Antipsychotics And Other Drug Approaches In Dementia Care
Antipsychotic drugs may be prescribed for people with dementia who develop changes such as aggression and psychosis. However this is usually only after other drugs have been tried such as anti-depressant, anti-dementia and anticonvulsant drugs.
Drugs for behavioural and psychological symptoms
Dementia Drugs And Heart Problems: What Does The Latest Research Say
The effect of dementia drugs on the health of a persons heart and blood vessels appears to be generally quite positive.
A recent review of studies found that people who took cholinesterase inhibitors had a 37 per cent lower risk of having a heart attack or stroke.
The research study found that these people were also less likely to die from a heart-related problem.
However, the review also found an increased risk of a relatively rare problem called bradycardia.
What Should You Do If You Take These Drugs
Keep in mind that the research shows associations and correlationsnot causation or definitive proof.
However, if you are an older person or have Alzheimers risk factors, its a good idea to talk with your doctor about your medications. Are there non-anticholinergic medications you can take instead? Do the benefits of your medication outweigh its risks? Perhaps you can revisit beneficial lifestyle habits to help control your symptoms.
Another question to ask is if you are taking the lowest possible effective dose. The researchers at the University of California in San Diego found that the older people in the study were taking much higher doses of anticholinergic drugs than recommended for their ages. The majority were taking double the recommended dosage and 18% were taking four times the optimal dose. One first step might be to find out if you are taking too high a dose another would be to see how many anticholinergic drugs you are taking to see your total intake.
A doctor in England has created an online tool, the Anticholinergic burden calculator, where you can plug in what drugs you are taking and see how they combine. If you have a score of three or higher on this calculator, you are considered at higher risk of developing cognitive impairment.
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Medicines To Treat Challenging Behaviour
In the later stages of dementia, a significant number of people will develop what’s known as behavioural and psychological symptoms of dementia .
The symptoms of BPSD can include:
- increased agitation
- aggression
- delusions and hallucinations
These changes in behaviour can be very distressing for both the person with Alzheimer’s disease and their carer.
If coping strategies do not work, a consultant psychiatrist can prescribe risperidone or haloperidol, antipsychotic medicines, for those showing persistent aggression or extreme distress.
These are the only medicines licensed for people with moderate to severe Alzheimer’s disease where there’s a risk of harm to themselves or others.
Risperidone should be used at the lowest dose and for the shortest time possible as it has serious side effects. Haloperidol should only be used if other treatments have not helped.
Antidepressants may sometimes be given if depression is suspected as an underlying cause of anxiety.
Sometimes other medications may be recommended to treat specific symptoms in BPSD, but these will be prescribed “off-label” .
It’s acceptable for a doctor to do this, but they must provide a reason for using these medications in these circumstances.
Treatment For Mild To Moderate Alzheimers
Treating the symptoms of Alzheimers can provide people with comfort, dignity, and independence for a longer period of time and can encourage and assist their caregivers as well. Galantamine, rivastigmine, and donepezil are cholinesterase inhibitors that are prescribed for mild to moderate Alzheimers symptoms. These drugs may help reduce or control some cognitive and behavioral symptoms.
Scientists do not yet fully understand how cholinesterase inhibitors work to treat Alzheimers disease, but research indicates that they prevent the breakdown of acetylcholine, a brain chemical believed to be important for memory and thinking. As Alzheimers progresses, the brain produces less and less acetylcholine, so these medicines may eventually lose their effect. Because cholinesterase inhibitors work in a similar way, switching from one to another may not produce significantly different results, but a person living with Alzheimers may respond better to one drug versus another.
Before prescribing aducanumab, doctors may require PET scans or an analysis of cerebrospinal fluid to evaluate whether amyloid deposits are present in the brain. This can help doctors make an accurate diagnosis of Alzheimers before prescribing the medication. Once a person is on aducanumab, their doctor or specialist may require routine MRIs to monitor for side effects such as brain swelling or bleeding in the brain.
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What Are The Common Side Effects Of Dementia Drugs
While many people can take dementia drugs without any problems, some may experience unpleasant side effects. The most common side effects include:
- nausea, vomiting, diarrhoea
- hallucinations
- agitation or aggression
If you experience any of these symptoms while you are taking drugs for dementia, you should contact your GP as soon as possible. Your GP may be able to offer an alternative treatment that is easier for you to take.
If You Take One Of These Drugs
It’s always good to review the potential benefits and harms of these medications with your doctor. If a drug appears problematic, the two of you can explore alternatives by considering the reason it was prescribed and seeing if there is a different type of drug that can be used as a replacement.
Don’t stop taking the drugs on your own. It isn’t safe to quit most benzodiazepines and anticholinergic drugs “cold turkey.” Work with your clinician to develop a plan for tapering off them.
