Question

A 79-year-old man presents to the clinic for follow-up of his Alzheimer's disease. The patient was diagnosed with late-onset Alzheimer's disease with mild neurocognitive impairment two months back. He was started on oral rivastigmine and memantine combination, along with advice to make social and dietary adjustments. The patient seems to be doing better, with decreased irritability and proper sleep. His memory remains impaired, and he is still inattentive and confused most of the time. It is reported that ever since patient began treatment, he's been nauseous with one to two episodes of vomiting in a week and on and off diarrhea. The patient expresses resistance in compliance to medication. What is the most appropriate management for the patient's gastrointestinal symptoms?

A. Stop rivastigmine and increase the dose of memantine
B. Decrease dose of both rivastigmine and memantine
C. Initiate daily metronidazole
D. Convert rivastigmine administration to transdermal patchE. Replace rivastigmine with donepezil

Answer 1

To manage the patient's gastrointestinal symptoms, it is appropriate to convert oral rivastigmine administration to a transdermal patch to reduce side effects while continuing Alzheimer's management.

Step-by-step explanation:

The most appropriate management for the patient's gastrointestinal symptoms, which include nausea, vomiting, and diarrhea potentially due to Alzheimer's disease medications, is to convert rivastigmine administration to a transdermal patch. This approach is likely to reduce the gastrointestinal side effects while still providing the cognitive benefits of the drug. Rivastigmine is a cholinesterase inhibitor and memantine is an NMDA receptor antagonist; both are used to manage symptoms of Alzheimer's disease. However, rivastigmine in oral form can cause gastrointestinal issues, and switching to a patch can mitigate these side effects. It is not recommended to stop rivastigmine all at once or to increase the dose of memantine in this scenario, nor to initiate metronidazole which is an antibiotic and not indicated here, or to replace rivastigmine with donepezil without proper assessment of donepezil's appropriateness and tolerability for the patient.