This document summarizes a presentation on the effectiveness and use of cholinesterase inhibitors in dementia. It discusses the three main cholinesterase inhibitors available in Canada - donepezil, rivastigmine, and galantamine - and provides details on their mechanisms of action, dosing, efficacy evidence, and guidelines for use. It also covers topics like optimizing therapy through adherence and expectations counseling, switching or discontinuing treatment, and situations where cholinesterase inhibitors should not be used, such as in mild cognitive impairment. The overall message is that cholinesterase inhibitors provide modest cognitive and functional benefits for mild to moderate Alzheimer's disease but each patient may respond differently based on tolerability and other factors.
Recomendaciones de Choosing Wisely para evitar intervenciones innecesarias en adultos mayores.
Fuente: http://www.americangeriatrics.org/files/documents/choosing_wisely_list2.pdf
Tackling the inappropriate use of psycho-active medication in ScotlandAlzheimer Scotland
Dr Stella Clark, Medical Director,
Primary Care, NHS Fife; Clinical lead for Mental Health Services, NHS 24
Presentation from Alzheimer Scotland conference 2011 - Creating Better Dementia Care.
Safety Considerations in the use of Psychotropic Medication in Children and T...Stephen Grcevich, MD
This presentation for the medical staff of Child and Adolescent Behavioral Health in Canton, OH is an introduction to basic safety concerns and monitoring associated with the use of psychotropics in children and teens. The presentation was tailored to newly graduated advanced practice nurses.
Providing quality pediatric pain management during end of life carecassidydanielle
Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.
Parent Education
Parent Coaching
Parent Learning Center
Back to Topics
To Medicate or Not [presentation]
The following presentation by Children’s Health Council Chief Psychiatrist and Medical Director Glen Elliott, Ph.D, M.D., explores treatment options for ADHD.
Karen Elta Anderson, MD, prepared useful practice aids pertaining to tardive dyskinesia for this CME activity titled "Finding the Path to Improved Recognition and Management of Tardive Dyskinesia." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/37MqcXB. CME credit will be available until September 27, 2021.
Recomendaciones de Choosing Wisely para evitar intervenciones innecesarias en adultos mayores.
Fuente: http://www.americangeriatrics.org/files/documents/choosing_wisely_list2.pdf
Tackling the inappropriate use of psycho-active medication in ScotlandAlzheimer Scotland
Dr Stella Clark, Medical Director,
Primary Care, NHS Fife; Clinical lead for Mental Health Services, NHS 24
Presentation from Alzheimer Scotland conference 2011 - Creating Better Dementia Care.
Safety Considerations in the use of Psychotropic Medication in Children and T...Stephen Grcevich, MD
This presentation for the medical staff of Child and Adolescent Behavioral Health in Canton, OH is an introduction to basic safety concerns and monitoring associated with the use of psychotropics in children and teens. The presentation was tailored to newly graduated advanced practice nurses.
Providing quality pediatric pain management during end of life carecassidydanielle
Author: Danielle Cassidy, PharmD, BCPS
Audience: continuing education for hospice nurses
Background: describes common developmentally appropriate tools for assessing pain in children, general principles of pediatric pharmacology, common pharmacological interventions, side effects commonly associated with opioid medications & side effect management strategies.
Parent Education
Parent Coaching
Parent Learning Center
Back to Topics
To Medicate or Not [presentation]
The following presentation by Children’s Health Council Chief Psychiatrist and Medical Director Glen Elliott, Ph.D, M.D., explores treatment options for ADHD.
Karen Elta Anderson, MD, prepared useful practice aids pertaining to tardive dyskinesia for this CME activity titled "Finding the Path to Improved Recognition and Management of Tardive Dyskinesia." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/37MqcXB. CME credit will be available until September 27, 2021.
الطّباعة ثلاثيّة الأبعاد هي إحدى تقنيات التصنيع، حيث يتم تصنيع القطع عن طريق تقسيم التصاميم ثلاثية الأبعاد لها إلى طبقات صغيرة جدا باستخدام برامج الحاسوبية ومن ثم يتم تصنيعها باستخدام الطابعات ثلاثية الأبعاد عن طريق طباعة طبقة فوق الأخرى حتى يتكون الشكل النهائي.
