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Best Practice Pharmacy Dementia care

Best Practice Pharmacy Dementia care. Dr Kreshnik Hoti BPharm, MPS, AACPA, PhD. Learning outcomes. Develop and understanding on medications used in dementia Identify medications that can worsen cognition

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Best Practice Pharmacy Dementia care

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  1. Best Practice Pharmacy Dementia care Dr Kreshnik Hoti BPharm, MPS, AACPA, PhD

  2. Learning outcomes • Develop and understanding on medications used in dementia • Identify medications that can worsen cognition • Develop an understanding on medication related monitoring needs and outcomes in patients with dementia • Develop an understanding on pharmacists’ role in Dementia care

  3. What is dementia? • Latin word ‘demens’ • Broad term • Symptoms descriptive of a range of conditions • Brain function impairment • Language, memory, perception, personality and cognitive skills • >65 years of age, likelihood doubles in 5 year intervals

  4. Definition (WHO) “a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not clouded.The impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. This syndrome occurs in Alzheimer’s disease, in cerebrovascular disease, and in other conditions primarily or secondarily affecting the brain”

  5. Early signs • Ability to learn and remember new information • Difficulties with tasks which are familiar Progression • More basic activities affected • Higher mental function impairment progress over months to years 

  6. Cognitive, psychiatric and behavioural symptoms • memory problems • communication difficulties • confusion, wandering, getting lost • personality changes and behaviour changes such as agitation, repetition, following • depression, delusions, apathy and withdrawal

  7. Dementia – national figures 3rd leading cause of death 1600 new cases weekly 280.000 Australians Worldwide cost: US$604 billion in 2010 Source: Alzheimer’s Australia

  8. Source: Alzheimer’s disease international; World Alzheimer’s report 2010. The global economic impact of dementia

  9. Dementia major contributor to disability Source: World Health Organization. World Health Report 2003—Shaping the future. Geneva: WHO, 2003.

  10. Dementia predictions • 35.6 million worldwide • 4.6 million cases every year • People affected double every 20 years • 81.1 million people affected by 2040

  11. Dementia predictions cont’d Ferri et al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–17

  12. Dementia – causes 62% (Alzheimer’s disease) 17% (vascular dementia) 10% (mixed dementia) 4%(lewy bodies) 3% (other) 2% (fronto- temporal)

  13. Dementia – causes • Alzheimer’s disease causes: • Biological • Genetics • Inflammation

  14. Risk factors • Modifiable: • Obesity • Smoking • Physical activity and exercise • Alcohol • Cognitive reserve • *head injury

  15. Risk factors • Treatable medical conditions: • stroke • diabetes • midlife hypertension • midlife hypercholesterolemia • hyperhomocysteinaemia • depression (?)

  16. Risk factors • Non-Modifiable: • age • family history • small head size • male gender

  17. Treatment • Patients and family involvement as soon as diagnosis is made • Support for daily activities • Address co-existing medical conditions • Avoid medications exacerbating cognitive function • Treat Vitamin B12 or folate deficiency if present

  18. Treatment • No cure • None of the available drugs prevent Alzheimer’s or modifies its pathology • Symptoms such as memory loss and confusion may be reduced (for a limited time) • Acetylcholinesteraseinhibitors& memantine • Combination

  19. Treatment - Acetylcholinesteraseinhibitors • Donepezil • Galantamine • Rivastigmine • Decrease the breakdown of acetylcholine and therefore reduce the deficiency of cholinergic neurotransmitter activity • First line agents

  20. Treatment - Acetylcholinesteraseinhibitors • 25-50% of patients experience delayed deterioration of cognition by 6 months • 12-20% of patients by 1 year • Benefits in cognition, function and global outcomes (MMSE gain 1.5-2 points) • Benefits assessed after 3 months

  21. Acetylcholinesterase inhibitors-ADVERSE EFFECTS • Incidence related to dose • Use in some patients is limited by adverse effects, especially gastrointestinal • Common: nausea, vomiting, loss of appetite, diarrhoea • Commonly increase bladder and bowel urgency and contribute to incontinence

  22. Treatment - memantine • AD associated with excess glutamate, therefore memantine reduces glutamate-induced neuronal degradation • Specialist initiated • Moderate to severe AD • Benefits in cognition, function, global outcome • Common adverse effects: Headache, constipation, confusion and dizziness

