MHM Magazine

38 | MENTALHEALTHMATTERS | Issue 3 | 2021 MHM Finance: This is a significant issue that is often overlooked. This is where the elderly are the most vulnerable. “Sudden” money mismanagement, irrational or over- the-top spending, accusations of theft are all warning signs. ACETYLCHOLINESTERASE INHIBITORS (ACHEIS) The first month of AChEI treatment is the most challenging because of the side-effects. Again, psychoeducation is crucial – prepare caregivers and the patient for what to expect and what to look out for. Donepezil must be titrated slowly upwards in the first month. Thereafter, AChEIs are always given in the mornings. The starting dose and subsequent mg dosage will be higher with Vascular Dementia, Parkinson’s Disease, Dementia and Diffuse Lewy Body Dementia. If a patient has chronic diarrheoa or rhinorrhoea, the medication must change to the other AChEI immediately. Monitor patients for vivid dreams, which they may act out. Ensure patients are taking the medication in the morning and either drop the dosage or change the medication if the dreams don’t abate. Memantine is an amantadine Rate in functional decline: IADL over 10 years preceding dementia N=986: >65yrs (104 =AD) Peres et al. J Am Geratr Soc 2008; 56:37 – 44a ACHEI RX: VASCULAR DEMENTIA, PARKINSON’S DISEASE DEMENTIA, DIFFUSE LEWY BODY DEMENTIA Donepezil dose titration (1 tab = 5, 10 mg) Month 1 2.5 mg at night (GIT) Month 2 onwards 5 mg in the morning OR Galantamine dose titration (1 tab = 8, 16, 24 mg) Month 1 8 mg in the morning Month 2 onwards 16 mg in the morning MEMANTINE RX: VASCULAR DEMENTIA, PARKINSON’S DISEASE DEMENTIA, DIFFUSE LEWY BODY DEMENTIA N-methyl-D-aspartate (NMDA) receptor antagonist half-life: 60- 100 hours Amantadine derivative enhances L-dopa and dopaminergic agonists Dose titration for Altzheimer’s (1 tab = 10 mg) Month 1 ½ tablet (5 mg) at night Month 2 onwards 1 tab (10 mg) at night If renal glomerular filtration rate (GFR) falls below 30 mL/min, reduce daily dose to 10 mg or less derivative so it will enhance L-dopa and is a dopaminergic agonist. This could be a benefit in Parkinson’s Disease patients but always be aware of dosage. Alzheimer’s patients tolerate 20 gm memantine, but be aware of the side-effects and co-effects. The most common side-effects are confusion during the day and excessive fatigue. Both of these are innate to the condition so it can be a challenge to identify those symptoms as a side-effect. Stop the medication for a couple of weeks if necessary. SIDE-EFFECTS OF ACHEIS Mild sedation (initially) Dizziness / postural hypotension Abdominal discomfort Anxiety, insomnia Vivid dreams Anorexia, nausea, vomiting Depression Diarrhoea Rhinorrhoea (discontinue) Sexual dysfunction Increased salivation Sweating Cramps SIDE-EFFECTS OF MEMANTINE Amantadine derivative: Confusion Dizziness Headache Fatigue Enhances L-dopa and dopaminergic agonists URGENCY INCONTINENCE An overactive bladder is a criteria of Vascular Dementia and is present is 30 to 60% of Alzheimer’s patients and in 10 to 20% of MVI patients. Overactive Bladder Syndrome (OBS) occurs both day and night but nocturnal urinary frequency (urinating up to six times a night) is highly disruptive. Patients often nap, or fall asleep, during the day which completely disrupts the day/night cycle. Dosage of quetiapine (or chlorprozamine) controls the bladder and helps the patient sleep better. Dosage requires 25 mg per two nocturnal urinary cycles.