Chapter 18 Pharmacology PDF

18 Antidementia Drugs Key Terms acetylcholine neurotransmitter that sends impulses across the parasympathetic branch of the autonomic nervous system Alzheimer disease (AD) progressive neurologic disorder that affects cognition, emotion, and movement amyloid plaque tangles of protein in nerve tissue...

18 Antidementia Drugs Key Terms acetylcholine neurotransmitter that sends impulses across the parasympathetic branch of the autonomic nervous system Alzheimer disease (AD) progressive neurologic disorder that affects cognition, emotion, and movement amyloid plaque tangles of protein in nerve tissue delirium an acute, temporary state of mental confusion dementia decrease in cognitive function parasympathetic pertaining to the part of the autonomic nervous system concerned with conserving body energy Learning Objectives On completion of this chapter, the student will: 1. Compare and contrast the clinical manifestations of Alzheimer disease (AD). 2. Explain the uses, general drug actions, general adverse reactions, contraindications, precautions, and interactions associated with the administration of antidementia drugs. 3. Distinguish important preadministration and ongoing assessment activities the nurse should perform with the client taking an antidementia drug. 4. List nursing diagnoses particular to a client taking an antidementia drug. 5. Examine ways to promote an optimal response to therapy, how to manage common adverse reactions, and important points to keep in mind when educating clients about the use of antidementia drugs. Drug Classes Cholinesterase inhibitors N-methyl-daspartate (NMDA) receptor antagonists PHARMACOLOGY IN PRACTICE Mrs. Moore, 85 years of age, has been experiencing progressive forgetfulness for about a year. Her daughter was in town last week and accompanied her to the clinic. After an initial examination, the primary health care provider decided to try a cholinesterase inhibitor. Mrs. Moore has called the clinic today complaining of gastrointestinal (GI) distress symptoms. She tells you to order an x-ray and find the ulcer in her tummy. You ask her to come to the clinic and she agrees. What assessment questions do you need to ask to determine if this is an appropriate request? INTRODUCTION One of the greatest fears of aging is dementia. Used as an overall term for a variety of diseases and conditions, dementia involves the decrease in cognitive functioning, such as memory, attention, language or communication ability, and problem-solving skills. Alzheimer disease (AD) is the cause of about 60%–80% of all cases of dementia. The specific pathologic changes of AD occur in the cortex of the brain. These changes involve the degeneration of nerves by amyloid plaques and tangled nerve bundles, which slows or blocks transmission within the brain. When neurotransmission is impaired, the clinical symptoms of dementia result. Cholinesterase inhibitors and the newer NMDA receptor antagonists are drugs used to strengthen neurotransmission and improve or maintain memory in those with dementia. Approximately 5.8 million people in the United States who are over the age of 65 years are diagnosed with AD (AA, 2020). AD progresses in a five-stage sequence as illustrated in Figure 18.1. This is a representation of the pathologic processes and not the “traditional” AD stages; these expanded stages help you understand the role of drug therapy in the treatment of the disease (Reisberg et al., 2012). Early on is a period of time called the preclinical stage when measurable changes are happening in the brain. The individual does not experience changes in cognitive or functional ability, yet these changes can be seen on magnetic resonance imaging and the biomarkers are present in blood and cerebrospinal fluid. Currently, drugs are not suitable for this time, which can occur up to 20 years before symptoms begin to appear. FIGURE 18.1 Continuum of Alzheimer disease progression. The second stage is when cognitive changes appear and is termed mild cognitive impairment. Clients are often identified because of mild to moderate anxiety as changes in thinking ability become noticeable to the client or, as frequently occurs, to family members. This is when other acute or chronic causes should be ruled out as causing the thinking or memory changes. PRACTICE CONSIDERATIONS Hypothyroidism can present with cognitive impairment. Researchers have found that some clients are treated for dementia when thyroid dysfunction is the true medical problem. A study looking at those prescribed antidementia medications found only 32% had thyroid function testing done before prescription of the medication to rule out other medical conditions first (Sakata & Okumura, 2018). During the second stage, a client’s functional ability is intact, and this is when medications can help to limit the cognitive progression into later stages of the disease (Reisberg et al., 2012). Antianxiety and antidepressant drugs (Chapters 19 and 21) may be prescribed before antidementia medications. If mental ability does not improve then cholinesterase inhibitors or NMDA receptor antagonists are