The Pharmacist s Role in Recognition and Management of Alzheimer s

Transcription

1 10:15am - 11:15am: Breakout 2 - Mental Health Option B: The Pharmacist s Role in Recognition and Management of Alzheimer s ACPE UAN L01-P 0.1 CEU/1.0 Hr. Activity Type: Application-Based Program Objectives for Pharmacists: Upon completion of this program, participants should be able to: 1. Understand the causes and risk factors for Alzheimer s disease. 2. Describe the early signs and symptoms and diagnostic criteria for Alzheimer s disease. 3. Evaluate the treatment options at each stage of the disease process. 4. Discuss potential side effects and drug interactions commonly seen with medications to treat Alzheimer s. 5. Apply knowledge to develop possible treatment recommendations for patients in your practice. Speaker: Kristin Meyer, PharmD, CGP, CACP, FASCP, holds an appointment as Assistant Professor of Clinical Sciences at Drake University, her practice site being the 750-bed Iowa Veterans Home in Marshalltown. She precepts approximately 28 students per year in a specialty geriatrics clerkship in addition to classroom teaching duties. Dr. Meyer is a 2000 graduate of Drake University COPHS and completed a geriatric specialty pharmacy residency at the Central Arkansas Veterans Healthcare System and University of Arkansas in Little Rock. She is a Certified Geriatric Pharmacist, Certified Anticoagulation Care Provider and a Fellow of the American Society of Consultant Pharmacists. Her areas of interest and expertise are Alzheimer s, Parkinson s and Drug Interactions. Speaker Disclosure: Kristin Meyer reports she has no actual or potential conflicts of interest in relation to this program. The speaker has indicated that off-label use of medications will be discussed during this presentation.

2 The Pharmacist s Role in Recognition and Management of Alzheimer s Kristin S. Meyer, PharmD, CGP, CACP, FASCP Assistant Professor, Clinical Sciences Drake University College of Pharmacy and Health Sciences Iowa Veterans Home Faculty Disclosure Kristin Meyer reports she has no actual or potential conflicts of interest associated with this presentation. Kristin Meyer has indicated that off-label use of medication will not be discussed during this presentation. Learning Objectives 1. Understand the causes and risk factors for Alzheimer s disease. 2. Describe the early signs and symptoms and diagnostic criteria for Alzheimer s disease. 3. Evaluate the treatment options at each stage of the disease process. 4. Discuss potential side effects and drug interactions commonly seen with medications to treat Alzheimer s. 5. Apply knowledge to develop possible treatment recommendations for patients in your practice. Pre-Assessment Questions 1. The number of persons diagnosed with Alzheimer s is expected to in the next 40 years. A. Double B. Triple C. Quadruple 2. Which of the following is least likely to be affected in early Alzheimer s disease? A. Balancing checkbook B. Bathing C. Driving Pre-Assessment Questions 3. Which of the following OTC medications may worsen cognitive function? A. OTC sleep aid B. Motion sickness remedy C. Tagamet HB D. All of the above Pre-Assessment Questions 5. The dose of should be adjusted if the creatinine clearance is less than 30 ml/min. A. Donepezil B. Galantamine C. Rivastigmine D. Memantine 4. An adequate trial of a cholinesterase inhibitor should last approximately: A. 6 weeks B. 3 months C. 6 months D. 1 year

3 Alzheimer s Disease Most common form of dementia More common than all other dementias combined Slow, progressive decline in activities of daily living (ADLs), global functioning including behavior, and cognition Symptom onset usually after age 65 Mean survival time 6-7 years Prevalence expected to quadruple by Functional Losses in Dementia Early stages Finances Taking medication Housekeeping Traveling independently Shopping Preparing meals Using telephone Middle stages Bathing Toileting Dressing Grooming Walking Eating meals 1. Alzheimers Dement. 2007;3(3): Folstein Mini-Mental Status Exam (MMSE) Assesses memory, orientation, language, praxis, and attention/concentration Interview environment should be quiet Directions should be slow and succinct Cut-off score: <24 = cognitive decline Age and education should be considered Untreated, Alzheimer s patients expected to decline 2-5 points/year Lacks some sensitivity and specificity Case Study Mrs. Applegate, a long-time customer of your pharmacy, is in today to pick up refills of medications for both herself and her husband. You haven t seen him in awhile, so you ask how he is. She seems relieved that you asked, and confides that she thinks Henry may have Alzheimer s. He s always losing things and she doesn t even trust him to run simple errands anymore. Anticholinergic Medications Can Worsen Cognition When should therapy be initiated? Amantadine Amitriptyline Older antipsychotics Baclofen Benztropine Chlorpheniramine Cimetidine Clozapine Cyclobenzaprine Cyproheptadine Desipramine Dicyclomine Diphenhydramine Hydroxyzine Imipramine Loperamide Loratadine Meclizine Nortriptyline Olanzapine Oxybutynin Prochlorperazine Pseudoephedrine Tolterodine As soon as possible Family members are key to early screening/identification and treatment When there s still some function to be preserved Patient feeds self, toilets self, ambulates independently Arch Inter Med. 2008;168(5):

