management of alzheimer’s disease and other dementias

OU NeurologyOU Neurology

Management of Management of Alzheimer’s Alzheimer’s

Disease and Other Disease and Other DementiasDementiasLinda A. Hershey, MD, PhDLinda A. Hershey, MD, PhD

Professor of NeurologyProfessor of Neurology

University of Oklahoma University of Oklahoma


DisclosuresDisclosures

I receive an honorarium to write for I receive an honorarium to write for Medlink Neurology about Memory Medlink Neurology about Memory Disorders.Disorders.

Our laboratory is funded by Baxter Our laboratory is funded by Baxter Healthcare Corporation to perform a Healthcare Corporation to perform a clinical trial of IVIg on patients with clinical trial of IVIg on patients with mild-moderate Alzheimer’s disease.mild-moderate Alzheimer’s disease.


Learning Objectives of Learning Objectives of this Talkthis Talk

To classify three common dementing illnesses To classify three common dementing illnesses (Alzheimer’s disease, dementia with Lewy (Alzheimer’s disease, dementia with Lewy bodies and vascular (mixed) dementia).bodies and vascular (mixed) dementia).

To describe the use of cholinesterase To describe the use of cholinesterase inhibitors and memantine in treating patients inhibitors and memantine in treating patients with AD, DLB and vascular (mixed) dementia.with AD, DLB and vascular (mixed) dementia.

To report the role of antidepressants, To report the role of antidepressants, anxiolytics and antipsychotic agents in anxiolytics and antipsychotic agents in treating patients with AD and other treating patients with AD and other dementing illnesses.dementing illnesses.


Question #1Question #1

Alzheimer’s disease is an illness Alzheimer’s disease is an illness associated with all of the following associated with all of the following features, EXCEPT:features, EXCEPT:

a) memory lossa) memory loss

b) diffuse brain atrophyb) diffuse brain atrophy

c) focal signs of weaknessc) focal signs of weakness

d) motor apraxiad) motor apraxia



Dementia with Lewy bodies is a an Dementia with Lewy bodies is a an illness associated with all of the illness associated with all of the following features, EXCEPT:following features, EXCEPT:


b) vertical gaze palsyb) vertical gaze palsy

c) parkinsonismc) parkinsonism

d) visual hallucinationsd) visual hallucinations



In the recent Great Britain study of drugs In the recent Great Britain study of drugs in moderate-severe AD, which statement is in moderate-severe AD, which statement is the most accurate summary of the results?the most accurate summary of the results?

a) Those assigned to donepezil alone had a) Those assigned to donepezil alone had the best cognitive outcome at 12 months.the best cognitive outcome at 12 months.

b) Those assigned to the combination of b) Those assigned to the combination of donepezil and memantine had the best donepezil and memantine had the best cognitive outcome at 12 mo.cognitive outcome at 12 mo.

c) Those assigned to placebo had the best c) Those assigned to placebo had the best behavioral outcome at 12 months. behavioral outcome at 12 months.



The advantages of mirtazapine for The advantages of mirtazapine for sleep in dementia patients include sleep in dementia patients include all of the following, EXCEPT:all of the following, EXCEPT:

a) It does not cause ataxia.a) It does not cause ataxia.

b) It is not an anticholinergic agent.b) It is not an anticholinergic agent.

c) It does not cause hypotension.c) It does not cause hypotension.

d) It is not habit-forming.d) It is not habit-forming.


56 year old female 711 56 year old female 711 cashiercashier

CC: “My head is in a fog most of the time”.CC: “My head is in a fog most of the time”.

May, 2010….Onset of poor conc & memoryMay, 2010….Onset of poor conc & memory (MRI = mild atrophy; MMSE = 25/30…poor recall).(MRI = mild atrophy; MMSE = 25/30…poor recall). April, 2011…She lost her job as a cashier at the 711April, 2011…She lost her job as a cashier at the 711 (MMSE in Aug = 21/30)…..no hallucinations.(MMSE in Aug = 21/30)…..no hallucinations. Jan, 2012…..Continued to have memory problemsJan, 2012…..Continued to have memory problems (IADL =11/16; MMSE = 18/30…exam = motor (IADL =11/16; MMSE = 18/30…exam = motor

apraxia, apraxia, but no signs of stroke or parkinsonism).but no signs of stroke or parkinsonism).

What is this woman’s diagnosis? Treatment?What is this woman’s diagnosis? Treatment?


