pharmacology

  // Alzheimer’s Disease

Alzheimer’s Disease 76-year-old Iranian Male

 

Decision Point One Begin Razadyne (galantamine) 4 mg orally BID

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• The client is accompanied by his son who reports that his father is “no better” from this medication
• He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
• You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Decision Point Two

Select what you should do next:

Increase Razadyne to 24 mg extended release daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated
• You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation

Decision Point Three

Select what you should do next:

Restart Razadyne extended release 24 mg

Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Begin Risperdal (risperidone) 0.5 mg orally BID to treat agitation

Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Assess for pain

Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Discontinue Razadyne and begin Aricept (donepezil) 10 mg orally daily

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• The client is accompanied by his son for today’s appointment who informs you that he stopped giving his father the mew medication because after just a few doses, his father began experiencing appetite loss, followed by nausea, diarrhea, and vomiting

Decision Point Three

Select what you should do next:

Restart Aricept at 5 mg orally daily at BEDTIME

Guidance to Student

The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.

The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Discontinue Aricept and restart Razadyne at 4 mg orally BID

Guidance to Student

The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.

The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Restart Aricept at 10 mg orally at BEDTIME and educate client and son about side effects of Aricept

Guidance to Student

The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.

The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Discontinue Razadyne and begin Exelon (rivastigmine) 1.5 mg orally BID

RESULTS OF DECISION POINT TWO

• Client returns to clinic in four weeks
• Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
• He states that his father is still not interested in attending religious services with the family, and he is still concerned that his father is still easily amused by things he once found serious

Decision Point Three

Select what you should do next:

Increase Exelon to 3 mg orally BID

Guidance to Student

Cholinesterase inhibitors can take months to demonstrate any stabilization in the degenerative course of Alzheimer’s disease. Since the client has had no side effects, it would be prudent to consider increasing the Exelon dose to 3 mg orally BID. Recall that the target dose of Exelon is 12 mg orally daily in divided doses, or a transdermal patch delivering 9.5 mg daily could be used. Slow titration of the drug toward a therapeutic dose will decrease the risk of side effects. These should be teaching points directed toward the client and his son.

You could maintain the current dose of Exelon and reevaluate at the next office visit, but since the client is having no side effects and the client has been on the current dose for at least 4 weeks, it would probably be advisable to increase at this time to facilitate the goal of arriving at a therapeutic dose of the medication.

It may be early to augment with Namenda. Maximization of the Exelon dose should first occur, then augmentation with an NMDA receptor antagonist would be appropriate, but Namenda should be started at 5 mg orally daily, and then titrated up to a maximum dose of 10 mg orally BID. Doses over 5 mg orally daily should be divided into two doses, or the drug can be switch to an extended release preparation.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Continue current dose of Exelon and reevaluate at next office visit

Guidance to Student

Cholinesterase inhibitors can take months to demonstrate any stabilization in the degenerative course of Alzheimer’s disease. Since the client has had no side effects, it would be prudent to consider increasing the Exelon dose to 3 mg orally BID. Recall that the target dose of Exelon is 12 mg orally daily in divided doses, or a transdermal patch delivering 9.5 mg daily could be used. Slow titration of the drug toward a therapeutic dose will decrease the risk of side effects. These should be teaching points directed toward the client and his son.

You could maintain the current dose of Exelon and reevaluate at the next office visit, but since the client is having no side effects and the client has been on the current dose for at least 4 weeks, it would probably be advisable to increase at this time to facilitate the goal of arriving at a therapeutic dose of the medication.

It may be early to augment with Namenda. Maximization of the Exelon dose should first occur, then augmentation with an NMDA receptor antagonist would be appropriate, but Namenda should be started at 5 mg orally daily, and then titrated up to a maximum dose of 10 mg orally BID. Doses over 5 mg orally daily should be divided into two doses, or the drug can be switch to an extended release preparation.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over

Augment with Namenda 10 mg orally at BEDTIME

Guidance to Student

Cholinesterase inhibitors can take months to demonstrate any stabilization in the degenerative course of Alzheimer’s disease. Since the client has had no side effects, it would be prudent to consider increasing the Exelon dose to 3 mg orally BID. Recall that the target dose of Exelon is 12 mg orally daily in divided doses, or a transdermal patch delivering 9.5 mg daily could be used. Slow titration of the drug toward a therapeutic dose will decrease the risk of side effects. These should be teaching points directed toward the client and his son.

You could maintain the current dose of Exelon and reevaluate at the next office visit, but since the client is having no side effects and the client has been on the current dose for at least 4 weeks, it would probably be advisable to increase at this time to facilitate the goal of arriving at a therapeutic dose of the medication.

It may be early to augment with Namenda. Maximization of the Exelon dose should first occur, then augmentation with an NMDA receptor antagonist would be appropriate, but Namenda should be started at 5 mg orally daily, and then titrated up to a maximum dose of 10 mg orally BID. Doses over 5 mg orally daily should be divided into two doses, or the drug can be switch to an extended release preparation.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Start Over