1. Alzheimers Disease: A Case Study Approach to Optimizing Patient Outcomes Applying Landmark Evidence to Clinical Practice Case Studies and Challenge the Experts

2. Clinical Approach and Issues: Is this early Alzheimers Disease? How would you confirm this? Is this early Alzheimers Disease? How would you confirm this? If this is AD, what are appropriate options for initial therapy in this patient? If this is AD, what are appropriate options for initial therapy in this patient? Should Vitamin E be given for neuroprotection? Should Vitamin E be given for neuroprotection? Should initial therapy consist of ChEI and memantine combination therapy? Should initial therapy consist of ChEI and memantine combination therapy? Is this MCI? How would you differentiate from AD? Would your choice of Rx be different? Is this MCI? How would you differentiate from AD? Would your choice of Rx be different? CASE STUDY # 1 A 78-year-old retired lawyer is seeing you for a 2 nd opinion regarding his memory. His PCP told him not to worryhe merely had Old-timer's disease. MRI was WNL and MMSE was 27. He is alert and charming as he denies any real problems wife insisted on appt with you and states Hes definitely slipping the past year or so…

3. Clinical Approach and Issues: What would be your initial choice for dementia therapy? What would be your initial choice for dementia therapy? Is this patient a good candidate for ChEI and memantine combination therapy? Is this patient a good candidate for ChEI and memantine combination therapy? How long should dementia therapy be continued? How long should dementia therapy be continued? What if this 78-year- old retired lawyer is referred to you for dementia and comes in with a diagnosis of AD with MMSE = 17?? What if this 78-year- old retired lawyer is referred to you for dementia and comes in with a diagnosis of AD with MMSE = 17?? CASE STUDY # 1

4. Clinical Approach and Issues: Should this patient continue on ChEI and memantine combination therapy? Should this patient continue on ChEI and memantine combination therapy? Would you consider switching ChEI? Under what circumstances? Would you consider switching ChEI? Under what circumstances? If he had never had a trial of dementia therapy previously, how would you proceed? If he had never had a trial of dementia therapy previously, how would you proceed? How long should dementia therapy be continued? How long should dementia therapy be continued? What are reasonable triggers for discontinuing dementia therapy? What are reasonable triggers for discontinuing dementia therapy? Finally, you are asked to consult and note if there is anything further you would recommend for the 78 year-old father of a colleague, still at home with dx AD x 6yrs, MMSE = 7 His current Rx include donepezil 10mg qD and memantine 10mg BID CASE STUDY # 1

5. Clinical Approach and Issues: Is this the time to switch to another ChEI? Is this the time to switch to another ChEI? Under what circumstances would current ChEI be continued? Under what circumstances would current ChEI be continued? Should ChEI be discontinued in favor of memantine? Should ChEI be discontinued in favor of memantine? Is this patient a good candidate for ChEI and memantine combination therapy? Is this patient a good candidate for ChEI and memantine combination therapy? CASE STUDY # 2 A 74-year-old white female with HTN and DM presents to you with her family. A neurologist diagnosed her with AD, but her decline has been erratic and she recently had a mini-stroke that left her more confused. She is on ChEI that her kids say doesnt help. You see MMSE = 15 in her recent hospital dishcarge summary

6. Clinical Approach and Issues: If further testing determined patient likely had a mixed AD + vascular dementia, would you change her dementia therapy? If further testing determined patient likely had a mixed AD + vascular dementia, would you change her dementia therapy? What if another dementia specialist subsequently diagnosed her as vascular dementia (VaD)? Would your therapy change? What if another dementia specialist subsequently diagnosed her as vascular dementia (VaD)? Would your therapy change? Is a response to CHEI or memantine diagnostic for AD or VaD? Is a response to CHEI or memantine diagnostic for AD or VaD? The patient was placed on a different ChEI with memantine subsequently added and had a good clinical response. She has remained quite stable on this regimen and the family is happy CASE STUDY # 2

7. Clinical Approach and Issues: How important is it to refine the dementia diagnosis in this case? How important is it to refine the dementia diagnosis in this case? Is her current pharmacotherapy adequate? Is her current pharmacotherapy adequate? What would be the next step in adjusting her dementia medications? What would be the next step in adjusting her dementia medications? An 82 year-old female was recently admitted to assisted Living after a car accident and loss of her car PMH: Dementia (never was Dx with AD), OA of L knee, HTN, DM, Ca Breast s/p mastectomy Medications: rivastigmine 3 mg BID, Lidoderm Patch 5%, glipizide 5 mg qD, enalapril 5mg qD PE: BP 160/92, slow gait, uses cane for walking MMSE=19, neuro exam otherwise normal An 82 year-old female was recently admitted to assisted Living after a car accident and loss of her car PMH: Dementia (never was Dx with AD), OA of L knee, HTN, DM, Ca Breast s/p mastectomy Medications: rivastigmine 3 mg BID, Lidoderm Patch 5%, glipizide 5 mg qD, enalapril 5mg qD PE: BP 160/92, slow gait, uses cane for walking MMSE=19, neuro exam otherwise normal CASE STUDY # 3

8. Clinical Approach and Issues: Are environmental manipulation and behavioral management techniques indicated? If so, what sorts of techniques? Are environmental manipulation and behavioral management techniques indicated? If so, what sorts of techniques? Is pharmacotherapy indicated for this pt? Is pharmacotherapy indicated for this pt? Would memantine be the next best choice? Would memantine be the next best choice? Would an antidepressant be the next best choice? Would an antidepressant be the next best choice? Would an atypical antipsychotic be the next best choice? Would an atypical antipsychotic be the next best choice? 81 year old widower living in NH for 6 mos Dx: Alzheimers Disease MMSE = 12 Rx with donepezil 10mg x 4 yrs. Pacing and wandering, looking for deceased wife/ Wants to go home. Intrudes into others rooms several times/day Argumentative and unpredictable 81 year old widower living in NH for 6 mos Dx: Alzheimers Disease MMSE = 12 Rx with donepezil 10mg x 4 yrs. Pacing and wandering, looking for deceased wife/ Wants to go home. Intrudes into others rooms several times/day Argumentative and unpredictable CASE STUDY # 4

9. Clinical Approach and Issues: Should memantine be added as well? Should memantine be added as well? If the SSRI does not show clear benefit, should an atypical antipsychotic be started? If the SSRI does not show clear benefit, should an atypical antipsychotic be started? Are the risks of using an atypical antipsychotic in this patient relatively equal to the expected benefits? Are the risks of using an atypical antipsychotic in this patient relatively equal to the expected benefits? NH staff responded with ongoing reassurance, family helped by personalizing pts room, OT made attempts to engage pt in crafts & activities RT promoted exercise & MD gave trial of SSRI antidepressant NH staff responded with ongoing reassurance, family helped by personalizing pts room, OT made attempts to engage pt in crafts & activities RT promoted exercise & MD gave trial of SSRI antidepressant CASE STUDY # 4

10. Clinical Approach and Issues: Should an atypical antipsychotic be started? Should an atypical antipsychotic be started? Are the risks of using an atypical antipsychotic in this patient relatively equal to the expected benefits? Are the risks of using an atypical antipsychotic in this patient relatively equal to the expected benefits? Are there effective alternative medication approaches available? Are there effective alternative medication approaches available? NH staff report pt cannot tolerate activities and has not responded to environmental manipulations. Pt has become increasingly aggressive, attacking other residents as well as staff providing care NH staff report pt cannot tolerate activities and has not responded to environmental manipulations. Pt has become increasingly aggressive, attacking other residents as well as staff providing care CASE STUDY # 4