4 Mild Alzheimer s Disease MMSE score Memory loss Uncharacteristic forgetfulness, impaired acquisition and retrieval of new information, geographic disorientation Language impairments Difficulty in proper word selection, hesitancy in speech Social withdrawal Passivity, disinterest Cholinesterase Inhibitors First-line PHARMACOtherapy for AD Clinical differences in effectiveness not clear Have shown benefits over placebo for up to three years 1, 2 May be beneficial for behavioral problems; use is recommended throughout the course of the illness Common side effects: GI (self-limiting), can reduce heart rate 1. N Engl J Med Jun 9;352(23): Lancet 2004; Aricept (donepezil) Initiate at 5 Increase in 4-6 weeks to 10 if tolerated Potential CYP450 2D6/3A4 drug interactions Orally-disintegrating tablet available Exelon (rivastigmine) Initiate at 1.5 mg BID with food Increase by 3 mg/day at 2 week intervals Minimum effective dose = 3 mg BID Maximum suggested dose = 6 mg BID GIVE WITH FOOD NO CYP450 drug interactions Oral solution available Exelon Patch (rivastigmine) Initial dose: 4.6 mg/24 hrs daily Maintenance dose: 9.5 mg/24 hrs daily Patients taking <6 mg oral = 4.6 mg patch Patients taking 6-12 mg oral = 9.5 mg patch Apply first patch day after last oral dose GI side effects much less than oral Razadyne (galantamine) Initiate at 4 mg BID with meals (ER=daily) Increase dose by 8 mg/day at 4 week intervals Recommended dose range is mg/day Moderate renal/liver impairment: 16 mg max Potential CYP450 2D6/3A4 drug interactions Oral solution and extended-release capsule available

5 Case Study It s been a few months since Mrs. Applegate first spoke with you about her husband. Today, they come in together with a prescription for donepezil (Aricept) 5 mg daily for Henry. The doctor says he has Alzheimer s disease. What are some important counseling points for this new prescription? If one cholinesterase inhibitor fails, should we switch to another? Adequate trial (~6 months) Non-responders >5 point decline on MMSE per year Intolerable side effects Washout period may be indicated (one week) Potential loss of function while titrating new drug Moderate Alzheimer s Disease MMSE score Inaccuracies in long-term memories Confusion over relationships and identities of friends and relatives Small tasks require supervision Disruptive behaviors may surface Agitation, restlessness, sleep disturbances, aggression Psychiatric symptoms Suspicions, delusions, hallucinations Namenda (memantine) Indicated for moderate to severe AD NMDA receptor antagonist Used in Germany since 1982 May be used in combination with cholinesterase inhibitors Available in oral solution Benefits for behaviors as well 1 1. The Annals of Pharmacotherapy. 2008;42: Namenda (memantine) Drug interactions Carbonic anhydrase inhibitors Sodium bicarbonate Most common adverse reactions Dizziness Confusion Insomnia Namenda (memantine) Initiation and titration 5 mg daily x 1 week 5 mg BID x 1 week 5 mg AM, 10 mg PM x 1 week 10 mg BID (recommended dose) Renally excreted: max dose is 10 mg daily for ClCr <30 ml/min

6 Combination Therapy for AD Memantine + donepezil or donepezil alone 1 Combination did significantly better on all outcomes at the end of 24 weeks Significantly more donepezil alone patients dropped out due to adverse events Memantine + ChEI treatment slowed decline for up to median 1.5 years compared to ChEI alone or no treatment 2 Case Study It s been about two years since you first visited with Mrs. Applegate about Henry s memory loss. He was recently admitted to a nursing home because she couldn t care for him at home. She wonders, Are the medications really doing him any good anymore? He doesn t even know who I am sometimes. 1. JAMA 2004;291: Alzheimer s Dis Assoc Disord. 2008;22(3): When should therapy be stopped? Controversial family plays a large part in this decision No function left to be preserved patient is totally dependent on caregiver Post-Assessment Questions 1. The number of persons diagnosed with Alzheimer s is expected to in the next 40 years. A. Double B. Triple C. Quadruple May see rapid decline in patient s condition when therapy discontinued 2. Which of the following is least likely to be affected in early Alzheimer s disease? A. Balancing checkbook B. Bathing C. Driving Post-Assessment Questions 3. Which of the following OTC medications may worsen cognitive function? A. OTC sleep aid B. Motion sickness remedy C. Tagamet HB D. All of the above Post-Assessment Questions 5. The dose of should be adjusted if the creatinine clearance is less than 30 ml/min. A. Donepezil B. Galantamine C. Rivastigmine D. Memantine 4. An adequate trial of a cholinesterase inhibitor should last approximately: A. 6 weeks B. 3 months C. 6 months D. 1 year