- Length: A minimum of 180 words per post, not including references
- Citations: At least one high-level scholarly reference in APA per post from within the last 5 years
Number 1 post: RO
In the week six discussion/case study, we discuss three different patients. Our first patient is Mrs. Williams, who has a diagnosis of mild dementia. With dementia, it is crucial to understand that there aren’t any medications to reverse this condition, but there are medications that can treat the symptoms of the disease itself (Blevins, 2018). As dementia progresses, behavioral disturbances such as psychosis and agitation can occur (Blevins, 2018). When working with families regarding treatment measures concerning dementia and the symptoms surrounding it, it is imperative to remember to utilize nonpharmacological interventions if possible (Blevins, 2018).
With medication related to dementia, there are two classes of this medication available for the treatment of this condition. These classes are cholinesterase inhibitors, or ChEls, which help in the treatment of mild to moderate dementia, and N-methyl-D-aspartate [NMDA] receptor antagonists, which are used to treat moderate to severe dementia (National Institute for Health and Care Excellence, 2018)). An example of a chEls is the medication donepezil (Wang et al., 2021). Donepezil is the generic name for this medication, while Aricept and Aricept ODT are examples of trade names for donepezil (Skidmore-Roth, 2022). This medication has side effects such as dizziness, insomnia, headache, fatigue, syncope, seizures, drowsiness, agitation, depression, confusion, hallucinations, nausea, vomiting, diarrhea, and urinary frequency (Skidmore-Roth, 2022). Prescribing donepezil with specific medications, such as ziprasidone, pimozide, probucol, and sparfloxacin can increase the patient’s risk of QT prolongation (Skidmore-Roth, 2022).
An example of medication from the NMDA class is memantine (National Institute for Health and Care Excellence, 2018). Memantine is the only licensed drug effective for treating moderate to severe dementia (National Institute for Health and Care Excellence, 2018). Memantine is the generic name for this medication, while some trade names are Namenda and Namenda XR (Skidmore-Roth, 2022). Some side effects of memantine include dizziness, confusion, headache, hypertension, anemia, rash, back pain, fatigue, etc. (Skidmore-Roth, 2022). It is essential to educate the patient-caregiver to monitor and report for increased restlessness, psychosis, visual hallucinations, stupor, or loss of consciousness (Skidmore-Roth, 2022). These specific side effects could indicate overdose (Skidmore-Roth, 2022).
As stated earlier, two behavioral disturbances associated with dementia progressing are psychosis and agitation. These behaviors are called behavioral and psychological symptoms of dementia, or BPSD (Wang et al., 2021. Medications that can treat BPSD are atypical neuroleptic drugs, selective serotonin reuptake inhibitors, benzodiazepines, and non-benzodiazepines (Wang et al., 2021). These medications have become the first-line treatment for the management of BPSD (Wang et al., 2021).
For the treatment of psychosis with dementia, a medication that can be used is pimavanserin (Marcinkowska et al., 2020). Pimavanserin is the generic name of this medication, while the trade name is Nuplazid (Skidmore-Roth, 2022). However, it is essential to monitor pimavanserin for at least six weeks when first starting this medication (Blevins, 2018). This is not only to observe that the medicine is therapeutic but also to ensure that the side effect of prolonged QT interval does not occur (Blevins, 2018).
With agitation, a medication that can be used for the treatment of this symptom is citalopram (Alzheimer’s Society, n.d). Citalopram is the generic name of this medication, while Celexa is the trade name (Skidmore-Roth, 2022). This should be given in lower doses, for higher doses can cause QT prolongation. It is recommended to be used to treat agitation that results from depression or anxiety (Alzheimer’s Society, n.d).
It is imperative to remember that antipsychotics have been discouraged in use for patients who have dementia, for these medications tend to increase the risk of death in said patients (Marcinkowska et al., 2020). This increase in death is related to the side effects of excessive sedation, cardiovascular complications, etc. (Marcinkowska et al., 2020). Antipsychotics should only be used if the benefits outweigh the risk and if the patient is a threat to themselves and others (Marcinkowska et al., 2020).
Our second patient, Mr. Lacy, was diagnosed with Parkinson’s disease about five years ago and recommended that he be treated with levodopa. Levodopa is an antiparkinsonian agent, a precursor to dopamine, a chemical that becomes depleted when a person has Parkinson’s disease (Skidmore-Roth, 2022). After it crosses the blood-brain barrier, levodopa is metabolized by striatal enzymes to dopamine (Skidmore-Roth, 2022). This medication’s side effects are involuntary choreiform movements, hand tremors, twitching, severe depression, orthostatic hypotension, leukopenia, agranulocytosis, thrombocytopenia, and hemolytic anemia (Skidmore-Roth, 2022).