added to the treatment regime. Extensive mental function testing is indicated and can help delineate a course of treatment. Unfortunately, many individuals are not identified during this stage and best outcomes from the antidementia medications are not seen because they are not started early. During the third through fifth stages of the disease, behaviors typically associated with the dementia of AD present, memory, thinking, and behavior changes, limit the ability to function independently (Jack et al., 2011). Reasoning and judgment become impaired. Socialization lessens due to behavioral changes, and variable degrees of assistance are needed for activities of daily living. Changes and additions in medications help to support function and behaviors. Refer to other chapters in Unit 4 to learn about the drugs used to support the client who is anxious (Chapter 19), depressed (Chapter 21), or may have difficulty controlling negative behaviors (Chapters 20 and 23). The drugs used to treat dementia slow the progression. They do not cure or stop the symptoms or the disease. Other diseases, such as Parkinson disease, may have a dementia component, but cholinesterase inhibitors are approved primarily to treat mild to moderate dementia caused by AD. Drugs used to treat AD do not cure the disease but slow the progression of dementia. Two classes of drugs that are used include the cholinesterase inhibitors such as donepezil (Aricept) and the NMDA receptor antagonist such as memantine (Namenda). Other drug classes are used for specific symptomatic relief. For example, wandering, irritability, and aggression in people with AD are treated with antipsychotics, such as risperidone and olanzapine. Other drugs, such as antidepressants or antianxiety drugs may be helpful in AD for symptoms of depression and anxiety; these drugs are all discussed in individual chapters. PHARMACOLOGY IN PRACTICE PATHOLOGY In the following stage of Alzheimer disease, there are brain changes detectable on an MRI but no cognitive changes. Which stage of the disease is being described? 1. Stage 1 2. Stage 3 3. Stage 5 ANTIDEMENTIA DRUGS Actions Acetylcholine is the transmitter substance in the parasympathetic (or cholinergic) neuropathway. Individuals with AD experience reduction in nerve impulse transmission because of plaques and tangles as illustrated in Figure 18.2. As a result, the client experiences problems with memory and thinking. The cholinesterase inhibitors act to increase the level of acetylcholine in the central nervous system (CNS) by inhibiting its breakdown and slowing neural destruction. However, the disease is progressive, and although these drugs alter the progress of the disease, they do not stop it. Cholinesterase inhibitors are not frequently used in late-stage AD. FIGURE 18.2 Amyloid plaques and nerve tangles clog neuropathways; cholinesterase inhibitors keep acetylcholine at the nerve junction longer to promote transmission. A newer drug used to treat AD dementia is the NMDA receptor antagonist drug, memantine (Namenda). The NMDA receptor antagonist is thought to work by decreasing the excitability of neurotransmission caused by an excess of the amino acid glutamate in the CNS. Glutamate is also a transmitter to areas of learning and memory in the brain, yet too much of this substance can damage cells. The NMDA blocker attaches to nerve cell receptors and helps to prevent the cell damage. USES Cholinesterase inhibitors and the NMDA receptor antagonist are used to treat early and moderate stages of dementia associated with AD. Their use for severe cognitive decline as well as other dementias, such as vascular or Parkinson dementia, is being studied. PRACTICE CONSIDERATIONS Currently, methylphenidate (CNS stimulant) is being researched as a medication to diminish apathetic affect and improve cognition in clients with AD. Initial results demonstrate good short-term improvement (Kishi et al., 2020). ADVERSE REACTIONS Generalized adverse reactions include: Anorexia, nausea, vomiting, diarrhea Dizziness and headache Additional adverse reactions are listed in the Summary Drug Table: Antidementia Drugs. NURSING ALERT Early diagnosis is the key to using drugs to slow AD symptoms. Brain imaging with positron emission tomography scans is enhanced with radioactive diagnostic drugs. Two drugs currently in use are flutemetamol (Vizamyl) and florbetapir (Amyvid). Adverse reactions of these drugs include flushing, headache, increased blood pressure, nausea, and dizziness. CONTRAINDICATIONS AND PRECAUTIONS These drugs are contraindicated in clients with hypersensitivity to the drugs and during pregnancy and lactation (pregnancy category B). The drugs are used cautiously in clients with renal disease, bladder obstruction, seizure disorders, sick sinus syndrome, GI bleeding, and asthma. In individuals with a history of ulcer disease, bleeding may recur. Some clients may experience delirium as well as their underlying dementia. These drugs are used to treat dementia and should not be used to treat confused clients experiencing delirium. Box 18.1 outlines the differences between delirium and dementia. BOX 18.1 Differences Between Confusion of Delirium and Dementia Onset Delirium Sudden change Dementia Progressive change Typical presentation Affects senses (see, hear, feel) Affects memory and judgment Reversibility Yes, when cause such as oxygen, chemical imbalances, or infection is found and treated No, can slow progression with drugs, need to change environment for client to remain safe PHARMACOLOGY IN PRACTICE ASSESSMENT A client with dementia may also have delirium. Which of the following signs indicate a cognitive problem is due to delirium and not dementia? Select all that apply. 