3:15pm - 4:15pm:
Breakout 4 - Technician Option:
Playing a Role in the Lives
of Patients with Alzheimer’s
ACPE UAN 107-000-11-021-L01-T
Activity Type: Knowledge-Based
0.1 CEU/1.0 Hr
Program Objectives for Technicians: Upon completion of this program, participants should be able to:
1. Identify the prevalence and implications of Alzheimer’s Disease in the community.
2. Recognize the diagnosis and treatment of Alzheimer’s Disease.
3. Discuss the impact of Alzheimer’s Disease on patient’s and caregiver’s lives.
4. List drug therapy options available for Alzheimer’s Disease.
5. Describe how to utilize a memory screening tool in your pharmacy practice.
Speaker: Anisa Fornoff, PharmD, is an Assistant Professor of Clinical Sciences at Drake University
College of Pharmacy and Health Sciences in Des Moines, Iowa. She provides clinical services at
three practice sites: Progress Industries in both Johnston and Newton, IA and Community Support
Advocates in Des Moines, IA. At Progress Industries she works closely with patients with intellectual
and developmental disabilities. Community Support Advocates serves patients with chronic mental
illness. Fornoff’s didactic teaching is in the Pharmacy Skills and Applications series with a focus on
physical assessment skills. She and her students are the contact for mental health related questions
for Passageway, a day habilitation program for people with mental illness and serves on their board
of directors. She also serves on the Independence in Action Committee at Candeo, a human rights
committee. In 2008, Fornoff was honored with the Innovative Pharmacy Practice Award from the Iowa
Pharmacy Association.
Speaker Disclosure: Anisa Fornoff reports she has no actual or potential conflicts of interest in
relation to this program. The speaker has indicated that off-label use of medications will not be discussed
during this presentation.
Playing a Role in the Lives
of Patients with Alzheimer’s
Faculty Disclosure


Anisa Fornoff, PharmD
Assistant Professor of Clinical Sciences
Anisa Fornoff reports she has no actual or
potential conflicts of interest associated with this
presentation.
Anisa Fornoff has indicated that off-label use of
medication will not be discussed during this
presentation.
Drake University College of Pharmacy and Health Sciences
[email protected]
Learning Objectives

Upon completion of this presentation,
pharmacy technicians will be able to:





Identify the prevalence and implications of Alzheimer’s
Disease in the community.
Recognize the diagnosis and treatment of Alzheimer’s
Disease.
Discuss the impact of Alzheimer’s Disease on patient’s
and caregiver’s lives.
List drug therapy options available for Alzheimer’s
Disease.
Describe how to utilize a memory screening tool in your
pharmacy setting.
Pre-Assessment Question #2
Signs of Alzheimer’s Disease include the
following:
a. Memory loss that disrupts daily life
b. Changes in mood and personality
c. Misplacing items
d. Difficulty completing familiar tasks
e. All of the above
Pre-Assessment Question #1
Which of the following statement(s) are
true regarding FDA approved medications
used to treat Alzheimer’s Disease?
a. May improve quality of life
b. May delay long term care placement
c. Will not reverse the illness
d. A and B only
e. All of the above
Pre-Assessment Question #3
Potential cause(s) of Alzheimer’s Disease
include:
a. Increase of Beta-amyloid plaques
b. Normal aging
c. Neurofibrillary tangles
d. A and C
e. All of the above
Pre-Assessment Question #4
Pre-Assessment Question #5
Memory testing performed in pharmacies
are valuable screenings, however, they
should not be considered diagnostic tools.
We can provide a positive impact on
caregiver’s lives by encouraging the
following activities in our pharmacies?
a. True
b. False
a. Providing an updated medication list
b. Identifying community resources
c. Suggesting products for assistance such
as medication planners
d. All of the above
Definition of Alzheimer’s Disease5
Alzheimer’s Disease was first described by
Dr. Alois Alzheimer in 1907.
 The illness is progressive, degenerative
brain disorder.
 Results in loss of memory, behavioral
changes, and thinking or language skills.

Statistics5,11
Alzheimer’s is the most common cause of
dementia in persons 65 years of age and
older.
 The risk of having this illness doubles
every 5 year beyond the age of 65.
 Approximate percentages in age groups:




65-74 years old: 7%
75-84 years old: 53%
Estimated to affect approximately 5.1
million Americans.
Life Expectancy11,12
Impact on the community1
Individuals live an average of 8-10 years
from diagnosis.
 6th leading cause of death in 2007.
 May not be the direct cause of death.





Pneumonia
Choking
Trauma
Alzheimer’s disease has a total health care
cost of over $100 billion annually.