تعريف الاقتصاد الرقمي
يعرف الاقتصاد الرقمي بأنه هو النشاط الناتج عن الاتصالات اليومية عبر الإنترنت، كما أن العمود الفقري له هو الارتباط التشعبي، ويعني تزايد الارتباط والترابط بين الأشخاص والمؤسسات والآلات، وتكنولوجيا الهاتف المحمول وإنترنت الأشياء. وهو عموما عبارة عن تصور لقطاع الأنشطة الاقتصادية ذات الصلة بالتقنية الرقمية. وتكون هذه الأنشطة مبنية على النماذج الاقتصادية الكلاسيكية أو الحديثة مثل نماذج الويب
التهديد المستمر المتقدم (Advanced persistent threat): هو مصطلح واسع يستخدم لوصف عملية هجوم يقوم فيها دخيل أو فريق من المتسللين بإنشاء وجود غير قانوني طويل الأمد على الشبكة من أجل استخراج البيانات شديدة الحساسية.
NICM HRI Seminar 2020: A heart healthy diet is good for the brain tooNatalie Connor
20 JULY 2020: NICM Health Research Institute presents guest seminar speaker, Professor Karen Charlton, Advanced Practising Dietitian at the Smart Foods Centre, School of Medicine, University of Wollongong.
Professor Charlton's presentation, 'A heart healthy diet is good for the brain too' explores her latest research and promising evidence that foods rich in anthocyanins (compounds that provide deep red, purple and blue pigmentation in foods) may help prevent further cognitive decline in people with mild-to-moderate dementia.
Evidence based treatment approaches for prevention of dementiaRavi Soni
This presentation reviews all the available treatment which have been used for prevention of dementia. The evidences were taken from the Cochrane reviews and library.
Basic rules of geriatric psychpharmacologyIhab M Saleh
1- Who are Geriatrics?
2- Why are they considered a specific group?
3- Pharmacokinetic and Pharmacodynamic changes in Geriatrics
4- Changes of the aged brain.
5- Psychiatric drugs using in Geriatrics in:
- Depression and Anxiety
- Mania
- Schizophrenia and Psychosis
- Mild cognitive impairment and Dementia
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
MS refresher for nurses. Teaching session for Bedford CCGs Modern matrons on Multiple Sclerosis. Incidene, Prevalence, diagnoses, symptom management and treatment of MS.
May 2015
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
1. Effectiveness & Use of
Cholinesterase Inhibitors in
Dementia
Dr. Donna Kay Buna, Pharm D
Dr. Dean Foti, MD, FRCP(C)
February 22, 2012
Some graphs are not included in this handout
because of copyright
3. Disclosures for Dr. Dean Foti
• Honoraria for speaking
engagements
• Consultant for Canadian
Advisory Boards
• No stock or financial
interests
• Novartis Canada
• Pfizer Canada
4. Learning Objectives
• Role of medications in management of Mild
Cognitive Impairment (MCI) and dementia
• Understand when initiation,
discontinuation, or switching of
cholinesterase inhibitors is appropriate
5. Outline
•
•
•
•
Overview of the drugs, benefits, expectations
Optimizing therapy
Counseling Points
Stopping, switching and when to avoid using
them
• Lots of time for questions!
6. The prevalence of dementia will triple by 2031!
Chertkow H. Diagnosis & treatment of dementia: Introduction. CMAJ
2008;178(3):316.
dkbuna 2010
8. Mechanism of
Action
Cholinesterase
Inhibitors
Adapted Figure 1.Beyond the Cholinergic Hypothesis: Do Current Drugs
Work in AD? CNS Neuroscience & Therapeutics 2010;16:235-245.
