hepatic CYP450 glucuronidation;
eliminated renally; |
|
|
Term
| galantamine ER (Razadyne ER) |
|
Definition
AChE inhbiitor with sustained release;
Dosing:
Initial - 8 mg once daily
Titrate - 4 wks
Effective Dose - 16-24 mg once daily;
Take in AM; WITH FOOD; Max of 16 mg/day w/ moderate hepatic/renal impairment; Avoid use w/ severe hepatic/renal impairment;
Forms: 8 mg, 16 mg, 24 mg capsule |
|
|
Term
| rivastigmine (Exelon) transdermal patch |
|
Definition
AChE inhibitor in patch form;
Dosing:
Initial - if new to drug, use 4.6 mg patch;
Maintenance - increase to 9.5 mg patch ONLY after 4 wks at previous dose & ONLY if previous dose has been WELL TOLERATED;
MAX - 9.5 mg/24 hrs;
Switching from Capsule to Patch:
if taking <6 mg ORAL daily --> switch to 4.6 mg patch;
if taking 6-12 mg ORAL daily --> switch to 9.5 mg patch;
1st patch applied day following last oral dose;
Application:
apply once a day to clean, dry, hairless, intact, healthy skin that won't be rubbed by tight clothing;
Apply on upper or lower back if possible;
Replace patch q24 hrs & time of day should be consistent;
Can swim, bathe, shower with patch on;
Press patch down firmly; Do not apply to cut, irritated, or red skin; Do not apply to same spot for at least 14 days; |
|
|
Term
|
Definition
Indications:
tx of moderate-severe dementia of Alzheimer's - monotherapy OR added to AChEI regimen;
MoA: uncompetitive antagonist of NMDA receptors;
Dosing:
Therapeutic - 10 mg BID;
Severe Renal Impairment - 5 mg BID (CrCL 5-29 mL/min);
Forms: 5 mg & 10 mg tab, 2 mg/mL oral solution (360 mL);
PKs:
100% bioavailable;
With or without food;
45% protein bound;
T1/2 = 60-80 hrs; |
|
|
Term
| ADRs of memantine (Namenda) |
|
Definition
constipation, vomiting, somnolence, dizziness, confusion, hallucinations, HA, pain, HTN, coughing
Warnings:
concomitant use of drugs that make urine alkaline (acetazolamide);
concomitant use of other NMDA antagonists (dextromethorphan);
genitourinary conditions that raise urine pH;
severe renal impairment or seizure disorders; |
|
|
Term
| Titration Schedule of memantine (Namenda) |
|
Definition
Wk 1: take 5 mg tab each day;
Wk 2: take 5 mg tab AM and 5 mg tab in HS;
Wk 3: take 10 mg tab in AM and 5 mg tab in HS;
Wk 4: take 10 mg tab AM and 10 mg tab HS
Take with or without food. |
|
|
Term
| Non-pharm Tx of Noncognitive Symptoms |
|
Definition
primary intervention for behavioral symptoms;
individualize strategies:
Possible Management Strategies - address unmet needs, maintain structured environment, stimulate reminiscence, remove excess stimulation, eliminate physical discomfort, provide meaningful activities according to pt's ability |
|
|
Term
| Pharmacological Treatment of Noncognitive Symptoms |
|
Definition
antipsychotics (haloperidol [Haldol], risperidone [Risperdal], olanzapine [Zyprexa]) - targets psychosis & disruptive behaviors;
SSRIs may benefit AD pts w/ depression (citalopram, sertraline) - monitor for clinical improvement & SEs |
|
|
Term
|
Definition
| extrapyramidal effects, hypotension |
|
|
Term
|
Definition
| extrapyrimidal effects; somnolence; abnormal gailt |
|
|
Term
| Prescribing Principles for Antipsychotics |
|
Definition
"Start dosage low and go slow";
Use lowest effective dosage possible;
Attempt gradual dose reductions;
Use for a limited period of time;
Document symptoms & response |
|
|
Term
|
Definition
physical, emotional, and financial toll of providing care;
higher amount --> increased morbidity & mortality;
Interventions: psychological support, social support system |
|
|
Term
|
Definition
vascular risk factor reduction;
Engage in cognitive activity;
Engage in physical activity;
Maintain social engagement;
Healthy diets |
|
|
Term
|
Definition
| absence or impairment of ability to communicate through speech, writing, or signs because of brain dysfunction |
|
|
Term
|
Definition
| loss of comprehension of auditory, visual, or other sensations although sensory sphere is intact |
|
|
Term
|
Definition
| inability to perform purposive movements although there is no sensor or motor impairment |
|
|