1. 2. 3. 4. 5. Sudden onset Client feels itchy Placing oxygen may resolve it Progressive changes Irreversible LASA ALERT The following drugs may sound alike; be sure to clarify when they are ordered: Drug Name Sounds Like Aricept Razadyne Ascriptin, Azilect Rozerem Drugs that look like a similar drug are noted in the Summary Drug Tables of each chapter. INTERACTIONS The following interactions may occur when a cholinesterase inhibitor or NMDA receptor antagonist is administered with another agent: Interacting Drug Common Use Effect of Interaction Interacting Drug Anticholinergics Common Use Decrease of bodily secretions Effect of Interaction Decreased effectiveness of anticholinergics Nonsteroidal antiinflammatory drugs Pain relief Increased risk of GI bleeding Theophylline Breathing problems Increased risk of theophylline toxicity Thiazide diuretics (with NMDA receptor antagonist) Reduce fluid retention Decreased effectiveness of the thiazide drug SUPPLEMENTS FOR BRAIN HEALTH Individuals are very fearful of memory loss leading to dementia. Here are two examples of supplements or herbal preparations clients may be taking to enhance memory and brain health—apoaequorin and ginko biloba. Apoaequorin is a calcium-binding protein originally discovered in a species of jellyfish. The company marketing a popular product for memory enhancement, Quincy Bioscience, has published several studies speculating the neuroprotective effects of apoaequorin. In their studies, individuals received the supplement or a placebo with results showing marked memory improvement in the group taking the supplement (Martin, 2012). The use of the supplement is based on the idea that brain cell death and subsequent dementia has to do with the amount of calcium in the cells of the brain (Martin, 2012). When calcium is not bound to proteins, it fluctuates in the circulation of the brain. Over time, this fluctuation in and out of the brain cells can cause cell death leading to the advancement of the dementia of Alzheimer disease (Martin, 2012). In an independent study, Bedlack (2013) was unable to replicate the calcium-binding capability of apoaequorin and found that it did not survive the process of digestion (destroyed by acid) and was not able to pass the blood–brain barrier. Any supplement should be discussed with a primary health care provider before starting self-treatment. Herbal Considerations Ginkgo, one of the oldest herbs in the world, has many beneficial effects. It is thought to improve memory and brain function and enhance circulation to the brain, heart, limbs, and eyes. Conflicting research both supports and disputes ginkgo’s ability to enhance memory. Medical studies in the United States and England (Snitz et al., 2009; UM, 2011) have not demonstrated increases in mental function. Despite this research, the “brain herb” is still taken by healthy adults hoping to retain their current memory and cognitive function. The recommended dose is 40 mg standardized extract ginkgo three times daily. The effects of ginkgo may not be evident until after 4–24 weeks of treatment. The most common adverse reactions include mild GI discomfort, headache, and rash. Excessively large doses have been reported to cause diarrhea, nausea, vomiting, and restlessness. Ginkgo is contraindicated in clients taking selective serotonin reuptake inhibitor or monoamine oxidase inhibitor antidepressants because of the risk of a toxic reaction. Moreover, individuals taking anticoagulants should take ginkgo only on the advice of a primary care provider. NURSING PROCESS—Steps to Building Clinical Judgment Client Receiving an Antidementia Drug ASSESSMENT A client receiving an antidementia drug may be treated in the hospital, long-term care facility, or outpatient setting. Preadministration Assessment Data gathering suggestions before the initial administration of antidementia drugs include: Objective data Description of general appearance, orientation to person, place, and time Vital signs (temperature, pulse, respirations, and blood pressure) and weight Observation of behavior during interview: poor eye contact, failure to answer questions completely, inappropriate answers to questions, monotone speech pattern, and inappropriate laughter, sadness, or crying, signifying varying stages of decline Cognitive screen with tools such as Mini-Mental Status Examination (MMSE) Battery of cognitive and functional ability testing, including orientation, calculation, recall, and language Subjective data Current history of symptoms that bother the client Self-report