Long term care costs
Causes of Alzheimer’s Disease1,5,11
Alzheimer’s is not a normal part of aging
 Abnormal brain lesions seen on autopsy




Beta-amyloid plaques: clumps of protein
fragments forming around and outside of
neurons which deposit in extracellular space.
Neurofibrillary tangles: insoluble, twisted fibers
that build up in a nerve cell, contain the
protein tau.
apo E4 gene on chromosome 19
Google images
Risk Factors1,5,11
Warning Signs11,12

Age
Positive family history
 Down syndrome
 Head injury
 Risks factors for vascular disease








High cholesterol
Heart disease
Smoking
Obesity
Diabetes
Short-term memory loss
Confusion regarding time and place
 Difficulty completing familiar actions
 Difficulty following conversations or
directions
 Changes in personality or mood
 Poor judgment
 Difficulty with tasks involving numbers
Memory Screenings9
Who should be screened?9,11,12
Not a diagnosis, used to indicate if a more
complete visit with a health provider is
needed.
 May help to recognize mild cognitive
impairment early.


Anyone concerned with memory loss,
Anyone currently experiencing signs of
loss
 Those with a family history
 Family or friends have seen changes in
memory or behavior
 As a benchmark for future comparison

Should I be screened: Questions to
consider12
Memory Tests9
Am I becoming more forgetful?
 Do I have trouble concentrating?
 Do I have difficulty performing familiar
tasks?
 Do I have trouble recalling words or
names in conversations?
 Am I misplacing things more often?
 Have I become lost when walking or
driving?

Three Word Recall
Clock Drawing


Ask patient to listen carefully to 3 words






dog, apple, house

Tests for cognition in these areas:



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
Orientation
Registration
Attention and Calculation
Recall
Language
Scoring:




Max is 30 points
20-24 mild dementia
13-20 moderate dementia
Less than 12 severe dementia
Clock Drawing
3 Word Recall
Memory Impairment Screen
Mini-Mental State Exam (MMSE)
Ask your patient

Ask patient to repeat back
 Use a distracter activity for 2 minutes
 Ask patient to repeat back the 3 words
 Recommend further evaluation if recall
one word or less.


Mini Mental State Exam (MMSE)
Mini-cog



Draw the face of a clock
Inside the circle, draw the hours of a clock as
they normally appear.
Place the hands of the clock to represent the
time “10 minutes after 11 o’clock”
Patients allotted as much time as needed.
1 point for closed circle, 1 point for numbers if
correct position, 1 point includes all 12 correct
numbers, 1 point places hands in correct
position.
How to Complete a Screening:
Practice with a Partner

Memory Impairment Screen. Alzheimer’s Foundation of America.
Diagnosis
DSM-IV Diagnostic Criteria3
Other memory problems will need to be
considered
 Multiple medical issues will be considered
 Blood tests are performed


The development of multiple cognitive
deficits by both of the following.


1. Memory impairment (impaired ability to
learn new information and to recall previously
learned information).
2. One (or more) of the following:




Aphasia (language disturbance)
Apraxia (inability to carry out motor activities)
Agnosia (failure to recognize objects)
Disturbance in executive functioning (planning,
organizing, sequencing)
Functional Assessment
Stages of Alzheimer’s Disease11
Ability to live alone
Pay bills, balance a checkbook
 Cook, turn off a stove
 Shop for food and household needs
 Understand the newspaper
 Remember appointments and special
dates
 Travel

Treatment4,5
Cholinesterase Inhibitors4
There is no cure.
There are no medications that will reverse
or prevent progression of the disease.
 Cholinesterase inhibitors may temporarily
stabilize or delay the progression of the
disease.




Mild: Difficulty remembering recent
events, preparing food and household
activities decline. May get lost while
driving, gives up hobbies.
 Moderate: Requires assistance with
activities of daily living, disoriented to
time, may be suspicious/tearful, may
forget details and names of family/friends.
 Severe: Loses ability to speak, walk, and
feed self.
Donepezil (Aricept®)





All stages of Alzheimer’s
Tablet, oral solution
Once daily in the evening, 5 -10 mg daily,
23mg newly available
Rivastigmine (Exelon®)



Mild to moderate stages
Capsule, oral solution, patch
Twice daily with meals, 3 – 6 mg twice daily
(capsule), 4.6/9.6 mg (patch)
Cholinesterase Inhibitors4

Galantamine (Razadyne®)




Mild to moderate stages
Tablet, oral solution
Twice daily with food, 8 – 12 mg twice daily
Has an ER formulation, Once daily
Cholinesterase Inhibitors4




Tacrine (Cognex®)

Mechanism of Action: Increase the levels of
acetylcholine which is a chemical messenger
involved in memory and judgment. Helps to
compensate for the loss of brain cells.
Gradual dose titration up. Avoid abrupt
discontinuation.
Side effects:

No longer used due to side effects



NMDA Receptor Antagonist4

Memanatine (Namenda®)



NMDA Receptor Antagonist4

Moderate to severe AD
Tablet, oral solution
10 mg twice daily, with or without food
Side effects:





GI: nausea, vomiting, diarrhea
Bradycardia (slow heart rate)
Weakness
Weight loss
Headache
Constipation
Confusion
Dizziness
Mechanism of Action: Regulates the
activity of glutamate in the cell which is
involved in information processing,
storage, and retrieval.
Communication Techniques12
Communication Techniques
Speak calmly and be reassuring.
Keep in mind the person may be confused
and anxious.
 Get their attention and maintain eye
contact.
 Ask only 1 question at a time.
 Eliminate distractions.
 Use simple steps
 Use non-verbal gestures


How do you respond?

