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

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

3. Treatment of Dementia Cholinesterase inhibitors Memantine
Combination therapy
Treatment of Dementia

4. 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

5. 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

6. 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

7. 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

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

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

10. 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

11. 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

12. 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

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

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

15. 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

16. 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

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

18. Decreases cognitive function
May increase confusion
Opiate Analgesics

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Questions?