compared with family members for ability to perform activities of daily living and self-care Unusual activity such as wandering or outbursts of anger or frustration Medical and mental health history Review chart for drugs that may cause changes in mental health When the disease is advancing, clients with AD are not always able to give a reliable history of their illness. A family member or primary caregiver may be helpful in verifying or providing information needed for an accurate assessment. Ongoing Assessment Ongoing assessment of clients taking antidementia drugs includes both mental and physical assessments. Cognitive and functional abilities are assessed routinely for changes. Initial assessments will be compared with the ongoing assessments to monitor the client’s improvement (if any) after taking the antidementia drugs. Using standardized tools to obtain an accurate description of the client’s behavior and cognitive ability aids the primary health care provider in planning therapy and thus becomes an important part of client management. Clients with poor response to drug therapy may require dosage changes, discontinuation of the drug therapy, or the addition of other therapies to the treatment regimen. However, response to these drugs may take several weeks. The symptoms that the client is experiencing may improve or remain the same, or the client may experience only a small response to therapy. It is important to remember that a treatment that slows the progression of symptoms in AD is a successful treatment. NURSING DIAGNOSES Drug-specific nursing diagnoses include the following: Malnutrition: less than body requirements related to anorexia, nausea, or vomiting Injury risk related to dizziness, syncope, clumsiness, or the disease process Nursing diagnoses related to drug administration are discussed in Chapter 4. PLANNING The expected outcomes for the client may include an optimal response to drug therapy, meeting client needs related to the management of adverse reactions, an absence of injury, and confidence in an understanding of the medication regimen. IMPLEMENTATION Promoting an Optimal Response to Therapy As you develop a care plan to meet the client’s individual needs, keep in mind this is a progressive disease. When the drugs no longer provide memory enhancement, environmental factors may need to change rather than modifying the client’s behavior. If the client is hospitalized, it is important to monitor vital signs and other assessments to determine if changes may be from the dementia or if the client is experiencing delirium (acute confusion) caused by reversible causes (see Box 18.1). NURSING ALERT Should cholinesterase inhibitor therapy be discontinued, individuals lose any benefit they have received from the drugs within 6 weeks. Rivastigmine (Exelon) is available in a transdermal form of the drug. The patches are changed on a daily basis and rotated to a clean, dry, and hairless area. Because the client is experiencing dementia, the site for application should be where the client is not able to pick at or remove the patch. The upper or lower portions of the back are recommended for the patch administration. Because the same site should not be used more than once every 2 weeks, document or teach the caregiver to make a chart of the back and indicate where patches have been applied during the last 14 days. Monitoring and Managing Client Needs Malnutrition: Less Than Body Requirements When taking an antidementia drug, clients may experience nausea and vomiting. Although this can occur with all of the cholinesterase inhibitors, clients taking rivastigmine (Exelon) appear to have more problems with nausea and severe vomiting. Attention to the dosing of medications can decrease adverse GI reactions and promote nutrition. The primary health care provider may discontinue use of the drug and then restart the drug therapy at the lowest dose possible. Restarting therapy at the lower dose helps to reduce nausea and vomiting. The antidementia drug can be taken with or without food. Although donepezil (Aricept) is administered orally once daily at bedtime, it can also be given with a snack. When administering rivastigmine as an oral solution, remove the oral dosing syringe provided in the protective container. The syringe provided is used to withdraw the prescribed amount. The dose may be swallowed directly from the syringe or first mixed with a small glass of water, cold fruit juice, or soda. Chronic Care Considerations Namzaric is the first combined cholinesterase inhibitor and NMDA receptor antagonist drug on the market. By combining these medications, drug administration is reduced to one daily pill in the evening instead of up to six pills throughout the day. This may ease distress on clients with AD who have difficulty taking medications. Weight loss and eating problems related to the inability to swallow are two major problems in the late stage of AD. These problems, coupled with anorexia and nausea associated with administration of cholinesterase inhibitors, present a challenge for caregivers. Typically, these drugs are not administered during the late stage