AAC Pharmacological Interventions 3 — Questions and Answers
Question 1: Which antipsychotic carries an FDA black box warning specifically for increased mortality risk when used in elderly patients with dementia-related psychosis?
- Only haloperidol
- All antipsychotics, both typical and atypical (Correct answer)
- Only risperidone and olanzapine
- Only clozapine
Correct answer: All antipsychotics, both typical and atypical
The FDA black box warning applies to all antipsychotic medications—both typical and atypical—regarding increased mortality in elderly patients with dementia-related psychosis.
Question 2: A person with Alzheimer's develops severe agitation during late-afternoon hours daily. Before considering pharmacological treatment, the standard guideline-recommended first step is:
- Start low-dose risperidone immediately
- Identify and address potential non-pharmacological triggers (Correct answer)
- Order an EEG to rule out seizure activity
- Initiate a benzodiazepine for immediate relief
Correct answer: Identify and address potential non-pharmacological triggers
Guidelines consistently recommend non-pharmacological interventions as first-line treatment for behavioral symptoms before considering medications.
Question 3: Tacrine (Cognex) was the first FDA-approved cholinesterase inhibitor for Alzheimer's but is no longer used primarily because of:
- Lack of any cognitive efficacy
- Serious hepatotoxicity requiring frequent liver monitoring (Correct answer)
- Cardiovascular toxicity causing fatal arrhythmias
- Severe nephrotoxicity requiring dialysis
Correct answer: Serious hepatotoxicity requiring frequent liver monitoring
Tacrine was withdrawn from clinical use due to significant hepatotoxicity, with patients requiring frequent liver function monitoring.
Question 4: When discontinuing a cholinesterase inhibitor after long-term use, the recommended approach is:
- Abrupt cessation to minimize side effects
- Gradual tapering over several weeks (Correct answer)
- Switching directly to memantine on the same day
- Halving the dose for one day then stopping
Correct answer: Gradual tapering over several weeks
Abrupt discontinuation of cholinesterase inhibitors can cause rapid cognitive or behavioral decline; gradual tapering is recommended to minimize this risk.
Question 5: Which medication class should generally be AVOIDED in Alzheimer's patients because anticholinergic effects can worsen cognitive function?
- Beta-blockers
- ACE inhibitors
- First-generation antihistamines like diphenhydramine (Correct answer)
- Calcium channel blockers
Correct answer: First-generation antihistamines like diphenhydramine
Anticholinergic medications like diphenhydramine block the acetylcholine system, directly counteracting cholinesterase inhibitor therapy and worsening cognition.
Question 6: Suvorexant (Belsomra), an orexin receptor antagonist, is FDA-approved for treating which specific symptom in Alzheimer's disease?
- Agitation and aggression
- Insomnia (Correct answer)
- Depression
- Psychosis
Correct answer: Insomnia
Suvorexant received FDA approval specifically for treating insomnia in patients with Alzheimer's disease in 2022.
Question 7: The 'start low, go slow' prescribing principle in Alzheimer's pharmacotherapy primarily exists because older adults with dementia often have:
- Higher renal clearance than younger adults
- Altered pharmacokinetics and increased sensitivity to CNS drugs (Correct answer)
- Lower rates of polypharmacy concerns
- Enhanced hepatic metabolism requiring higher doses
Correct answer: Altered pharmacokinetics and increased sensitivity to CNS drugs
Aging and dementia alter drug absorption, distribution, metabolism, and excretion, while also increasing CNS sensitivity, necessitating conservative dosing.
AAC Pharmacological Interventions 3
Which antipsychotic carries an FDA black box warning specifically for increased mortality risk when used in elderly patients with dementia-related psychosis?