Alzheimer’s Disease (AD)Alzheimer’s Disease (AD) Insidious onset and gradual decline in Insidious onset and gradual decline in

activities, behavior and cognition over activities, behavior and cognition over time.time.

Dementia by DSM IV criteria:Dementia by DSM IV criteria: … ….memory loss.memory loss … ….1 or more other cognitive .1 or more other cognitive

impairmentsimpairments … ….functional impairment in IADLs.functional impairment in IADLs … ….exclusion of delirium.exclusion of deliriumMcKhann et al. Neurology 1984; 34: 939-944.


Lawton’s IADL ScaleLawton’s IADL Scale Using the telephone….2 (no help)….0 Using the telephone….2 (no help)….0

(unable).(unable). Driving………………2….......1……0………Driving………………2….......1……0……… Grocery shopping……2……..1……0………Grocery shopping……2……..1……0……… Preparing meals……...2……...1……0………Preparing meals……...2……...1……0……… Doing housework……2……..1……0………Doing housework……2……..1……0……… Doing laundry……….2……...1……0………Doing laundry……….2……...1……0……… Taking medications….2……...1……0………Taking medications….2……...1……0……… Managing money…….2……..1…….0………Managing money…….2……..1…….0………

Lawton & Brody, The Gerontologist 1969; 9:179-186.


The Cholinergic Hypothesis The Cholinergic Hypothesis for ADfor AD

Cholinergic cells in the nucleus Cholinergic cells in the nucleus basalis of Meynert die early in AD:basalis of Meynert die early in AD:


Management of Mild Management of Mild Alzheimer’sAlzheimer’s

Start donepezil (Aricept) 5mg/dStart donepezil (Aricept) 5mg/d Advise caregiver to attend an AD support Advise caregiver to attend an AD support

groupgroup Advise her wearing an ID (Medic Alert) Advise her wearing an ID (Medic Alert)

braceletbracelet Advise patient to assign POA to caregiverAdvise patient to assign POA to caregiver Obtain screening labs (B12, TSH, RPR, Obtain screening labs (B12, TSH, RPR,

HbA1c)HbA1c) Reduce alcohol intake to 1-2 beers/dReduce alcohol intake to 1-2 beers/d Begin discussion of “the driving issue”Begin discussion of “the driving issue”


What about ginkgo What about ginkgo biloba?biloba?

Objective:Objective: The Ginkgo Evaluation of The Ginkgo Evaluation of Memory study compared 1545 older adults Memory study compared 1545 older adults or MCI pts or MCI pts

on G biloba and 1524 older adults or MCI pts on G biloba and 1524 older adults or MCI pts on placebo…they were followed for 6.1 yrs.on placebo…they were followed for 6.1 yrs.

Results:Results: Annual rates of decline on Annual rates of decline on cognitive tests cognitive tests did notdid not differ differ between G between G biloba group (120mg bid) and the placebo biloba group (120mg bid) and the placebo group (attention, memory, language, group (attention, memory, language, executive function).executive function).

Snitz, BE, et al: JAMA 2009: 302: 2663-2670.


What about What about Mediterranean diet?Mediterranean diet?

ObjectiveObjective: To assess the association : To assess the association between food combination and AD risk.between food combination and AD risk.

Design:Design: Prospective cohort study. Prospective cohort study. Methods:Methods: 2148 elderly subjects without 2148 elderly subjects without

dementia in NYC were evaluated every 1.5 dementia in NYC were evaluated every 1.5 yrs.yrs.

Results:Results: 253 subj developed AD within 3.9 253 subj developed AD within 3.9 yrs.yrs.

Lower risk of ADLower risk of AD with oils, nuts, fish, with oils, nuts, fish, tomatoes, poultry, fruits, vegetables. tomatoes, poultry, fruits, vegetables.

Gu Y, et al. Arch Neurol 2010; 67: 699-706.


47 year old retired 47 year old retired supervisorsupervisor

CC: memory loss, parkinsonism, visual hallucinationsCC: memory loss, parkinsonism, visual hallucinations

2007: He first noted REM sleep behavior disorder.2007: He first noted REM sleep behavior disorder. 2008: Memory loss began to impair his work.2008: Memory loss began to impair his work. 2010: Tremors began & he c/o visual hallucinations.2010: Tremors began & he c/o visual hallucinations. 2011: He began to c/o excessive daytime sleepiness.2011: He began to c/o excessive daytime sleepiness. 2011: MMSE=17/30; IADL=12/16.2011: MMSE=17/30; IADL=12/16. Exam: Motor apraxia + BL rigidity, bradykinesia.Exam: Motor apraxia + BL rigidity, bradykinesia. Shuffling gait with postural instability (eyes closed).Shuffling gait with postural instability (eyes closed).