of dementia, but there may be a period of worsening symptoms before the drugs are stopped entirely. Mealtime should be simple and calm. Offer the client a well-balanced diet with foods that are easy to chew and digest. Frequent, small meals may be tolerated better than three regular meals. Offering foods of different consistency and flavor is important in case the client can handle one form better than another. Fluid intake of six to eight glasses of water daily is encouraged to prevent dehydration. Injury Risk Physical decline and the adverse reactions of dizziness and syncope place the client at risk for injury. The client may require assistance when ambulating. Assistive devices such as walkers or canes may reduce falls. To minimize the risk of injury, the client’s environment should be controlled and safe. Encouraging the use of bed alarms, keeping the bed in low position, and using night lights, as well as frequent monitoring, will reduce the risk of injury. The client should wear medical identification, such as a MedicAlert bracelet, at all times. Educating the Client and Family Early in the disease, the client may be able to understand changes, yet suspicion and denial are classic symptoms of the disease; therefore, the client may not be amenable to treatment. As cognitive abilities decrease, focus on educating the family and primary caregiver of the client’s needs. Depending on the degree of cognitive decline, discuss the drug regimen with the client, family member, or caregiver. It is important to evaluate accurately the client’s ability to assume responsibility for taking drugs at home. The client and family should feel confident in understanding that the drugs used do not cure but rather control symptoms of the disease. It is your task to help family members assume responsibility for medication administration when the client appears to be unable to manage their own drug therapy in the home. Teach and provide written handouts in the preferred language about the drugs and adverse reactions that may occur with a specific drug, and encourage the caregiver or family members to contact the primary health care provider immediately when a serious drug reaction occurs. As you develop a teaching plan for the client or family member, include the following points: Keep all appointments with the primary care provider or clinic, because close monitoring of therapy is essential. Dose changes may be needed to achieve the best results. Report any unusual changes or physical effects to the primary health care provider. Take the drug exactly as directed. Do not increase, decrease, or omit a dose or discontinue use of this drug unless directed to do so by the primary health care provider. Do not drive or perform other hazardous tasks if drowsiness occurs. Discuss with your primary health care provider when clients should be evaluated for their continued ability to drive. Do not take any nonprescription drug before talking to your primary health care provider. Keep track of when the drug is taken. Marking the calendar, cell phone alarms, or a pill counter that holds the medicine for each day of the week may be helpful tools to remind the client to take the medication or determine whether the medication has been taken for the day. Notify the primary care provider if the following adverse reactions are experienced for more than a few days: nausea, diarrhea, difficulty sleeping, vomiting, or loss of appetite. Immediately report the occurrence of the following adverse reactions: severe vomiting, dehydration, or changes in neurologic functioning. Notify the primary health care provider if the client has a history of ulcers, feels faint, experiences severe stomach pains, vomits blood or material that resembles coffee grounds, or has bloody or black stools. Remember that these drugs do not cure AD but slow the mental and physical degeneration associated with the disease. The drug must be taken routinely to slow the progression. PHARMACOLOGY IN PRACTICE MANAGING NEEDS A client with moderate dementia of the Alzheimer type repeatedly spits out pills. They are being changed to a transdermal patch. Where should the nurse place a cholinesterase inhibitor transdermal patch so that the client cannot easily remove it? 1. 2. 3. 4. Upper arm Side of thigh Chest Lower back EVALUATION Therapeutic effect is achieved and cognitive function is maintained. Adverse reactions are identified, reported to the primary health care provider, and managed successfully through appropriate nursing interventions: Client maintains an adequate nutritional status. No injury is evident. Client (if able) and family express confidence and demonstrate an understanding of the drug regimen. PHARMACOLOGY IN PRACTICE USING CLINICAL REASONING While Mrs. Moore is putting on a patient gown at the clinic, you notice she appears to have multiple “bandages” all over her body. Upon closer examination, the bandage reads EXELON PATCH. Does this explain her GI distress? KEY POINTS AD is one of the conditions in which dementia is a major issue. This occurs because of the buildup of plaques and tangles in the neurons of the brain. Acetylcholine