  23. Treatment summary

  24. Pharmaceutical Benefits Scheme implications • Acetylcholinesterase inhibitors and memantine require authority approval • Donepezil example: • INITIAL APPLICATION FOR THE TREATMENT OF MILD TO MODERATELY SEVERE ALZHEIMER'S DISEASE - Patients with an (S)MMSE of 10 or more • Confirmation of diagnosis must be made by or in consultation with a specialist/consultant physician (including a psychiatrist). • To continue treatment: patient demonstrated improvement in cognitive function

  25. Vitamins and supplements Do they help? Vitamin E Ginkgo Biloba Aspirin Brahmi • B vitamins • Omega 3 • Mediterranean diet

  26. Other agents • Statins • Testosterone • Oestrogen • Anti-inflammatory agents • Selegiline • Future therapies

  27. Medications negatively affecting dementia

  28. Medications negatively affecting dementia • Anticholinergic Cognitive Burden (ACB) • Score 1-3 • Definite anticholinergics score 2&3 • Every definite anticholinergic increases the risk of cognitive impairment by 46% over 6 years • 1 point increase in ACB score = 0.33 decline in MMSE over 2 yrs • Antipsychotics • Sedatives • Tricyclic antidepressants

  29. Behavioural and psychological symptoms in dementia (BPSD) • Challenging & distressing • Causes: • Brain cells progressively deteriorate • Environmental • Medications

  30. BPSD Later stages: aggression agitation emotional distress hallucinations outbursts delusion sleep disturbances restlessness • Early stages: • irritability • anxiety • depression

  31. BPSD Review/Treat potential underlying causes: • Possible physical causes of distress or delirium • Pain, dehydration, LUTS, infection… • Medications which impair cognition • Environmental factors • Depression

  32. BPSD treatment • Non-drug options – first line • Antipsychotics (hallucinations, delusions or seriously disturbed behaviour) • Mood stabilizers such as carbamazepine or valproate • Antidepressants • Acetylcholinesterase inhibitors or memantine • Anxiety and agitation (oxazepam for no longer than 2 weeks)

  33. Antipsychotics – considerations: • Risperidone approved for BPSD • Recommended for use when symptoms cause severe distress or immediate risk of harm • Monitor if behaviour improved and adverse effects tolerated • Therapy reviewed every three months • Many troublesome symptoms do not respond • BPSD often resolves spontaneously within 12 weeks • Antipsychotics increase the risk of death in BPSD patients

  34. Pharmacists’ role • Refer patients with suspected cognitive impairment • Early diagnosis • Patient & family counselling and education • Promotion of risk reduction strategies

  35. Pharmacists’ role • Source of information • Patient, • Family, • Health professionals • Monitoring drug interactions • Monitoring drug contraindications • Monitor medication compliance

  36. Pharmacists’ role • Dose administration aids • Medication reviews • Medication usage reviews • Home medication reviews • Identifying medications contributing/exacerbating cognitive decline • Quality use of medicines

  37. References • Australian Medicines Handbook 2012 • eTherapeutic Guidelines, Neurology • Alzheimer’s Australia; http://www.fightdementia.org.au • Alzheimer’s Association; www.alz.org • Ballard et al. Alzheimer’s disease. Lancet 2011; 377: 1019–31 • Ferriet al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–17 • Alzheimer’s disease international; World Alzheimer’s report 2010. The global economic impact of dementia • World Health Organization. World Health Report 2003—Shaping the future. Geneva: WHO, 2003. • McCullagh CD et al. Risk factors for dementia. Advances in Psychiatric Treatment 2001; 7:24–31 • Australian Institute of Health and Welfare 2007. Dementia in Australia. National data analysis and development • Archer et al. The effects of commonly prescribed drugs in patients with Alzheimer’s disease on the rate of deterioration. J Neurol Neurosurg Psychiatry 2007;78:233–239. • The Aging Brain Program at the IU Center for Aging Research. Anticholinergic Cognitive Burden List (ACB). 4/4/12 • Campbell N, Boustani M, Limbil T, Ott C, et al. The cognitive impact of anticholinergics: a clinical review. Clinical Interventions in Aging. 2009;4(1):225-33

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