ChAT=choline acetyltransferase
Ach=acetylcholine
AChE=acetylcholinesterase
VAChT= vesicles of ChAT
nα7AChR= nicotinic Ach receptor
M1AChR= muscarinic receptor
HACU= high affinity choline transporter
AChEI=acetylcholinesterase inhibitor
9. Donepezil
5 & 10mg regular tablets
5 & 10mg rapidly disintegrating tablets
• First CHEI on the market – August 1997
• Indicated for mild, moderate and severe AD
• Starting dose 2.5-5mg and titrate up to maximum of 10mg
daily
• Extensively metabolized to 4 metabolites; 2 active; minor
substrates for Cytochrome P450 – 2D6 & 3A4 – not
usually clinically significant drug interactions.
• No dose adjustments necessary in hepatic or renal
dysfunction
• Best tolerated of the 3 available
10. Rivastigmine
1.5, 3, 4.5 and 6mg
capsules
2mg/ml solution
Also available generically –
PMS, Ratio, Sandoz, Teva
Approved in Canada since ~ 2000
Inhibits both ACHE and BuCHE-”pseudo-irreversible”
Indicated for mild to mod AD and mild to mod Parkinson’s
dementia
Start 1.5mg twice daily, increase by 3mg/day q4 weeks to MAX
of 12mg/day
Minimally involved in cytochrome P450 systems , so reduced
risk of drug interactions
No dose adjustment in renal or hepatic disease
11. • Exelon 5 – 5 cm2 patch
contains 9mg base – release
4.6mg/ 24 hours
• Exelon 10 – 10 cm2 patch
contains 18mg base –
releases 9.5mg/24 hours
Introduced in 2007
Indicated for mild to mod AD
Improved tolerability over oral formulation- 3x
fewer reports N/V IDEAL Study*
Health Canada warning April 2010
*IDEAL. Int J Geriatr Psych
2007;22:456-67.
12.
13. • Galantamine
• 8, 16, 24mg ER
tablets
• Generic - Patriot
Introduced in 2001, indicated for mild-mod AD
Unique dual mechanism-reversible competitor inhibitor ACHE AND
allosteric modulator of nicotinic receptor
Start with 8mg ER daily and titrate up to 8mg to MAX 24mg/day
Extensively metabolized by cytochrome P450 – 2D6 and 3A4 to
metabolites of low activity
Hepatic insufficiency; Max dose 16mg/day in mod disease (C-P 7-0)
and not recommended in severe disease (C-P 10-15)
Renal insufficiency: Max dose 16mg/day in mod disease; not
recommended in severe disease (CrCL < 10 mL/min)
14. Canadian Dementia Guidelines 2007
14.Recommendations regarding the use of
cholinesterase inhibitors
a) All three cholinesterase inhibitors available
in Canada are modestly efficacious for mild
to moderate AD. They are all viable
treatment option for most patients with mild
to moderate AD. (Grade A, Level I)
16. Mod-Severe AD: Donepezil v. Placebo
Activities of Daily Living
Donepeziln=134
Placebo n=140
125
129
121
126
(134)
(140)
Feldman et al 2000
17. Galantamine Reduces Caregiver Time
by One Hour per Day in Mild-Mod AD
30
*
20
Change From
Baseline in
Daily Time
Spent
Assisting With
ADL (min)
10
0
–10
–20
–30
–40
–50
*P < .05 vs baseline.
Sano M, Wilcock GK et al., Int J Ger Psy, 2003:942-50.
18. Initiating Cholinesterase Therapy:
It’s all about expectations
•
•
•
•
20 % will improve noticeably
50 % will remain unchanged
20 % will continue to worsen
10-15 % are intolerant
Expect the majority to remain unchanged
19. ChEI’s: Use Across Dementias
• Mild - Moderate AD
• Moderate - Severe AD
• Dementia with Lewy Bodies &
Parkinson Disease Dementia
• Vascular/Mixed Dementia
20. Which ChEI to use for
mild-moderate AD?
• All equal efficacy
• Ask patient and family: Pill or Patch?