What is this man’s diagnosis? Treatment? What is this man’s diagnosis? Treatment?


Dementia with Lewy Dementia with Lewy BodiesBodies

DLB is 2DLB is 2ndnd most common dementia after AD. most common dementia after AD. REM sleep disorder improves Dx accuracyREM sleep disorder improves Dx accuracy

(50% of all DLB pts have RBD).(50% of all DLB pts have RBD). Two or three core features are needed for Two or three core features are needed for

Dx:Dx:

a) fluctuations in alertness during the daya) fluctuations in alertness during the day

b) parkinsonism (bradykinesia, b) parkinsonism (bradykinesia, rigidity>tremor)rigidity>tremor)

c) visual hallucinationsc) visual hallucinations

Ferman TJ et al: Neurology 2011; 77:875-882.


The Cholinergic Hypothesis The Cholinergic Hypothesis for DLBfor DLB

Cholinergic cells in the nucleus Cholinergic cells in the nucleus basalis of Meynert die early in DLB:basalis of Meynert die early in DLB:


Dementia with Lewy Dementia with Lewy BodiesBodies

SPECT changes in DLB can look like SPECT changes in DLB can look like AD.AD.


Management of DLBManagement of DLB Start donepezil (Aricept) 5mg/d for dementia.Start donepezil (Aricept) 5mg/d for dementia. Start Sinemet 25/100 tid for parkinsonism.Start Sinemet 25/100 tid for parkinsonism. Start clonazepam 0.5mg qhs for RBD. Start clonazepam 0.5mg qhs for RBD. Advise caregiver to attend AD/DLB support Advise caregiver to attend AD/DLB support

group.group. Neuropsychology testing (Dr. Scott/Dr. Neuropsychology testing (Dr. Scott/Dr.

Adams). Adams). P.T. x 2/wk for gait & balance training.P.T. x 2/wk for gait & balance training. Advise wearing a MedicAlert ID bracelet.Advise wearing a MedicAlert ID bracelet. Recommend that the pt STOP DRIVINGRecommend that the pt STOP DRIVING (pt meets criteria for moderate dementia). (pt meets criteria for moderate dementia).


63 year old bench 63 year old bench jewellerjeweller

CC: Adm in Oct, 2010 with an acute CC: Adm in Oct, 2010 with an acute HTN emergency (he was acutely HTN emergency (he was acutely confused and disoriented). He had confused and disoriented). He had forgotten to take pills.forgotten to take pills.

Gait disorder and falls had been Gait disorder and falls had been present x 2 yrs.present x 2 yrs.


Vascular DementiaVascular Dementia Acute or subacute onset of gait disorder and/or memory Acute or subacute onset of gait disorder and/or memory

loss. loss.

Cerebrovascular disease by history, exam, or brain Cerebrovascular disease by history, exam, or brain imagingimaging

(and a temporal relationship between the CVD and (and a temporal relationship between the CVD and dementia).dementia).

Dementia according to DSM-IV criteria:Dementia according to DSM-IV criteria: … ….memory disorder.memory disorder … ….other cognitive deficits (loss of exec func).other cognitive deficits (loss of exec func) … ….functional impairment (IADLs).functional impairment (IADLs) … ….absence of delirium.absence of delirium

Roman et al. Neurology 1993; 43: 250-260.


Management of VaDManagement of VaD Start donepezil (Aricept) at 5mg/d.Start donepezil (Aricept) at 5mg/d. Start ECASA 325mg/d.Start ECASA 325mg/d. Start lisinopril 10mg/d (keep BP < 140/90). Start lisinopril 10mg/d (keep BP < 140/90). Start simvostatin 40mg/d (keep LDL <70). Start simvostatin 40mg/d (keep LDL <70).

Advise caregiver to attend caregiver Advise caregiver to attend caregiver classes.classes.

P.T. x 2 days/wk for gait & balance P.T. x 2 days/wk for gait & balance training.training.

Recommend that the pt STOP DRIVINGRecommend that the pt STOP DRIVING (he has homonymous hemianopsia). (he has homonymous hemianopsia).


Does Donepezil Improve Does Donepezil Improve Symptoms in Mod-Severe Symptoms in Mod-Severe

Alzheimer’s?Alzheimer’s?