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Why These Drugs Have A Stronger Effect In Older People
As we age, our ability to process medication changes. The kidneys and liver clear drugs more slowly, so drug levels in the blood remain higher for a longer time. People also gain fat and lose muscle mass over time. Both these changes affect the way drugs are distributed to and broken down in body tissues. And because these drugs are stored in body fat, they can continue to produce effects days after people stop taking them, especially in people with a higher proportion of body fat. In addition, older people tend to take more prescription and over-the-counter medications, each of which has the potential to suppress or enhance the effects of the others.
Fdas Accelerated Approval Program
Aducanumab was approved through the FDAs Accelerated Approval Program, which provides a path for earlier approval of drugs that treat certain serious conditions. This helps people living with the disease gain earlier access to the treatment. The approval of aducanumab was based on the ability of the drug to reduce amyloid in the brain. When using the accelerated approval pathway, drug companies are required to conduct additional studies to determine whether there is in fact clinical benefit after the drug is approved. If the follow-up trial fails to verify clinical benefit, the FDA may withdraw approval of the drug. Results of the phase 4 clinical trial for aducanumab are expected to be available by early 2030.
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What To Do If A Family Member Is Using These Medications
Many medicines mentioned above are a part of the regime for a lot of elderly or mid-aged patients.
Now that we know that anticholinergic and benzodiazepines medication use and incident dementia are related, it is important not to panic if you notice a medicine in a family members routine, which comes under the class of medications that can worsen dementia. Often, individuals abruptly stop their medications, leading to other problems that can turn into a disease in the long term. Always consult the doctor and put forward your concerns before you stop taking prescribed medicine. Ask them to review the prescription and list alternatives. Moreover, medical tests for dementia can help with diagnosis.
In the case of over-the-counter medications, usually, anticholinergics can be stopped without the consultation of a doctor. However, using alternatives is a must because therapy cannot be terminated. For example, over-the-counter sleeping pills are strongly anticholinergic, and anticholinergic medications and dementia are linked. The therapy can be concluded if the patient exhibits symptoms of dementia or the condition declines. However, other therapeutic measures must be employed.
Types Of Medication For Difficult Behaviors In Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1.Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms.
Commonly used drugs: Antipsychotics often used in older adults include:
- Risperidone
- Haloperidol
- For a longer list of antipsychotics drugs, see this NIH page.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but its rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
- Increased risk of falls
- Increased risk of stroke and of death this has been estimated as an increased absolute risk of 1-4%
- A risk of side-effects known as extrapyramidal symptoms, which include stiffness and tremor similar to Parkinsons disease, as well as a variety of other muscle coordination problems
- People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects in such people, quetiapine is considered the safest choice
2. Benzodiazepines. This is a category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
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Medications That Have Side Effects
Dr. David S. Knopman, a clinical neurologist at the Mayo Clinic in Rochester, Minnesota, as well as a member of the Alzheimers Association Medical and Scientific Advisory Group, told Healthline that the key medications to look at are pain medications, sleep medications, anticholinergic medications, antidepressants, and other psychotropic drugs.
He said the anticholinergic class of medications is often considered the worst offender.
For all of them medication misadventures, somnolence, and increased confusion are the common concern, and the third is worsening gait and balance, he said. People who didnt have a prior diagnosis of impairment who are now acting confused, sleepy, or have more balance problems, that in somebody who doesnt have prior diagnosis should trigger a concern.
Your doctor may suggest alternatives to medications that could potentially cause side effects.
When I suggested to one of my patients that we try an alternative to Xanax like melatonin, she became very anxious, said Knopman. Its a difficult problem. Its one best treated by avoidance for starting it in the first place.
Steinman stressed the importance of investigating the side effects medications could be causing.
Unless were really active in exploring that opportunity sometimes it gets missed, and its just written off as dementia and the person sort of keeps deteriorating, he explained.
Learn About Your Medications
We all could benefit from being more informed consumers of medications and that doesnt just mean attempting to read the insert that is stapled to your prescription.
Youll drive yourself crazy because its 50 pages of tiny type that lists all of the terrible things that the medication can cause, Steinman said. So going to another trusted source that really says what are the most important side effects this medication can cause, what to do if you think you might be experiencing them, are more useful.
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Why The Drugs Affect Your Mind
Both anticholinergics and benzodiazepines affect the activity of neurotransmitterschemical messengers that work in the central nervous systembut the drugs work in slightly different ways.
Anticholinergic drugs block the action of acetylcholine. In the brain, acetylcholine is involved in learning and memory. In the rest of the body, it stimulates the autonomic nervesthose that regulate contractions of blood vessels, airways, and our cardiovascular and digestive systems. The strongest anticholinergic drugs include some antihistamines, tricyclic antidepressants, medications to control overactive bladder, and sleeping pills.
Benzodiazepines boost another neurotransmitter’s effectiveness. They make gamma-aminobutyric acid which slows the activity of neurons in the brain-more potent. For that reason, they are used to calm anxiety and help people sleep.
