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Dementia: A priority in Hampshire

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by Kazeem Olalekan MRPharmS

dementiaThe dilemma of Dementia was brought into sharp focus for me recently when I attended the events organised by the Wessex Local Pharmacy Forum. The event took place on the 14th of October at Holiday Inn Eastleigh.  Stephen Bleakley, Deputy Chief Pharmacist at Southern Health NHS Foundation Trust and a representative from Hampshire Dementia Action Alliance, Debbie made powerful cases for keeping this at the very top of our professional agenda.

 

National Lead:

At a national level, the Department of Health set out a national Dementia challenge in March 2012 led by Prime Minister David Cameron to tackle one of the most important issues we face as the population ages. The key area aims of the strategy are:

  • Improve Awareness
  • Earlier diagnosis and intervention, and
  • Higher quality of care.

The questions I always ask in cases like this is where do I fit into the overall strategy? How will my practice change? How can I make a difference?

The anguish faced by people living with dementia was brought to my door step by the story featured in the Express, where Lady Sally Grylls, mother of that TV adventurer Bear Grylls, described a scenario where frail and elderly patients lay in agony, confused, isolated and terrified with no one to reassure them! She lives in Hampshire & Isle of Wight – my patch!

How can I, as a pharmacist, respond to the challenges posed by Dementia?

I attended the Wessex LPF event for a start!

Stephen Bleakley did a great job in refreshing my memory about the condition. Dementia, he observed, is a progressive degenerative neurological disease. About 800,000 people in UK have Dementia and the figure is expected to double over the next 30 years! The symptoms may include ongoing decline of the brain and its abilities and may include:

  • memory loss
  • thinking speed
  • mental agility
  • language
  • understanding
  • judgement

More information on condition is available on the NHS Choices website.

The types of dementia include:

Stephen Bleakley’s talk introduced us to a Mini Mental state Examination toolkit (MMSE) which is an assessment toolkit most commonly used to test for complaints of memory problems. The Alzheimer’s society has produced a fact sheet the MMSE here. This is of course a validated proprietary tool which is available to buy through Psychological Assessment Resources (PAR).

CHALLENGE ONE

If the national strategy, is for early diagnosis, then this tool should be available for use by the front line pharmacist supported by training on appropriate use of the tool. Suffice to say the aim is not to diagnosis (that is not our role), but to provide early indication of potential problem.

In general, scores of 27 or above (out of 30) are considered normal. However, getting a score below this does not always mean that a person has dementia – their mental abilities might be impaired for another reason or they may have a physical problem such as difficulty hearing, which makes it harder for them to take the test. In any case, it provides an objective starting point in our contact with patients. It may form part of the Medicines Use Review Service.

Stephen then went on to describe pharmaceutical agents currently available for managing patients living with dementia:

  • Acetylcholinesterase inhibiting drugs such as Donepezil, Galantamine and Rivastigmine
  • N-methyl-D-aspartate (NMDA) antagonist sometimes known as glutamate receptor antagonist such as Memantine

There is a NICE guideline (TA217), which discusses the place of each treatment in the management of Alzheimer’s

Stephen further went on to describe the role of other pharmaceutical agents in the management of comorbid symptoms:

  • Benzodiazepines may increase the risk of falls
  • Anti-depressants have mixed effectiveness and risk vs benefit must be carefully considered
  • Mood stabilisers like Carbamazepines and Valproates may be considered where appropriate

As far as managing people with dementia, the best practice is identified in the NICE Dementia Guideline CG42 and Dementia Quality standards.

CHALLENGE TWO:

What do I know about the key drugs used in managing dementia?

Donepezil

  • Indicated for mild to moderate dementia in Alzheimer’s disease
  • start at 5mg daily at bedtime, then increase if necessary after 1 month to maximum of 10mg daily
  • Common side effects include: nausea, vomiting, anorexia, diarrhoes, headache and dizziness
  • Caution in mild to moderate hepatic impairment (Metabolized by CYP2D6 and CYP3A4)
  • The elimination half-life is approximately 70 h
  • Formulated as tablets and orodispersible tablets

Galantamine

  • Indicated for mild to moderate dementia in Alzheimer’s disease
  • start at 4mg BD for 4 weeks, increase to 8mg BD for 4 weeks; maintenance 8-12mg BD (normal release tablets)
  • start 8mg OD for 4 weeks, increase to 16mg OD for 4 weeks; maintenace 16-24mg OD (M/R tablets)
  • dosing adjustment required in hepatic impairment – see BNF
  • Avoid if eGFR less than 9ml/minute/1.73m2
  • Common side effects include: nausea, vomiting, anorexia, diarrhoes, headache, dizziness, weight loss, hypertension and bradycardia.
  • The elimination half-life of galantamine is about 7-8 hours
  • Available tablets, M/R tablets (The extended release formulation of galantamine, galantamine-ER, is a capsule composed of pellets. While 25% of the dose is in an immediate release form, the remaining 75% is in a controlled release form) and oral solution.
  • Great article

Rivastigmine

  • Indicated for mild to moderate dementia in Alzheimer’s disease
  • oral: start at 1.5mg BD, increase in steps of 1.5mg BD at intervals of at least 2 weeks according to response and tolerance; usual range 3-6mg BD; maximum 6mg BD. IF TREATMENT IS INTERRUPTED FOR MORE THAN 7 DAYS, TREATMENT SHOULD BE RETITRATED FROM 1.5mg BD.
  • patch: initially 4.6mg/24hrs patch and increase after 4 weeks; usual mantenance 9.5mg/24hrs; after 6 months may be increased to 13.3mg/24hrs (caustion if weight is less than 50kg). IF TREATMENT IS INTERRUPTED FOR MORE THAN 3 DAYS, TREATMENT SHOULD BE RETITRATED FROM 4.6mg/24hrs.
  • The strategy for switching from tablet to patch is in the BNF.
  • Common side effects include: nausea, vomiting, anorexia, diarrhoes, headache, dizziness, weight loss, hypertension and bradycardia.
  • Patches are less likely to cause GI side effects
  • Half-life after patch administration 3.4hrs; capsules 1.5hrs
  • Take oral with or after food
  • Available as capsules, oral solutions and patches (counsel on how to apply – see BNF)

Memantine

  • Indicated for mild to moderate dementia in Alzheimer’s disease
  • start 5mg OD, increase in steps of 5mg at weekly intervals to maximum of 20mg OD
  • Use with caution in patients with history of convulsion
  • Avoid in severe hepatic imparement
  • Reduce dose to 10mg OD if eGFR 30-19ml/minute/1.73m2
  • Important interactions with OTC medication: DEXTROMETHORPHAN
  • half-life 60-80 hrs
  • Available as tablets and oral solution

Apart from the above, how else can we help as pharmacists?

CHALLENGE THREE:

dementia

With this post, how is bookapharmacist.com doing it’s bit for Dementia?:

  • Improving public and professional awareness and understanding
    of dementia
  • Good-quality early diagnosis and intervention for all
  • Good-quality information for those with diagnosed dementia
    and their carers
  • Enabling easy access to care, support and advice following
    diagnosis
  • Development of structured peer support and learning networks
  • Improved community personal support services
  • Put Dementia on the Pharmacist agenda

At the end of the Wessex LPF event, I interviewed some pre-registration pharmacists. These were their comments:

http://youtu.be/_3qsmyXa4YU

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