Treating the symptoms of dementia

1. Treating the symptoms of dementia Canning Division of General Practice Presented By: Saloni Shah An interactive workshop for GPs, Pharmacists & Nurses 2009

2. Key Messages: Use non-pharmacological strategies at all stages Benefits of cholinesterase inhibitors and memantine are small, some people will not respond and adverse effects are common Monitor and objectively assess the effectiveness of cholinesterase inhibitors and memantine if they are to be used Trial a withdrawal of antipsychotics if there are no clear beneficial effects Plan to review medications regularly as well as opportunistically Counsel patients and their carers on the limited benefits of drug therapy

3. Case Scenario • Dashen is an 81 year old retired farmer who recently moved into the city so he and his wife could live near their only daughter, Sonya. • By his wife’s report, Dashen has a history of two years of progressive memory loss, and has had a decline in his ability to perform ADLs (Activities of Daily Living). He is unable to perform household tasks like preparing meals. He cannot manage to cheque book or pay bills and requires help with daily buying needs. • He is able to drive his own car, but gets lost when driving around his neighborhood. He still performs his basic activities of daily living, such as personal hygiene and dressing. He was referred to a geriatrician.

4. Case Scenario cont’d • The geriatrician diagnosed Dashen with moderate Alzheimer’s disease with findings of immediate and recent memory loss, word finding difficulties, confirmation of his orientation deficits, and inattention to simple tasks. • He and his wife drop by to discuss his treatment options with you. • Medical History • Oesophagitis (15 years) • Dyslipidaemia (12 years) • Angina (10 years) • Social History • He does not drink alcohol or smoke • His wife is his main carer

5. Case Scenario cont’d • On Examination • Dashen is alert and interactive • Blood Pressure is 134/80, pulse 80 • He is not dyspnoeic or febrile. • MMSE is 17/30 (unchanged from 3 months ago) • His gait is steady and visual acuity is 6/6 in each eye • Physical examination is unremarkable except for his mental status exam revealing the deficits described previously • No vascular changes were reported on his CT brain scan • Urea and electrolytes are normal • B12 and thyroid function tests are normal • Urine analysis is clear

6. Current Medications • Medication Dose Frequency • Omeprazole 20mg daily • GTN spray 1-2 sprays when required • Aspirin 100mg once daily • Atorvastatin 10mg at night • Metoprolol 50mg twice daily • Isosorbidemononitrate 120mg daily

7. Questions • What non-pharmacological strategies (e.g. memory prompts) would you recommend to help him cope with memory loss and activities of daily living?

8. Questions • 2. Are there any dementia resources or support services available in your area that may benefit Dashen and his family?

9. Questions • 3. Would you recommend a cholinesterase inhibitor (donepezil/Aricept, galantamine/Reminyl, rivastigmine/Exelon) or memantine/Ebixafor Dashen?

10. Questions • 4. If a cholinesterase inhibitor or memantine was to be started, what guidance would you provide Dashen and his care-giver?

11. Questions • 5. If drug therapy was started, what investigation/s or assessment/s would help monitor their effectiveness?

12. Case Scenario cont’d • It has been two years since Dashen was diagnosed with Alzheimer’s disease. He complains that he wakes up several times at night to go to the toilet and his most recent MMSE score was 13/30. • The only medication added was amitriptyline 25mg for nocturnal incontinence. • Recently, his GP receives a phone-call from the local pharmacist reporting that Dashen’s repeats are not being picked up regularly. • The GP is concerned that Dashen may not be taking his medicines and/or using them correctly. He talks to Dashen and suggests a Home Medicines Review.

13. Questions • 6. Based on the information you have, what initial problems have you identified that suggest Dashen may benefit from a Home Medicines Review (HMR)?

14. Case Scenario cont’d • At the GP’s request, an accredited pharmacist visits Dashen’s home. • The pharmacist finds a variety of opened and unopened medications. On questioning, Dashen says that he has difficulty remembering when to take his medications and is not quite sure what his medications are for. • Dashen’s wife usually helps with his tablets but has recently been unwell herself. He crushes some of his medications as he has problems swallowing. • Dashen is often confused during the interview and is unsure whether he sometimes has indigestion or chest pain. He usually uses Gaviscon liquid for indigestion but says that it hasn’t been very helpful. When Dashen leaves the room to get the amitryptiline, his wife says he has got much worse, “wandering more”, saying “odd things” and sometimes gets very angry.

15. Questions • 7. Discuss an HMR Management Plan in light of the above findings.

16. Questions • 8. Would you consider prescribing an antipsychotic?

17. Evaluation Forms Thank You!