Risks Should Be Carefully Considered
To assess the strength of anticholinergic drugs and how often the participants took them, the team looked at available information about prescriptions over a period of 10 years.
However, they note that this is an observational study, so they cannot confirm whether the drugs are directly responsible for the increased risk of dementia.
The researchers add that doctors may have prescribed some of these drugs to their patients precisely for the treatment of very early dementia symptoms.
Nevertheless, Prof. Coupland argues that the study adds further evidence of the potential risks associated with strong anticholinergic drugs, particularly antidepressants, bladder antimuscarinic drugs, anti-Parkinsons drugs, and epilepsy drugs.
The risks of this type of medication should be carefully considered by healthcare professionals alongside the benefits when the drugs are prescribed and alternative treatments should be considered where possible.
Prof. Carol Coupland
These findings also highlight the importance of carrying out regular medication reviews.
We found a greater risk for people diagnosed with dementia before the age of 80, which indicates that anticholinergic drugs should be prescribed with caution in middle-aged people as well as in older people, she concludes.
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What Are Antipsychotic Drugs
Antipsychotic drugs are used to treat people who are experiencing severe agitation, aggression or distress from psychotic symptoms, such as hallucinations and delusions. They tend to be used only as a last resort, such as when the person, or those around them, are at immediate risk of harm.
For some people, antipsychotics can help to reduce the frequency or intensity of these changes. However, they also have serious risks and side effects, which the doctor must consider when deciding whether to prescribe them.
The first prescription of an antipsychotic should only be done by a specialist doctor. This is usually an old-age psychiatrist, geriatrician or GP with a special interest in dementia.
Why Anticholinergics Cause Dementia Symptoms
Anticholinergics block acetylcholine, a neurotransmitter thats used for learning, memory, and muscle functions.
You can think of neurotransmitters as messengers that carry instructions within the brain and from the brain to the rest of the body.
Older adults already have fewer of these messengers because our bodies produce less of this neurotransmitter as we age.
On top of that, blocking it with drugs makes it even harder for instructions to get delivered.
If instructions arent getting delivered, the brain and body wont be able to work normally.
This causes dementia symptoms to worsen or even to start showing up in seniors without dementia.
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What Newer Medications Are Under Study
All currently approved medications target Alzheimers disease after it develops. Scientists are currently researching ways to stop or slow the progress of Alzheimers disease before it starts.
Some of the drugs in late-stage investigation are called monoclonal antibodies. These drugs target the amyloid protein that builds up in brain cells. They work by attaching to the amyloid proteins as they float in the brain and remove them, before they form into the plaques and tangles that interfere with the brains ability to properly function.
These drugs are still in clinical trials and are several years away from Food and Drug Administration approval in the United States. Early results have been mixed, with some trials showing no improvement in brain function others showing a slight improvement . Despite the mixed results, researchers are excited about this new potential method to modify the disease process.
What To Do If Your Older Adult Is Taking Anticholinergic Medications
Important: NEVER start, stop, or adjust the dosage for any medications without asking your older adults doctor for advice that can cause serious health problems.
The first step is to discuss any medication concerns with the doctor as soon as possible. Ask them to explain the risks versus the benefits and to make a recommendation.
Because many seniors have multiple health conditions, they may be taking more than one type of anticholinergic medication.
One anticholinergic drug might not be harmful, but the side effects and doses can add up across different medications.
Thats why its so important for a doctor to review all the medications that your older adult takes.
And if different drugs are being prescribed by different doctors, ask their primary physician to review the full medication list, including over-the-counter drugs and supplements.
This could also be a good opportunity for the doctor to safely discontinue drugs that are no longer needed.
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How Do I Know My Loved One Has Medication
Early diagnosis of the disease can help manage it properly and slow down the progression. A person developing medication-induced dementia will show symptoms that can be examined to confirm the diagnosis. The medical symptoms of dementia include:
- The patient struggles to concentrate for a long period
- Behavioural changes
- Struggling to remember daily life information
- State of confusion
If the symptoms are overlooked and the medication is not stopped, the condition may worsen with time. As dementia is a progressive disease, it never stops advancing and continues to aggravate. Different medicines are used to treat the symptoms such as dementia medication donepezil is used to manage the state of confusion.
It is of utmost importance to get yourself checked frequently if dementia runs in the family or you are of age. Communicate to the doctor about common medications that may cause dementia and act accordingly.
What Drugs Are Available To Treat The Cognitive Symptoms Of Dementia
The main drugs used to treat cognitive symptoms of dementia are called cholinesterase inhibitors.
Cholinesterase inhibitors include donepezil, rivastigmine and galantamine. There is also a drug called memantine, which works slightly differently.
These drugs dont work for everyone, and the average effect is fairly small. But, for most people, theyre still well worth trying.
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