Donepezil vs Memantine for Donepezil vs Memantine for Mod-Severe Alzheimer’s Mod-Severe Alzheimer’s

DiseaseDisease Who?Who? 295 community-dwelling AD patients 295 community-dwelling AD patients

in Great Britain, who scored 5-13 on the in Great Britain, who scored 5-13 on the MMSE and were taking donepezil (Aricept).MMSE and were taking donepezil (Aricept).

What?What? Randomized to continue donepezil, Randomized to continue donepezil, d/c donepezil, d/c donepezil and start d/c donepezil, d/c donepezil and start memantine, or continue donepezil and start memantine, or continue donepezil and start memantine. memantine.

Outcomes?Outcomes? Clinically important outcomes= Clinically important outcomes=

1.4 pts on the MMSE; 3.5 pts on the BADLs. 1.4 pts on the MMSE; 3.5 pts on the BADLs.

Howard, Robert et al: NEJM 2012;366:893-903.


Kaplan–Meier Actuarial Plot of the Cumulative Probability of Withdrawal from the Assigned Study Drug.

Howard R et al. N Engl J Med 2012;366:893-903.


Donepezil vs Memantine for Donepezil vs Memantine for Mod-Severe Alzheimer’s Mod-Severe Alzheimer’s

DiseaseDisease In pts with moderate-severe AD, continued In pts with moderate-severe AD, continued

treatment with donepezil was associated with treatment with donepezil was associated with cognitive benefits that exceeded the minimum cognitive benefits that exceeded the minimum clinically important difference over 12 clinically important difference over 12 months:months:

Those assigned to donepezil (vs placebo) Those assigned to donepezil (vs placebo) had MMSE scores that were 1.9 pts had MMSE scores that were 1.9 pts higher.higher.

Those assigned to memantine (vs placebo) Those assigned to memantine (vs placebo) hadhad

MMSE scores that were 1.2 pts higher.MMSE scores that were 1.2 pts higher.


Other Pearls from the Other Pearls from the NEJM StudyNEJM Study

D/C of donepezil did not produce a D/C of donepezil did not produce a withdrawal phenomenon. withdrawal phenomenon.

Memantine was beneficial in moderate-Memantine was beneficial in moderate-severe AD, but it was not as dramatic severe AD, but it was not as dramatic an effect as donepezil’s benefit. an effect as donepezil’s benefit.

There was no significant benefit from There was no significant benefit from adding memantine to donepezil in mod-adding memantine to donepezil in mod-severe AD.severe AD.


Does Donepezil Delay NH Does Donepezil Delay NH Placement in AD? Placement in AD?

Objective:Objective: To assess relationship between To assess relationship between donepezil treatment and NH placement in AD.donepezil treatment and NH placement in AD.

Design:Design: F/U of 1115 pts enrolled in 3 trials. F/U of 1115 pts enrolled in 3 trials.

Results:Results: Use of donepezil at a dose of at Use of donepezil at a dose of at least 5mg/d was associated with significant least 5mg/d was associated with significant delays in NH placement delays in NH placement

(time gained was 17-21 months). (time gained was 17-21 months).

Geldmacher et al. J Am Geriatr Soc 2003;51: 937-944.


Memantine for Mild-Mod Memantine for Mild-Mod ADAD


Memantine for Moderate-Memantine for Moderate-Severe ADSevere AD


Do Cholinesterase Do Cholinesterase Inhibitors help DLB Inhibitors help DLB

patients? patients? Objective:Objective: To determine whether To determine whether

galantamine would improve global function, galantamine would improve global function, behavior, or cognition in patients with DLB. behavior, or cognition in patients with DLB.

Design:Design: A 24-wk open-label, multi-center A 24-wk open-label, multi-center study of 50 DLB patients at 4 centers (VT, study of 50 DLB patients at 4 centers (VT, WNY, IN, TX).WNY, IN, TX).

Results:Results: At 24 wks, improvements were seen At 24 wks, improvements were seen in visual hallucinations (p=0.01), night-time in visual hallucinations (p=0.01), night-time behaviors (p=0.004) and global cognitive behaviors (p=0.004) and global cognitive impression of change (p=0.01).impression of change (p=0.01).

Edwards et al. Dementia 2007; 23: 401-405.


Does memantine help Does memantine help DLB ?DLB ?

Objective:Objective: To determine whether memantine To determine whether memantine would help pts with PDD and DLB.would help pts with PDD and DLB.