Levodopa is commonly combined with the medication carbidopa, which helps enhance levodopa into converting dopamine in the brain (Parkinson’s Foundation, n.d). Carbidopa also helps with the side effect of nausea, which can occur if levodopa is taken alone (Parkinson’s Foundation, n.d). The carbidopa-levodopa combination has the trade name Sinemet or Sinemet CR (American Parkinson Disease Association, n.d). Some other medications that can be used for the treatment of Parkinson’s disease are pramipexole [Mirapex] and ropinirole [Requip] (American Parkinson’s Disease Association, n.d). Both of these medications are DA agonists, unlike carbidopa, which is a DOPA decarboxylase inhibitor (American Parkinson Disease Association, n.d).
Our third and final patient is a 50-year-old man who has been prescribed venlafaxine for depression after his wife passed. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor, otherwise known as SSRIs, and is different from tricyclic antidepressants or TCAs in many ways. SSRIs are more tolerated and safer than TCAs (Rosenthal & Burchum, 2021). TCAs, unlike SSRIs, have an adverse reaction to cardiac toxicity (Rosenthal & Burchum, 2021). It is important to note that overdosing on TCAs can be highly lethal (Rosenthal & Burchum, 2021).
Some adverse reactions to be expected with the patient taking venlafaxine are dizziness, weakness, headache, insomnia, anxiety, hypertension, chest pain, abnormal vision, ear pain, ecchymosis, photosensitivity, and others (Skidmore-Roth, 2022). When taking SSRIs, the provider should continually educated about the risk of serotonin syndrome and neuroleptic malignant syndrome (Skidmore-Roth, 2022). Side effects related to serotonin syndrome include but are not limited to an increase in heart rate, dilated pupils, tremors, elevated blood pressure, headache, and confusion (Skidmore-Roth, 2022 ). If these occur, it is imperative to stop the product and then administer a serotonin antagonist if it is needed (Skidmore-Roth, 2022 ).
Number 2 Post: AF
For a 75-year-old newly diagnosed with dementia we have two medications that can be considered for treatment. There are no medications that cure dementia/Alzheimer’s however there are medications that can slow the progress and help with some of the physical manifestation so dementia. One medication, generic name donepezil, brand name Aricept is an acetylcholinesterase inhibitor. Acetylcholinesterase is an enzyme that degrades acetylcholine is an enzyme that degrades acetylcholine after release from the pre-synapsis. Donepezil binds to acetylcholinesterase and increases the availability of acetylcholine at the synapsis. Aricept is not recommended for patients diagnosed with frontotemporal lobe dementia (Alzheimer’s Association, 2022). The initial dose should be started at 5mg per day and can be increased to 10mg over the next 4-6 weeks. Some side effects of Aricept can cause bradycardia and heart block in persons with underlying cardiac conduction related to vagotonic properties along with other less common cardiac related effects such as hypertension, hypotension and hypertension. Aricept has been known to cause nightmares, sleep disturbances so it is suggested one takes it in the morning. Some other side effects are weight loss, diarrhea, nausea vomiting, nervousness and mood/behavior changes (Kumar et al., 2021).
A second drug class and medication used to treat dementia is memantine, brand name Namenda. Namenda blocks the N-methyl-d asparte (NMDA) receptors (Pub Med, 2022). We would start a patient off on 5mg a day and increase as needed over time. Some side affects include constipation, dizziness, headache and confusion (Alzheimer’s Association, 2022).
Some behavioral presentations with dementia would be agitation/aggression related to paranoia and apathy/depression. The behavioral issues related to dementia can be treated non-pharmacologically or pharmacologically. Some medication classes used to help treat these behavioral issues could be sedatives and antidepressants. Sertraline, brand name Zoloft, is an antidepressant that has been found to be helpful with depressive disorders in dementia patients. Gabapentin, brand name Neurontin, has shown some promise as a mood stabilizer in dementia patients. Benzodiazepines can help with agitation however are linked to increased falls in elders and can cause the opposite desired effects that manifest as extrapyramidal effects (Madhusoodanan, 2014).
For a patient with Parkinson’s disease (PD), a provider will most likely proscribe levodopa. Levodopa works by converting dopamine in the brain. Carbidopa is a medication that is often combined with levodopa to make Carbidopa-Levodopa. Carbidopa is a class of medication that is a decarboxylase inhibitor and works by preventing Levodopa from being broken down before it reaches the brain. This prevents less nausea and vomiting effects associated with Levodopa (UNLM, 2022). Pramipexole is another medication used to treat PD. Pramipexole belongs to a class of medications called dopamine agonist and works in the place of dopamine which is the body’s natural chemical that helps the brain to control movement (UNLM, 2022).
For a 50-year-old man that is diagnosed with depression and prescribed venlafaxine, brand name Effexor. Venlafaxine is an inhibitor neuronal serotonin and norepinephrine reuptake and a weak inhibitor of dopamine reuptake however, the dual reuptake action of venlafaxine helps with the efficacy in treatment of depression in more patients than other tricyclic antidepressants (RL, 2022).