Pharmacologic management of Dementia
Standard drugs used for Alzheimer's are designed to protect the cholinergic system which is essential for memory and learning and is progressively destroyed in this disease.
http://www.gcrweb.com/alzheimersDSS/

• Acetylcholinesterase Inhibitors
  May produce measurable improvement in cognition and slow disease progression (if so, may delay need for NH placement), but do not change the underlying disease process. Exhibit ameliorative effects, may produce slight improvement in ADLs and contributes to reduced incidence of abnormal behavior in mild-to-moderate AD.
  • Use
    • Begin as early as possible
    • Low daily dose, build up to therapeutic dosing over a period of weeks
  • Types
    • Tacrine (Cognex) - taken four times a day this was the first drug of this class to be developed; now with limited usefulness and significant hepatic toxicity
    • Donepezil (Aricept) - taken once a day, it boosts levels of acetylcholinesterase; modest benefits; helps slow the loss of function and reduce caregiver burden.
    • Rivastigmine (Exelon) - taken twice a day, it boosts levels of both acetylcholinesterase and butyrycholinesterase; may be particularly beneficial for clients with rapidly progressing disease by slowing or even slightly improving disease status even in those with advanced disease.
    • Galantamine (Reminyl) - taken twice a day, it protects the cholinergic system and acts on nicotine receptors which are depleted in Alzheimer's; effects are similar to Aricept and Exelon, but it has also been helpful for improving function.
    • Memantine - for late stage use
  • Side-effects
    • Nausea
    • Vomiting
    • Diarrhea
    • Dizziness
    • Anorexia
    • Insomnia
  • Monitoring
    • serial MMSE to monitor stability or improvement
    • laboratory evaluations per specific medication recommendations
    • ongoing assessment every 3-4 months after stability achieved
    • may consider stopping the medication when complete loss of independence with ALS's occurs, but literature varies
      
      
• Medications for Psychiatric Complications   http://www.alzheimers.org/pubs/medications.htm
  • Situations where medication for disruptive behavior may be primary option
    • Thought and perceptual disturbances: Neuroleptics
    • Anxiety and agitation: Benzodiazepines
    • Depression: Antidepressants
    • Agitation and impulsivity: Atypical anti-psychotics, anti-convulsants, Benzodiazepines
    • Benzodiazepines
  • Common Complications from Treating Difficult Behaviors
    • Adverse reactions to medication
    • Drug interactions
    • Worsening of disruptive or socially unacceptable behavior
    • Increase lethargy or confusion
    • Cardiac arrhythmias
    • Orthostatic hypotension
      
      
• Other Current Therapies for Alzheimer's Disease
  • Vitamin E
    • may slow disease progression
  • Seligiline (Eldepryl)
  • Nonsteroidal Anti-inflammatory Drugs - may reduce risk due to neuropathic evidence of inflammation ( cytocines, complement, and activated microglin) that is involved in CNS dysfunction.
  • Ginkgo Biloba - common herb with antioxidant properties; appears to increase blood flow to the brain; may slightly improve the memory in the mild to moderate stages of Alzheimer's.
  • Melatonin - an antioxidant and natural hormone involved in sleep regulation; may break down beta amyloid; deficiences have been noted in Alzheimer's.

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Non-pharmacologic strategies

The guiding principle of care is that caregivers must modify the environment or their own behavior because the client is not capable of modifying his or her own response unless the situation changes.

• Address any underlying or comorbid conditions
• Maintain environmental stability and calm
• Prevent major injuries
• Maintain weight
• Maintain verbal and nonverbal interactions
• Promote independence
• Mediate family stress
• Preserve patient dignity

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Intervention

• Non-pharmacological
  • intervene for safety as indicated - direct others away
  • remain calm, do not overreact or confront
  • evaluate event specific factors and intervene appropriately
  • try to understand what is being communicated
  • attempt to satisfy request if feasible
  • divert attention to diffuse behavior
  • involve staff members who might have positive rapport with patient
  • be aware of racial or gender bias that may be causative
    
    
• Pharmacological
  *see pharmacologic management table (need this)
  
  
• Preventive
  • provide calm environment - decrease stimulation
  • be familiar with, watch for the early signs of agitation, and intervene to prevent catastrophic reactions
  • involve families in care planning for understanding of patient preferences
  • involve interdisciplinary team for long term management

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