Antidepressants do not appear effective and often

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-Antidepressants do not appear effective and often cause unwanted drug interactions/ adverse effects Cardinal Points of Treatment -early diagnosis and initiation may delay disease progression; CI stabilize cognitive and functional ability for about 1 year; pharmacologic treatment should begin as soon as AD is suspected; base choice of medication on tolerability, adverse effect profile, ease of use, cost of medication; depression/delirium should be identified and treated; avoid medications with sedative or anticholinergic effects as they contribute to falls; avoid polypharmacy; treat metabolic disorders, infections, and comorbid illnesses; avoid alcohol; antipsychotics may be used, although controversial and should be used no longer than 6 moths Nonpharmacologic Treatment: -educate caregivers on behavioral and environmental management, recommend support groups, and use community resources; caffeine consumption may reduce the risk; exercise Pharmacologic Treatment: -Donepezil, galantamine ER, or rivastigmine patch are considered first line -patients who should switch medications include those who show initial lack of efficacy, initially respond to treatment but subsequently fail to benefit, or experience safety/tolerability issues (switching should only be considered after 6 months) -drug-free period is necessary to “wash out” the drug before a new one begins -all medications are metabolized by cytochrome P450 hepatic enzyme system and have the potential for drug interactions; anticholinergic and cholinomimetics; used in caution for patients with myasthenia gravis -patients with severe dementia may be started on memantine, which can be given concomitantly with donepezil -some controversial studies suggest that patients with long-term ASA or NSAID use may have a reduction in incidence (vitamin E slows progression) -if the patient cannot tolerate CI due to GI or cardiac effects, sole NDMA can be used How to Monitor: -monitoring of functional ability and staging: Folstein Mini-Mental State Exam, Global Deterioration Scale, Katz Assessment of ADLs and IADLs (measure improvement or decline in function) -clinical evaluation and family observation of behavior and function may be the most useful and reliable monitor of therapy -Lab tests: monitor hepatic function, CBC and routine chemistry, monitor HR and BP, monitor s/s of toxicology (vomiting, diarrhea, urinary incontinence, diaphoresis, psychosis, tremor, weight loss); visual hallucinations are a sign of Levy body dementia Patient Variables: -geriatrics: age does not influence the metabolism or clearance of CI; reduce dose of galantamine and memantine with caution in patients with severe renal impairment -pediatrics: has not been established; used in head injuries -pregnancy: Category B/C -gender: plasma concentrations are 50% higher in women Patient Education:
-do not change dosage without consulting HCP; advise of initial and long-term/delayed side effects (GI are more common; sleep disturbances may need to be addressed); advise of

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