Dementia_Rajib

Dementia
A group of thinking and social symptoms that
interferes with daily functioning.
Presented By : Rajib Barua

Key points :
Impairment of multiple domains of cognitive functions:
Memory impairment – (Must)
1. New material learning
2. Forget previous learning
With at least one of the following cognitive disturbance:
1. Aphasia : Language disturbance
2. Apraxia : Impaired ability to carry out motor activities despit
intact motor function
3. Agnosia: Failure to recognize/ identify familiar object
despite intact sensory function
4. Disturbance in executive functions
Significant impairment of social & occupational functioning decline
from previous level

Types Of Dementia

The global “prevalence” of
dementia
• 46.8 million people worldwide
are living with dementia in 2015.
• This number will almost double
every 20 years.
• Reaching 74.7 million in 2030 and
131.5 million in 2050.
• These new estimates are 12-13%
higher than those made for the
World Alzheimer Report 2009.
Ref : www.alz.co.uk/worldreport2015

“Prevalence” in Bangladesh
According to the study of
Alzheimer Society of Bangladesh :
• There are about 4,60,000 people
with dementia in Bangladesh in
2015.
• While the number will rise to
8,34,000 in 2030 and
21,93,000 in 2050 respectively.
Ref : http://alzheimerbd.com/dementia-
statistics/

Risk Factors

Alzheimer’s Dementia (AD)
Alzheimer's is the most
common form of dementia,
a general term for memory
loss and other intellectual
abilities serious enough to
interfere with daily life.
Alzheimer's disease accounts
for 60 to 80 percent of
dementia cases.
Ref:
http://www.alz.org/alzheimers_disease_wha
t_is_alzheimers.asp

1. Recent memory loss that affects job
skills.
2. Difficulty performing familiar tasks.
3. Problem with language.
4. Disorientation of time and place.
5. Poor or decreased judgment.
6. Problem with abstract thinking.
7. Misplacing things.
8. Changes in personality.
9. Changes in mood or behavior.
10. Loss of initiative.
“10 warning signs” of
Alzheimer’s Disease

Memory, Language & Judgment centre
of human brain.

Healthy brain
Vs
Alzheimer's brain

What a normal brain loses in AD?
The cholinergic deficit in AD underlies the
clinical symptom :
Progressive loss of Cholinergic neurons
Progressive decrease in available Ach*.
Impairment in ADL*, behavior & cognition.
*Ach = Acetylcholine
*ADL = Activity of daily living

Strategies for Medical Treatment
of Dementia
• Prevention of disease
• Delay of onset
• Slow rate of progression
• Treat primary symptoms (cognitive)
• Treat secondary symptoms (behavioural)

Management of Dementia
• Supportive treatment
(Non-pharmacological)
• Treatment of complications
& co-morbidities
• Symptomatic treatment

Supportive treatment
(Non-pharmacological)
• Advice, support and a sensible
explanation are important for the
caregiver.
• Reduce excessive stimulation.
• Divide tasks into small, simple
steps; allow ample time.
• Eliminate caffeine and alcohol.
• Take their concern seriously.

Treatment of complications
and co-morbidities
Like AD other diseases rise with advancing age :-
• Hypertension
• Diabetes mellitus
• IHD
• Heart failure
• Arthritis
• Infections

Symptomatic treatment
Symptomatic treatment of mild to moderate forms of
Alzheimer's dementia is “Cholinesterase inhibitor”.
• It increases acetylcholine in the brain, &
• Slowing down of the disease's progression.

Overview of AChE inhibitors
– Obsolete because, very short lasting (half life 30 mints)
necessitating frequent oral administration
– Potentially serious dose-limiting S/E
– Again S/E; 50% of the patients treated with tacrine
discontinued treatment because of adverse events especially
hepatotoxicity.
Oldest (probably most extensively tested):
“Physostigmine”
In the past : “Tacrine”

Overview of AChE inhibitors
(cont’d.)
– Launched in the USA in January 1997 and in the UK in March
1997
– Modest benefits in terms of cognition
– Most common S/E are similar to those seen with tacrine
– Launched in the USA in April 2000; received approval for use in
60 countries including all member states of EU and USA
– Improvements were seen in cognition, ADL & severity of
dementia
– Dose of 6-12 mg/day
– Lower risk of adverse effects
Recent past : “Donepezil”
Recent : “Rivastigmine”

What is “Rivastigmine” ?
• Rivastigmine is Acetyl Cholinesterase (AChE) as well as Butyl
Cholinesterase (BChE) inhibitor.
• Rivastigmine treats Alzheimer’s disease as well as other
dementias.