Design:Design: Double-blind, placebo-controlled Double-blind, placebo-controlled clinical trial in Norway, Sweden and UK clinical trial in Norway, Sweden and UK (n=72).(n=72).

Results:Results: At 24 wks, the pts on memantine At 24 wks, the pts on memantine had better clinical global impression of had better clinical global impression of change scores, compared to the placebo pts change scores, compared to the placebo pts (p=0.03). (p=0.03).

Aarsland et al. Lancet Neurology 2009; 8: 613-618.


Does donepezil delay onset Does donepezil delay onset of AD in patients who have of AD in patients who have

MCI? MCI? No. At three yrs, donepezil pts = No. At three yrs, donepezil pts =

placebo pts.placebo pts.

Petersen RC, et al. NEJM 2005; 352: 2379-2388.


What is the Exception to What is the Exception to the MCI “Rule”?the MCI “Rule”?

Donepezil delays progression to AD in MCI Donepezil delays progression to AD in MCI subjects who have subjects who have depressive symptomsdepressive symptoms..

Design:Design: n=756 participants in the 3-yr study n=756 participants in the 3-yr study of donepezil vs placebo in MCI patients.of donepezil vs placebo in MCI patients.

Results:Results: n=208 pts were found to be n=208 pts were found to be depressed using the Beck Depression depressed using the Beck Depression Inventory. These depressed MCI pts Inventory. These depressed MCI pts progressed to AD more slowly if they were progressed to AD more slowly if they were treated with donepezil (p=0.025 at 2 yrs). treated with donepezil (p=0.025 at 2 yrs).

Lu PH, et al. Neurology 2009; 72: 2115-2121.


Donepezil for MCI + Donepezil for MCI + depressiondepression

Lu PH, et al. Neurology 2009; 72:2115-2121.


Antidepressants for Antidepressants for Dementia Patients who Dementia Patients who

Cannot SleepCannot Sleep Mirtazapine (Remeron)…....7.5mg Mirtazapine (Remeron)…....7.5mg

qhs.qhs.


Advantages of mirtazapine Advantages of mirtazapine for sleepfor sleep

It does not cause gait & falling problems It does not cause gait & falling problems like benzodiazepines (important for DLB & like benzodiazepines (important for DLB & PSP).PSP).

It does not have anticholinergic activity It does not have anticholinergic activity like diphenhydramine, amitriptyline, like diphenhydramine, amitriptyline, trazodone, or hydroxyzine. trazodone, or hydroxyzine.

It is not habit-forming like zolpidem It is not habit-forming like zolpidem (Ambien). (Ambien).


Antipsychotic Agents for Antipsychotic Agents for DementiaDementia

ID = 68 year old man with a 3 yr Hx of ID = 68 year old man with a 3 yr Hx of memory loss, geographic disorientation memory loss, geographic disorientation and excessive daytime sedation & and excessive daytime sedation & agitation (“He starts sundowning at agitation (“He starts sundowning at noon”, according to his wife). noon”, according to his wife).

HPI = For the last 2 yrs, this pt has had HPI = For the last 2 yrs, this pt has had visual hallucinations, paranoid ideas, visual hallucinations, paranoid ideas, agitation, tremors, motor restlessness and agitation, tremors, motor restlessness and acting out his dreams at night (REM sleep acting out his dreams at night (REM sleep behavior disorder).behavior disorder).


Antipsychotic Agents for Antipsychotic Agents for Dementia Pts who have Dementia Pts who have Paranoia & InsomniaParanoia & Insomnia

Quetiapine (Seroquel)……..25mg Quetiapine (Seroquel)……..25mg qhs.qhs.


Clinical Outcome Clinical Outcome MeasuresMeasures

Clinical Dementia Rating (CDR)Clinical Dementia Rating (CDR)

Instrumental Activities of Daily Living Instrumental Activities of Daily Living (IADL)(IADL)

Neuropsychiatric Inventory (NPI) Neuropsychiatric Inventory (NPI)

Mini-Mental State Examination (MMSE)Mini-Mental State Examination (MMSE)


Clinical Dementia Rating Clinical Dementia Rating (CDR)(CDR)

0.5 = Questionable dementia …..no 0.5 = Questionable dementia …..no impairment of IADLs or BADLs.impairment of IADLs or BADLs.

1.0 = Mild dementia…….some impairment 1.0 = Mild dementia…….some impairment of IADLs, but no impairment of BADLs.of IADLs, but no impairment of BADLs.

