Regarding Alzheimer's disease...

A 69-year-old man who is known to have Alzheimer's disease is reviewed in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30.
According to NICE guidelines, what further action should be taken?
A. Supportive care + memantine
B. Supportive care + trial of citalopram
C. Continue supportive care
D. Supportive care + donepezil + low-dose aspirin
E. Supportive care + donepezil

Answer:
E. Supportive care + donepezil

Discussion: 

Alzheimer's disease is a progressive degenerative disease of the brain accounting for the majority of dementia seen in the UK 

Genetics 

 most cases are sporadic 

 5% of cases are inherited as an autosomal dominant trait 

 mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form 

 apoprotein E allele E4 - encodes a cholesterol transport protein 

Pathological changes 

 macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus 

 microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein 

 biochemical: there is a deficit of acetylecholine from damage to an ascending forebrain projection 

Neurofibrillary tangles 

 paired helical filaments are partly made from a protein called tau 

 in AD are tau proteins are excessively phosphorylated 

Management 

 NICE now recommend the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer's disease 

 memantine (a NMDA receptor antagonist) is reserved for patients with moderate - severe Alzheimer's