"Treatment of Alzheimer Disease" (My Synopsis)

A synopsis of;
Treatment of Alzheimer Disease
BRADFORD T. WINSLOW, MD, Swedish Family Medicine Residency, Littleton, Colorado MARY K. ONYSKO, PharmD, University of Wyoming School of Pharmacy, Laramie, Wyoming CHRISTIAN M. STOB, DO, Denver Health Medical Center, Denver, Colorado KATHLEEN A. HAZLEWOOD, PharmD, University of Wyoming School of Pharmacy, Laramie, Wyoming
Am Fam Physician. 2011 Jun 15;83(12):1403-1412.
http://www.aafp.org/afp/2011/0615/p1403.pdf

     Alzheimer's disease is a progressive disease that affects memory and cognition. About 50% of people over 85 have it. It is more common in women. It occurs through the accumulation of amyloid plaques and neurofibrillary tangles. It leads to loss of neurotransmitters, inflammation, ischemia, cholesterol metabolism, and mitochondrial metabolism. Although thoroughly studied, there does not appear to be evidence that diet, environment, disease, or socioeconomic factors are associated with alzheimer's disease. The author appears to be hopeful,according to the abstract.
     There are a few different types of medications used in the treatment of alzheimer's disease. Donepezil, rivastigmine, and galantamine are acetylcholinesterase inhibitors which stop the enzyme that destroys the acetylcholine. It is a first line agent for any stage of alzheimer's disease.  It has shown improvement in behavior and ADLs, but the effect is small. If the medication does not help in 8 weeks, it can be discontinued.
     Memantine is an N-methyl-D-aspartate receptor antagonist, which is thought to lower amino acid neurotoxicity by preventing glutamatergic activity. It can be used to treat moderate to severe alzheimer's disease. The effect on cognition is statistically significant but not clinically significant. Its benefits in moderate alzheimer's disease are inconsistent, but its better than nothing.  Combining memantine and acetylcholinesterase inhibitors does not appear to show much benefit.
     Selegiline is a MAO-b inhibitor that appeared to have improvement in cognition, but the benefit is no different than placebo after six weeks.  Antipsychotics, such as olanzapine and risperidone, have been used to treat agitation in the past, but are not recommended because they cause worsening of functional ability. Estrogen and vitamin E have also not shown benefit. Testosterone has shown mild improvement to quality of life, but it is not clinically meaningful and does cause an increase of cardiovascular side effects.
     Once a patient is diagnosed with alzheimer's disease, a baseline functional assessment should be performed. The patient and family need to be educated on the disease process. If the condition is severe, the patient is started on an acetylcholinesterase inhibitor (with or without the memantine). If the disease is moderate, then the patient will be treated with the acetylcholinesterase alone. During the first 2-4 weeks of treatment, any side effects should be addressed. The medication can be switched to another acetylcholinesterase if the patient cannot tolerate it. Memantine can be added if the disease becomes severe. The medication can be stopped if the patient continues to deteriorate, if the patient is noncompliant to the medication, if the patient develops a serious comorbid disease, or if the patient/ caregiver decide to discontinue it.