Patient Encounter Part 1

A woman arrives at the clinic with her 80-year-old mother, LB, complaining that her mother is becoming increasingly forgetful and confused with old age. The woman complains that her mother sometimes takes her diabetes and hypertension medications at a frequency greater than that prescribed. This has become more frequent in the last 6 months and the mother has been getting very agitated when her daughter confronts her. The woman asks for a pill organizer and if any of the over-the-counter drugs claiming to help with memory would help her mother.

What information is suggestive of AD?

Does the mother have any risk factors for AD?

How would you approach and address the daughter's question?

Table 35-4 Basic Principles in the Treatment of Patients With AD

• Using a gentle, calm approach to the patient

• Giving reassurance when needed

• Empathizing with the patient's concerns

• Using distraction and redirection

• Maintaining daily routines

• Providing a safe environment

• Providing daytime activities

• Avoiding overstimulation

• Using familiar decorative items in the living area

• Bringing abrupt declines in function and the appearance of new symptoms to professional attention

Conventional Pharmacologic Treatment for Cognitive Symptoms ChE Inhibitors (Donepezil, Rivastigmine, and Galantamine)

® The ChE inhibitors all have the indication for the treatment of dementia of the Alzheimer's type. Guidelines for the treatment of AD recommend the use of ChE inhibitors as a valuable treatment for AD and the use of memantine for moderate-to-severe AD. None of the ChE inhibitors have been compared in head-to-head studies, so the decision to use one over another is based on differences in mechanisms of action, adverse reactions, and titration schedules.

Treatment should begin as early as possible in patients with a diagnosis of AD.

Figure 35-2 provides a recommended treatment algorithm for AD. Patients should be switched to another ChE inhibitor from their initial ChE inhibitor if they show an initial lack of efficacy, initially respond to treatment but lose clinical benefit, or experience safety/tolerability issues. This switch should not be attempted until the patient has been on a maximally tolerated dose for a period of 3 to 6 months. The switch

should also be based on realistic expectations of the patient and/or caregiver. ChE inhibitor therapy should be discontinued in patients who experience poor tolerance or adherence, who show a lack of clinical improvement after 3 to 6 months at optimal dosing, who continue to deteriorate at the pretreatment rate, or who demonstrate dramatic clinical deterioration following initiation of treatment.34

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