Cholinergic function in AD:
from pathology to therapy – summary
• In AD brains BuChE activity increases significantly; BuChE as well
as AChE regulates ACh levels.
• Dual AChE/BuChE inhibition may result in cholinergic function
being effectively maintained along the continuum of AD.
• Rivastigmine is a dual AChE/BuChE inhibitor.
• Inhibition of CSF AChE and BuChE with Rivastigmine correlates
with clinical benefits in AD patients.
Ref : Perry et al.,1978, 1984;Giacobini, 1997, Cutler et al; 1998, Costa et al., 1999

What is Exelon?
• Exelon is rivastigmine.
• Exelon is Acetyl Cholinesterase (AChE) as well as (BChE)
inhibitor.
• Exelon treats Alzheimer’s dementia as well as other dementias.
Rivastigmine Brand :-
HISTORY :
Rivastigmine was developed by Marta Weinstock-Rosin of the
Department of Pharmacology at the Hebrew University of Jerusalem
and sold to Novartis by Yissum for commercial development.
It is a semi-synthetic derivative of physostigmine.
It has been available in capsule and liquid formulations since 1997.
In 2006, it became the first product approved globally for the
treatment of mild to moderate dementia associated with Parkinson's disease
and in 2007 the rivastigmine transdermal patch became the first
patch treatment for dementia.
Ref : https://en.wikipedia.org/wiki/Rivastigmine

Available Dosage Forms
CapsuleCapsule Transdermal PatchTransdermal Patch
1.5 mg =
3.0 mg =
4.5 mg =
6.0 mg =
Exelon Patch 5 cm2
= 4.6 mg/24 h
Exelon Patch 10 cm2
=9.5 mg/24 h

Aim to achieve maximum tolerated individual
dose
 Start with 1.5mg, BID.
 Increase by 3mg/day at intervals of minimum 02 weeks, up to
maximum 12mg/day.
 Omit dose(s) in response to adverse events.
 Reduce dose if problems persist.
Exelon Capsule Dosage Guideline

Exelon Patch Dosage Guideline
1. “Exelon Patch is once daily”.
2. Target dose is Exelon Patch-10
(9.5mg/ 24h).
3. Only one patch should be worn
at a time.
4. Patch should be replaced by a
new one after 24 hours.
5. It is recommended that location
for new patch be rotated.

Exelon Patch:
How Delicately it is made
Coloured backing layer
Acrylic (drug) matrix
Silicone (adhesive) matrix
Release liner
(peeled off just before patch application)
Designed with new generation matrix technology

Exelon Patch:
How drug is Delivered Across the Skin
Epidermis
Patch
Dermis
Subcutis
Blood Vessels

Dosage Guideline for newly
diagnosed patient
Exelon
4.6 mg/24 h
Patch
Exelon
9.5 mg/24 h
Patch
Starting
dose
Target
dose
4 weeks
One-step dose
increase
Exelon Patch-5 Exelon Patch-10

Algorithm for Starting or Switching to
Exelon Patch
< 6 mg/day*
Start on Exelon
4.6 mg/24 hours patch
4weeks
Switch directly to target
dose Exelon 9.5 mg/24 hours patch
Is the patient already receiving oral Exelon?
NO YES
What dose of oral Exelon is the patient receiving?
Increase to Exelon
9.5 mg/24 hours patch
6–12 mg/day*

Smooth and continuous drug
delivery over 24 hours
Graphic representation (not ‘real’ data) Imbimbo 2001
Increased
side effects
Poor activity
“Optimal
therapeutic
window”
Druglevelintheblood
Peak
Oral Dose
Trough
Patch
Time

Exelon Patch: How to apply
1. The patch should be
removed from the pouch,
2. Remove one side of the
protective liner,
3. Place the patch at the
selected application site,
4. Remove the other side of
the protective liner,
5. Press the patch firmly into
place for 20–30 seconds.

Exelon Patch: Where to apply
• Exelon Patch can be applied to:
– Upper or lower back
– Upper arm
– Chest
• When replacing the patch, the
new patch should be applied to a
different spot of skin.
– Do not use the same spot
more than once every 14 days
• Normal daily activities, such as
bathing are permitted.

Advantage of Exelon Patch
1. Easy to apply.
2. Reduce patients’ pill burden.
3. Reduce care giver’s distress.
4. Achieve optimal therapeutic dose.
5. Dramatically improved GI Tolerability.
6. Ensures Continuous & Consistent drug
delivery that results fewer side effects &
Improved efficacy.

Conclusion : The time to act
• Promoting a dementia-friendly society.
• National public health and social care priority.
• Improving public and professional attitudes and
understanding of dementia.
• Investing to improve care and services for
dementia affected people.
• Priority given to dementia in the
public health research agenda.

““Love them while they are with you”Love them while they are with you”

Dementia_Rajib

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