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Bromocriptine
0%
0/5
Pramipexole
20%
1/5
Ropinirole
Rivastigmine
40%
2/5
Memantine
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An elderly lady with dementia with no focal neurological deficits and diffuse cortical atrophy on MRI is likely suffering from Alzheimer's disease and should be treated with first-line therapy of acetylcholinesterase inhibitors (ex. rivastigmine). Alzheimer's disease is a disease characterized by progressive memory loss and cognitive decline that may result in patients' inability to perform activities of daily living. It is more common in women and patients above 65 years of age. It occurs over a period of years and presents with amyloid plaques and neurofibrillary tau tangles in the brain. This pathology causes destruction of the cholinergic neurons resulting in an acetylcholine deficiency which manifests itself with cognitive decline. Winslow et al. discuss the treatment of Alzheimer's disease. They state that hypertension treatment, omega-3 fatty acid supplementation, physical activity, and cognitive engagement demonstrate some potential in slowing the decline caused by Alzheimer's disease. They also state that the first line pharmacotherapy is acetylcholinesterase inhibitors such as rivastigmine and donepezil with NMDA agonists such as memantine as second line therapy. They state that this is because several meta-analyses have failed to find memantine as effective as traditional acetylcholinesterase inhibitors in improving cognitive symptoms. Lanctot et al. discuss the benefit of acetylcholinesterase inhibitors on patients with Alzheimer's disease. In their meta-analysis, they report that the number needed to treat (NNT) for 1 additional patient to benefit was 7 patients (95% CI 6-9) for stabilization or better, 12 (95% CI 9-16) for minimal improvement or better and 42 (95% CI 26-114) for marked improvement. They also noted that the NNT for 1 patient to experience an adverse event was 12 (95% CI 10-18). Incorrect Answers: Answers 1, 2, and 3: Bromocriptine, pramipexole, and ropinirole all act on dopamine-2 (D2) receptors in the CNS and are used for Parkinson's disease. Answer 5: Memantine is used in Alzheimer's disease and is an NMDA antagonist. It is a second line drug after acetylcholinesterase inhibitors.
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