is reduced, resulting in symptoms of dementia. The progression of memory loss associated with dementia is treated with cholinesterase inhibitors/NMDA receptor antagonist agents. These drugs slow progression but do not cure dementia. Clients with dementia may at times experience acute confusion, known as delirium. These drugs do not treat delirium. Some of the most common adverse reactions of these drugs include dry mouth, nausea, and vomiting. Nutrition becomes a primary issue in treatment because clients with AD also may have reduced appetite and difficulty eating. Involvement of family members or caregivers is essential for the treatment and management of the client with AD because of the cognitive and functional changes involved. SUMMARY DRUG TABLE Antidementia Drugs Generic Name Trade Name Uses Adverse Reactions Dosage Ranges Cholinesterase Inhibitors donepezil doh-NEP-e-zil Aricept Mild to severe dementia caused by AD, memory improvement in dementia caused by stroke, vascular disease, multiple sclerosis Headache, nausea, diarrhea, insomnia, muscle cramps 5–10 mg/day orally galantamine ga-LAN-ta-meen Razadyne Mild to moderate (AD) dementia Nausea, vomiting, diarrhea, anorexia, dizziness 16–24 mg BID orally rivastigmine ri-va-STIG-meen Exelon (transdermal) Mild to moderate dementia of AD and Parkinson disease Nausea, vomiting, diarrhea, dyspepsia, anorexia, insomnia, fatigue, dizziness, headache 1.5–12 mg/day BID orally; 4.6, 9.5, 13.3 mg daily transdermal patch Namenda Moderate to severe (AD) dementia Dizziness, headache, confusion 5–10 mg BID orally Namzaric Moderate to severe (AD) dementia See individual drugs above 14–28/10 mg orally every evening NMDA Receptor Antagonist memantine me-MAN-teen Combination Drugs memantine/donepezil CHAPTER REVIEW Know Your Drugs Clients sometimes know a medication by the brand (or trade) name and not the generic name. To help you recognize both names, match the brand name with the generic name of the same medication. Generic Name Brand Name 1. donepezil A. Aricept 2. galantamine B. Exelon 3. memantine C. Namenda 4. rivastigmine D. Razadyne Calculate Medication Dosages 1. Rivastigmine oral solution 6 mg is prescribed. The drug is available as an oral solution of 2 mg/mL. The nurse administers _________. 2. Oral memantine (Namenda) 10 mg is prescribed for a client with AD. On hand are 5mg tablets. The nurse administers _________. Prepare for the NCLEX RECALL THE FACTS 1. AD involves protein plaques and nerve tangles that limit which neurotransmitter? 1. acetylcholine 2. dopamine 3. norepinephrine 4. serotonin 2. Adverse reactions that the nurse would assess for in a client taking rivastigmine (Exelon) include _________. 1. occipital headache 2. vomiting 3. hyperactivity 4. hypoactivity 3. When administering donepezil (Aricept) to a client with AD, the nurse would most likely expect which diagnostic test to have been prescribed? 1. complete blood count 2. cholesterol levels 3. brain scan 4. electrolyte analysis 4. Which of the following nursing diagnoses would the nurse most likely place on the care plan of a client with AD that is related to adverse reactions of the cholinesterase inhibitors? 1. Malnutrition 2. Confusion 3. Self-harm risk 4. Bowel incontinence 5. The nurse correctly administers donepezil (Aricept) _________. 1. three times daily around the clock 2. twice daily 1 hour before meals or 2 hours after meals 3. once daily in the morning 4. once daily at bedtime ANALYZE THE FACTS 6. When a client’s dementia causes them to pick at items, the rivastigmine transdermal patch should be placed: 1. on the abdomen. 2. on the upper arms. 3. between the shoulder blades. 4. on the thigh. 7. * The nurse correctly disposes the rivastigmine transdermal patch by first: 1. placing it in a tissue and discarding in trash can. 2. flushing the patch in the client’s toilet. 3. folding it over so the adhesive side sticks together. 4. disposing in a sharps contaminated box in the client’s room. 8. Which of the following is an indicator of delirium? 1. progressive, insidious onset 2. caused by bladder infection 3. ongoing confusion 4. problems with memory ALTERNATE-FORMAT QUESTIONS 9. Which of the following are used to monitor progression of AD? Select all that apply. 1. MMSE 2. brain scan 3. blood studies 4. urinalysis 5. memory testing 10. For drug development purposes, AD is now defined in five stages. Cholinesterase inhibitors are used during which stage(s)? Select all that apply. 1. stage 1 2. stage 2 3. stage 3 To check your answers, see Appendix F. * Indicates the question is directly linked to the NCLEX-PN test plan in Appendix G. WANT TO KNOW MORE? A wide variety of resources are available to enhance your learning and understanding of this chapter. ■ Visit for resources such as: NCLEX-Style Student Review Questions Journal Articles Dosage Calculations Drug Monographs Watch and Learn Videos Concepts in Action Animations ■ The Study Guide to Accompany Introductory Clinical Pharmacology, 12th edition, sold separately, will help you review and apply essential content. ■ is available to help students prepare for the NCLEX-PN examination.