• Influences:
– Familiarity
– Cost
– Side effect profile
21. Optimizing Therapy
• Early vs Late start
• Hi dose vs low dose
• Low dose start with high dose
“rescue” later
• Adherence
• Counseling – set expectations; ensure
adherence
22. Early VS Late Treatment
“Defining optimal treatment”. Alzheimer’s & Dementia
2011;7:177-184.
23. High Dose vs Low Dose
“Defining optimal treatment”. Alzheimer’s & Dementia
2011;7:177-184
24. Lower dose Start with “Rescue” Later
“Defining optimal treatment”. Alzheimer’s & Dementia
2011;7:177-184
25. Compliance/Adherence
• Average treatment duration 4-5 months
• Susceptible to poor compliance – age,
comorbidities, memory deficits, pill
burden
• Educate patient/family/caregiversestablish expectations
• Ensure a follow-up plan
26. Counseling Point
Symptomatic, not curative
Higher
Function
Outcome
Can delay progression
Time
Symptomatic
No Treatment
Lower
Function
dkbuna 2010
27. Counseling point
Some respond, some don’t
Responder
Non-Responder
(Continued
worsening)
25%
25%
50%
Average response
= mild improvement
or same for 1 year
(Brain Cancer)
Super Responder
(Much better)
dkbuna 2010
Dalziel B. Dementia Newsletter for Physicians 2008; 6(4):3-4.
28. Counseling Point
How do you know if it is working?
• What target symptoms are important to
the patient & their family?
– A- ADL, functional measure
– B-behavioral
– C-cognitive
• Document at baseline
• Persist for the duration to realize long
term benefits.
dkbuna 2010
29. Counseling Point
Watching for side effects
• Start low, titrate up if tolerated
• Visit physician at 4-6 weeks to assess
• Common side effects:
–
–
–
–
–
N/V, diarrhea
Anorexia with weight loss
Sleep disturbances
Muscle/leg cramps
Syncope/dizziness
dkbuna 2010
30. Counseling Point
6 month Follow-up
• Assess if it is working
• Compare to baseline
• Documentation required to continue
coverage
• Key components:
– FMMSE still between 10-26
– GDS still between 4 & 6
– Global assessment
dkbuna 2010
31. How long to continue
ChEI’s in Alzheimer Disease?
• No specific reason to discontinue if function &
behaviour reasonable
• NOT correct that only effective for 6-12 months
• Trial discontinuation not recommended
• Consider discontinuation when limited
contribution to self-care and interactions
33. Should you change ChEI’s?
• Generally not too helpful in gradually declining
patient on prolonged therapy
• Switch ChEI’s when:
– Intolerant due to side effects
– Significant early progression: ‘nonresponder’
– family strongly requests and is motivated
34. How to Switch ChEI’s
• Generally no wash out period required
when switching for declining patient
– Usual titration schedule for new medication
– When changing from high dose donepezil or
rivastigmine, start at galantamine ER 16mg
• Combining ChEI’s not recommended
• When switching for tolerability issues, wait
about one week for resolution of s/e’s
35. When not to use ChEIs?
• Normal Aging
• Mild Cognitive Impairment
• Frontal-temporal lobar dementias
(eg Pick’s disease)
36. MCI Definition
Mild Cognitive Impairment
•
•
•
•
•
Memory complaint
Objective memory impairment
Normal general cognitive function
Activities of daily living generally intact
Not demented
Petersen et al., Neurology, 2001
37. MCI Becoming Dementia
• MCI is a high risk state for future dementia
– 10 % per year over the first 5 years
• 30 % stay the same
• 20 % of MCI may revert to normal
38. Should MCI patients be treated
with cholinesterase inhibitors?
• Generally Not
• Clinical trials with all 3 ChEI’s negative
• …..but……
– Positive early results from donepezil MCI trial
– Some patients are very amnestic and have early
AD but do not meet the criteria for dementia
39. Summary
• ChEI’s have modest but significant
benefits in meaningful outcomes to
patients and families across a spectrum
of dementia severities and types
• Tolerability and formulation of ChEI’s
vary between patients – try different
ones