2.0 = Moderate dementia…pt is dependent 2.0 = Moderate dementia…pt is dependent on others for most IADLs and some BADLs.on others for most IADLs and some BADLs.

3.0 = Severe dementia…...pt is dependent 3.0 = Severe dementia…...pt is dependent on others for all IADLs and BADLs. on others for all IADLs and BADLs.

Morris JC Neurology 1993; 43: 2412-2414


Lawton’s IADL ScaleLawton’s IADL Scale Using the telephone….2 (no help)….0 Using the telephone….2 (no help)….0

(unable).(unable). Driving………………2….......1……0………Driving………………2….......1……0……… Grocery shopping……2……..1……0………Grocery shopping……2……..1……0……… Preparing meals……...2……...1……0………Preparing meals……...2……...1……0……… Doing housework……2……..1……0………Doing housework……2……..1……0……… Doing laundry……….2……...1……0………Doing laundry……….2……...1……0……… Taking medications….2……...1……0………Taking medications….2……...1……0……… Managing money…….2……..1…….0………Managing money…….2……..1…….0………

Lawton & Brody, The Gerontologist 1969; 9:179-186.


Neuropsychiatric Inventory Neuropsychiatric Inventory (NPI)(NPI)

Delusional ideas Delusional ideas HallucinationsHallucinations Agitation Agitation DepressionDepression AnxietyAnxiety Elation/euphoriaElation/euphoria Apathy/loss of interestsApathy/loss of interests DisinhibitionDisinhibition Irritability/labilityIrritability/lability Motor disturbance/pacingMotor disturbance/pacing Nighttime behaviorsNighttime behaviors Appetite/weight changeAppetite/weight change

Cummings J L, et al. Neurology 1994;44:2308-2314.



Alzheimer’s disease is an illness Alzheimer’s disease is an illness associated with all of the following associated with all of the following features, EXCEPT:features, EXCEPT:


b) diffuse brain atrophyb) diffuse brain atrophy

c) *** focal signs of weaknessc) *** focal signs of weakness

d) motor apraxiad) motor apraxia



Dementia with Lewy bodies is an Dementia with Lewy bodies is an illness associated with all of the illness associated with all of the following features, EXCEPT:following features, EXCEPT:


b) *** vertical gaze palsyb) *** vertical gaze palsy

c) parkinsonismc) parkinsonism

d) visual hallucinationsd) visual hallucinations


Question #3Question #3 In the recent Great Britain moderate-severe In the recent Great Britain moderate-severe

AD study, which statement was the most AD study, which statement was the most accurate?accurate?a) ** Those assigned to donepezil alone a) ** Those assigned to donepezil alone had the best cognitive outcomes at 12 mo.had the best cognitive outcomes at 12 mo.b) Those assigned to the combination of b) Those assigned to the combination of donepezil and memantine had the best donepezil and memantine had the best cognitive outcomes at the end of 12 months.cognitive outcomes at the end of 12 months.c) Those assigned to placebo had better c) Those assigned to placebo had better behavioral outcomes at the end of 12 months.behavioral outcomes at the end of 12 months.



The advantages of mirtazapine for The advantages of mirtazapine for sleep in dementia patients include sleep in dementia patients include all of the following, EXCEPT: all of the following, EXCEPT:

a) It does not cause ataxia.a) It does not cause ataxia.

b) It is not an anticholinergic agent.b) It is not an anticholinergic agent.

c) ** It does not cause c) ** It does not cause hypotension.hypotension.

d) It is not habit-forming. d) It is not habit-forming.


SummarySummary Cholinesterase inhibitors and memantine “buy Cholinesterase inhibitors and memantine “buy

time” for AD and DLB pts, but they do not time” for AD and DLB pts, but they do not change the underlying disease processes.change the underlying disease processes.

The depression and psychosis associated with The depression and psychosis associated with dementing illnesses are treatable conditions.dementing illnesses are treatable conditions.

CDR, IADL, NPI and MMSE are useful CDR, IADL, NPI and MMSE are useful outcome measures to use in a clinical setting outcome measures to use in a clinical setting to monitor the effectiveness of drug therapy.to monitor the effectiveness of drug therapy.

management of alzheimer’s disease and other dementias

Documents

dementia patients

memory disorders

vascular mixed dementia

memory problems iadl

best cognitive outcome

moderatesevere ad

onset of poor conc memory

following features