Alzheimer Disease [Print]   eMedicine Neurology
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Alzheimer Disease [Print] eMedicine Neurology


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Precaut io ns
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Pre gnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Pre caut ions
Administer with large meals to minimize adverse effects; titrate up slowly
Rivast igmine t ransdermal pat ch (Exelo n pat ch)
Competitive and reversible acetylcholinesterase inhibitor. While mechanism of action unknown, may reversibly inhibit cholinesterase, which may, in turn, increase
concentrations of acetylcholine available for synaptic transmission in CNS and thereby enhance cholinergic function. Effect may lessen as disease process advances
and fewer cholinergic neurons remain functionally intact.
Available as 5-cm2 patch containing 9 mg (releases 4.6 mg/24 h) and 10-cm2 patch containing 18 mg (releases 9.5 mg/24 h). Indicated for dementia of Alzheimer
disease and for dementia associated with Parkinson disease.
Do sing
Adult
Apply patch to upper or lower back, upper arm, or chest
Initiating patch therapy (not switching from oral therapy): 4.6 mg/24 h patch (5 cm2) applied qd initially; if well tolerated and after minimum of 4 wk, increase to 9.5
mg/24 h patch (10 cm2) applied qd
Switching from oral administration to patch therapy:
Apply first patch on day following last oral dose
Total daily oral dose <6 mg/d: Switch to 4.6 mg/24 h patch
Total daily oral dose 6-12 mg/d: Switch to 9.5 mg/24 h patch
Pe diat ric
Not indicated
Int eract io ns
May reduce effects of anticholinergics; increases effects of cholinergic agonists and neuromuscular blockers; risk of bradycardia increases when administered
concurrently with beta-blockers without ISA, the calcium channel blockers diltiazem or verapamil, and digoxin
Co nt raindicat io ns
Documented hypersensitivity
Precaut io ns
Pre gnancy
 PDFmyURL.com
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Pre caut ions
Apply patch to clean, dry, and hairless area of back, upper arm, or chest; area where patch is applied must be free of powder, oil, moisturizer, lotion, or other
substances that would keep patch from adhering properly to skin; also, apply to areas free of cuts, rashes, or other irritation; may cause significant nausea, vomiting,
anorexia, and weight loss if taken in doses higher than recommended; if significant adverse effects occur, patient should discontinue treatment for several doses, then
restart at lowest dose; extrapyramidal symptoms may occur or be exacerbated (especially tremor); caution in history of peptic ulcer disease, sick sinus syndrome,
urinary obstruction, pulmonary conditions (eg, COPD, asthma), and bradycardia or supraventricular conduction conditions
Galant amine (Razadyne, Razadyne ER)
Enhances central cholinergic function; likely to inhibit AChE.
Do sing
Adult
IR: 16-24 mg/d PO divided bid
ER: 16-24 mg PO qd
Pe diat ric
Not established
Int eract io ns
Can interfere with effect of anticholinergics; synergistic effect if given with other ChEIs, succinylcholine, or other neuromuscular blocking agents
Co nt raindicat io ns
Documented hypersensitivity
Precaut io ns
Pre gnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Pre caut ions
Most frequent adverse events are nausea, vomiting, diarrhea, anorexia, and weight loss; dose titration needed in patients with hepatic and/or renal dysfunction; can
cause bladder outflow obstruction; prescribe with care in patients with lung disease; could potentiate tendency for seizures
Nutrit ional supplement
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Approval for caprylidene was based on a double-blind, randomized, placebo-controlled, 90-day study that enrolled 152 patients with mild- to-moderate Alzheimer
disease in the United States.[29 ]At day 45, ADAS-Cog scores stabilized in the caprylidene group; whereas, a decline in cognition was observed in the placebo group.
The point difference in ADAS-Cog change from baseline scores at day 45 between groups was 1.91 (P =0.024). The point difference in ADAS-Cog change from
baseline scores at day 90 between groups was 1.54 (P =0.0767).
The ADAS-Cog change from baseline score was also analyzed in subgroups of patients based on APOE4 genotype. The APOE4(- ) patients receiving caprylidene
showed improved cognitive function when compared with APOE4(- ) patients receiving placebo. The point difference in change from baseline ADAS-Cog scores for
APOE4(- ) patients receiving either caprylidene or placebo at day 45 was 4.77 (P <0.0005), and was 3.36 at day 90 (P =0.015). In APOE4(+) patients, the mean
change in ADAS-Cog total scores for the 2 groups was essentially identical at all time points, with more patients showing decline rather than improvement at days 45
and 90.
Caprylidene (Axo na)
Prescription medical food that is metabolized into ketone bodies. The brain can use these ketone bodies for energy when its ability to process glucose is impaired.
Brain- imaging scans of older adults and persons with Alzheimer disease reveal dramatically decreased uptake of glucose. Indicated for clinical dietary management
of metabolic processes associated with mild- to-moderate Alzheimer disease. Available as oral powder (40 g/packet; contains 20 g medium-chain triglycerides).
Do sing
Adult
40 g (1 packet) PO qd at breakfast
Mix contents of each packet with 4-8 oz of water; shake until fully blended and drink immediately
Reconstituted product may be refrigerated for up to 24 h, then reblended and thoroughly mixed before consumption
If adverse GI effects occur, may temporarily give simethicone, antacids, or antidiarrheal agents
For persistent GI symptoms, decrease dose to half a packet qd until adverse effects resolve, then resume taking full packet
Pe diat ric
Not indicated
Int eract io ns
None reported
Co nt raindicat io ns
Allergy to milk or soy (contains caseinate, whey, and lecithin)
Precaut io ns
Pre gnancy
 PDFmyURL.com
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Pre caut ions
Caution with hypersensitivity to palm or coconut oil; caution in patients at risk for ketoacidosis (eg, alcoholism, poorly controlled diabetes) or history of GI inflammatory
conditions (eg, IBS, diverticulitis, chronic gastritis, GERD); may increase triglyceride, BUN, uric acid, or serum creatinine levels; adverse effects observed in clinical
trials include diarrhea, flatulence, dyspepsia, dizz iness, and headache
Follow-up
Deterrence/Prevention
Although previous reports reflect delayed onset of Alzheimer disease (AD) in individuals who used nonsteroidal anti- inflammatory drugs (NSAIDs), a study by Breitner
et al showed NSAIDs do not protect against AD, at least in very old people. Relying on computerized pharmacy dispensing records and biennial dementia screening,
investigators found Alzheimer disease incidence was increased in heavy NSAID users. These findings may represent deferral of Alzheimer disease symptoms from
earlier to later old age.[30 ]
Increased cardiorespiratory fitness levels are associated with higher hippocampal volumes in patients with mild Alzheimer disease, suggesting that cardiorespiratory
fitness may modify Alzheimer disease- related brain atrophy.[23 ]
Patient Education
For excellent patient education resources, visit eMedicine's Dementia Center. Also, see eMedicine's patient education articles Alzheimer Disease, Alzheimer Disease
in Individuals With Down Syndrome, Dementia Overview, and Dementia Medication Overview.
Miscellaneous
Medicolegal Pitfalls
Patients with dementia, in general, and those with Alzheimer disease, in particular, usually have a progressive deterioration in their behavior, cognition, and
ability to perform activities of daily living.
These changes may result in patients making inappropriate