Dementia and Medication Considerations Kelly Green Boesen, PharmD, BCPS, CDE

Overview of Medication Use Treatment of dementia Treatment of behavioral issues associated with dementia Medications to avoid Overview of Medication Use

Treatment of Dementia Cholinesterase inhibitors Memantine Combination therapy Treatment of Dementia

Cholinesterase Inhibitors Keeps acetylcholine levels high Important chemical for nerve cell function and communication Approved for early to moderate stage Alzheimer’s May delay worsening of symptoms for 6-12 months Side effects: Nausea Vomiting Loss of appetite Constipation Cholinesterase Inhibitors

Cholinesterase Inhibitors Donepezil (Aricept®) Start with 5 mg/day for 4-6 weeks, then increased to 10 mg/day, increased to 23 mg/day after 3 months if needed Increasing doses, increases side effects Rivastigmine (Exelon®) Patch: 4.6 mg changed every 24 hours, may be titrated to 9.5 mg after 4 weeks, then again to 13.3 mg after 4 more weeks If treatment has been interrupted for longer than 3 days, must re-titrate Capsules/Oral Solution: 1.5mg/twice daily, may increase every 2 weeks up to 6mg/twice daily Cholinesterase Inhibitors

Cholinesterase Inhibitors Galantamine (Razadyne®) ER: Start at 8 mg/day, titrate every 4 weeks up to 24 mg/day Tablets/solution: 4 mg/twice daily, titrate every 4 weeks up to 12 mg/twice daily Cholinesterase Inhibitors

Namenda® Tablets/solution: 5 mg/daily, increase to 10 mg/daily after 1 week Approved for moderate to severe Alzheimer’s Regulates the activity of glutamate, another chemical messenger Delays worsening of symptoms temporarily Side effects: HA, constipation, confusion, dizziness Memantine

Treatment of Behavioral Issues Non-drug therapies Antipsychotic medications Antidepressants Treatment of Behavioral Issues

Non-Drug Therapies Calm responses from caregiver Explanation Reassurance Distraction Reorientation Encouraging regular meal-times, sleep schedule, regular exercise Non-Drug Therapies

Antipsychotic Medications To reduce the delusions, hallucinations, disorganized thinking Dopamine blocking activity Newer agents have serotonin activity First generation High potency: low to moderate weight gain, minimally sedating, higher risk of EPS Haloperidol Fluphenazine Perphenazine Low Potency: highly sedating, significant weight gain, moderate risk of EPS Chlorpromazine Antipsychotic Medications

Antipsychotic Medications Second generation Risperidone (Risperdal®) Aripiprazole (Abilify®) Quetiapine (Seroquel®) Clozapine (Clozaril®) Olanzapine (Zyprexa®) Ziprasidone (Geodon®) Paliperidone (Invega®) Asenapine (Saphris®) Lurasidone (Latuda®) Weight gain, diabetes, hyperlipidemia, EPS (but at lower rate) Antipsychotic Medications

Antipsychotic Medications Atypical antipsychotics preferred Lowest dose possible Treatment of agitation, hallucinations, delusions, aggression Sedation, rigidity, Parkinsonian type movements Increased rate of mortality with use of these medications Risk/benefit should be weighed carefully Antipsychotic Medications

Antidepressant Therapy SSRIs Start with low doses Escitalopram 10 mg/day, Citalopram 20 mg/day Antidepressant Therapy

Medications to Avoid Anticholinergic medications Benzodiazepines Sleep Aids Opiate analgesics Cognitive impairment and risk for falls Beers criteria (see handout) Medications to Avoid

Anticholinergic medications Block acetylcholine activity Antihistamines (diphenhydramine, chlorpheniramine) TCA’s (amitriptyline, nortriptyline) Muscle relaxants (cyclobenzaprine) Urinary incontinence medications (oxybutynin, solifenacin, tolterodine) Table 7 of Beers criteria article Anticholinergic medications

Benzodiazepines Enhance effect of GABA Results in sedative, hypnotic, anxiolytic effects Older adults typically have decreased metabolism Increases cognitive impairment, confusion, weakness May be being used for sleep or behavioral issues alprazolam, lorazepam, temazepam, diazepam Benzodiazepines

Sleep Aids Non-benzodiazepine, benzodiazepine receptor agonists Have the same basic mechanism and side effect profile of benzo Eszopiclone Zolpidem Zaleplon Sleep Aids

Decreases cognitive function May increase confusion Opiate Analgesics

Other Considerations Alcohol and other illicit drug use Electrolyte disturbances Liver failure/hepatic encephalopathy Infection Dehydration and malnutrition Other Considerations

Evaluating Medications Dementia specific medications: Following titration schedules to avoid side effects Evaluate if the drug is making a difference Improvement may only be temporary (6 months-1 year) May still be continued as part of over all treatment plan with other medications Evaluating Medications

Evaluating Medications Medications for behavioral issues: Preference for non-drug therapy first If required start with low doses and monitor for adverse effects Evaluating Medications

Evaluating Medications If the patient is newly experiencing Alzheimer’s symptoms, review medications and discontinue potential problem medications If the patient has abrupt worsening or change in cognitive function, ask about any new medications or changes in doses Evaluating Medications

Case Scenario 85 year old female, she is very “out of it” Family says she has been worsening for the last couple of days, more confused than normal, sleeping a lot Usual medications: amlodipine 5mg daily, donepezil 10mg daily, ASA 81mg daily What questions would you ask? What would you ask in regards to medication use? Case Scenario

Case Scenario 74 year old male with known Alzheimer’s disease Has been increasingly more combative with his family Has had recent medication changes and is now experiencing a tremor Medications: Donepezil 23mg daily, Memantine 10 mg daily, metoprolol XL 50mg daily, lisinopril 20mg daily, quetiapine 200mg at bedtime What questions would you ask? Which drug could be contributing? What would you recommend? Case Scenario

Questions?