The patient asks you the same question 4
times in 5 minutes.
Counseling Considerations12
Counseling Considerations12

What is the expected effectiveness of this
medication?
 What possible side effects may occur?
 Are there other methods of medication
delivery?
 Community resources
 Provide an updated medication list.
 Products for assistance
 Customized pharmacy services.

Impact on the Patient and Caregiver
Caregiving Tips: Strategies for
Success 12
Estimates show that 1-4 family members
act as a caregiver for an individual with
Alzheimer’s Disease.
 Supervision
 Assistance

Caregiving Tips: Strategies for
Success12
Do cognitive stimulating activities.
Foster communication with
physicians/health care providers.
 Take care of financial, legal, and longterm care planning issues.
 Smile
 Think positive
 Reach out for care

Design/Distribute educational materials.
 Provide community education.
 Participate in support group meetings.
 Strive to be proactive.
Educate yourself about the disease.
Learn caregiving techniques.
 Understand the experience of your loved
one.
 Avoid burnout.
 Maintain your own physical and mental
health.
 Discuss the situation with family and
friends.


Resources for patients and familiy

Alzheimer’s Foundation of America






Local support groups
Alzheimer's Association



1-866-AFA-8484
www.alz.org
24-hour Helpline: 1-800-272-3900
www.alzfdn.org
www.caregiver.org
Alzheimer's Disease Education and Referral
(ADEAR) Center
1-800-438-4380
Post-Assessment Question #1
Post-Assessment Question #2
Which of the following statement(s) are
true regarding FDA approved medications
used to treat Alzheimer’s Disease?
a. May improve quality of life
b. May delay long term care placement
c. Will not reverse the illness
d. A and B only
e. All of the above
Post-Assessment Question #3
Signs of Alzheimer’s Disease include the
following:
a. Memory loss that disrupts daily life.
b. Changes in mood and personality
c. Misplacing items
d. Difficulty completing familiar tasks.
e. All of the above
Post-Assessment Question #4
Potential cause(s) of Alzheimer’s Disease
include:
a. Increase of Beta-amyloid plaques
b. Normal aging
c. Neurofibrillary tangles
d. A and C
e. All of the above
Post-Assessment Question #5
We can provide a positive impact on
caregiver’s lives by encouraging the
following activities in our pharmacies?
a. Providing an updated medication list
b. Identifying community resources
c. Suggesting products for assistance such
as medication planners
d. All of the above
Memory testing performed in pharmacies
are valuable screenings, however, they
should not be considered diagnostic tools.
a. True
b. False
References
1.
2.
3.
4.
5.
6.
7.
Bird Thomas D, Miller Bruce L, "Chapter 365. Dementia" (Chapter). Fauci AS,
Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's
Principles of Internal Medicine, 17e:
http://www.accesspharmacy.com/content.aspx?aID=2904052. Accessed 12/5/10.
Christensen, DD Lin, P. Practical Treatment Strategies for Patients with Alzheimer;s
disease. The Journal of Family Practice Supplement. December 2007. S 17-S23.
DSM-IV Criteria. www.psychiatryonline.com. Accessed 12/09/10.
Lexi-Comp Online. Available at:http://www.crlonline.com/crlsql.CRLLogin.jsp.
Accessed 12/5/10.
Mcilvried Robb, "Chapter 20. Pharmacotherapy for Alzheimer's Disease" (Chapter).
William D. Linn, Marion R. Wofford, Mary Elizabeth O'Keefe, L. Michael Posey:
Pharmacotherapy in Primary Care:
http://www.accesspharmacy.com/content.aspx?aID=3602525. Accessed 12/5/10.
Practice guidelines for the treatment of patients with Alzheimer’s Disease and other
dementias. Oct 2007. APA.
www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007.
Accessed 12/5/2010.
Setter, SM, Neumiller JJ, JohnsonM, et al. The Mini-Cog: a rapid dementia screening
tool suitable for pharmacists’ use. The consultant Pharmacist. 2007y:22(10):855861.
References
8.
Slattum Patricia W, Swerdlow Russell H, Hill Angela M, "Chapter 67. Alzheimer's
Disease" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R. Matzke,
Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach,
7e: http://www.accesspharmacy.com/content.aspx?aID=3186564. Accessed
12/5/10.
9. Skelton, JB. Pharmacy-based Identification and Screening for Memory Decline:
Curricular Guide for Schools and Colleges of Pharmacy. The American Association of
Colleges of Pharmacy. July 2009.
10. Smith, DA. Treatment of Alzheimer’s disease in the long-term-care setting. American
Journal of Health System Pharmacists. 2009; 66: 899-907.
11. The Alzheimer’s Association. http://www.alz.org/. Accessed 12/13/2010.
12. The Alzheimer’s Foundation of America. http://www.alzfdn.org/index.htm. Accessed
12/13/2010.