Why And When To Stop Alzheimers Treatments
Alzheimers is a progressive disease, so your older adults symptoms and care needs will change over time. The drugs will also become less effective over time.
When the doctor starts them on an Alzheimers drug, they should include a plan for when the medication should be discontinued.
But if your older adult stops taking an Alzheimers drug and you notice a sharp decline in their condition, contact their doctor right away. They may want to restart the medication.
Before Taking This Medicine
You should not use Aricept if you are allergic to donepezil or certain other drugs. Tell your doctor if you are allergic to any medicines.
To make sure Aricept is safe for you, tell your doctor if you have:
a heart rhythm disorder
epilepsy or other seizure disorder
trouble swallowing or
asthma, chronic obstructive pulmonary disease , or other breathing disorder.
It is not known whether Aricept will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medicine.
It is not known whether donepezil passes into breast milk or if it could harm a nursing baby. Tell your doctor if you are breast-feeding a baby.
What Are Cholinesterase Inhibitors
If your loved one has Alzheimerâs disease that isnât too severe yet, their doctor might prescribe them a cholinesterase inhibitor. If they have another type of dementia, their doctor may consider it, too.
What they do: Scientists think these help prevent a âmessenger chemicalâ in our brains called acetylcholine from breaking down. Acetylcholine is important in learning, memory, and mood. Cholinesterase inhibitors also appear to delay the worsening of Alzheimerâs symptoms.
These medicines include:
What to expect: Most people with Alzheimerâs who take one of these medications get some benefit from it, including less anxiety, improved motivation, and better concentration and memory. And some are able to continue with their regular activities.
But the improvements donât seem to last long — about 6 to 12 months. They mainly delay the worsening of the disease for a period of time.
All three medicines work similarly, but one might work better for your loved one than it does for someone else.
Side effects: Most people donât have side effects when they take cholinesterase inhibitors, but some do have:
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Questions To Ask The Doctor
If your loved one’s doctor prescribes a new medication, you could ask:
- What is its name? Does it go by any other names?
- Why have you prescribed this?
- Do they have to take this medication? Are there any alternatives?
- How often and at what time of day should they take it?
- Should they take it with food or on an empty stomach?
- Are there any side effects that I should watch for?
- How much does it cost? Are there less costly or free alternatives?
Could Medications Contribute To Dementia
- By Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing
Alzheimers disease and other illnesses that cause dementia are devastating, not only for those affected but also for their friends and family. For most forms of dementia, there is no highly effective treatment. For example, available treatments for Alzheimers disease may slow the deterioration a bit, but they dont reverse the condition. In fact, for most people taking medications for dementia, it may be difficult to know if the treatment is working at all.
Experts predict that will become much more common in the coming years. We badly need a better understanding of the cause of these conditions, as this could lead to better treatments and even preventive measures.
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Tips For Reducing Dementia Risk
More than 55 million people worldwide are believed to be living with dementia, according to the World Health Organization. Ronald Petersen, M.D., a neurologist and director of Mayo Clinic’s Alzheimer’s Disease Research Center, says you can’t prevent dementia, but you can reduce your risk.
Dementia is not one disease, but instead a term for a group of symptoms affecting memory, thinking and social abilities. Alzheimer’s disease is the most common form of dementia.
There are more than a dozen risk factors that people can address, Dr. Petersen says.
“They include blood pressure, smoking, obesity and diabetes,” Dr. Petersen says. “Sleep is an important factor. Many people have difficulty sleeping, for a variety of reasons, as they age.”
Heavy alcohol use, hearing loss and air pollution also may be risk factors.
“If you attack one or more of these, you may actually be able to reduce your risk of developing cognitive impairment as you age.”
Dr. Petersen says it is important to stay activephysically, socially and intellectually.
Drugs To Treat The Cognitive Symptoms Of Dementia
A number of drugs are currently available in Australia for use by people with dementia. These drugs fall into two categories, cholinergic treatments and Memantine.
Cholinergic treatments offer some relief from the symptoms of Alzheimers disease for some people for a limited time. Drugs known as acetylcholinesterase inhibitors work by blocking the actions of an enzyme called acetylcholinesterase which destroys an important neurotransmitter for memory called acetylcholine.
Current cholinergic treatments are approved for use for people with mild to moderate Alzheimers disease. A number of the acetylcholinesterase inhibitors are available as subsidised medicines under the Australian Pharmaceutical Benefits Scheme.
People may receive these drugs at nominal cost if a physician or psychiatrist has found them to have a diagnosis of Alzheimers disease.
They must show improvement on a commonly used test of mental function in the first six months of treatment in order to receive further supplies of subsidised medication.
Memantine targets a neurotransmitter called glutamate that is present in high levels when someone has Alzheimers disease. Memantine blocks glutamate and prevents too much calcium moving into the brain cells causing damage. It is the first in a new class of therapies and acts quite differently to the acetylcholinesterase inhibitors that are currently approved for treatment in Australia.
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Antipsychotics Use In Assisted Living And Memory Care
Assisted living and memory care residences have been caught using antipsychotics to manage residents behavior. This practice is called chemical constraints, and has resulted in massive penalties for drug manufacturers. The manufacturers of Zyprexa, for instance, had to pay more than $1.4 billion after settling with the government over accusations they marketed the drug to nursing homes as a treatment for dementia. In 2017, Human Rights Watch released a report titled They Want Docile. It began: In an average week, nursing facilities in the United States administer antipsychotic drugs to over 179,000 people who do not have diagnoses for which the drugs are approved. They determined it was the sedative effect, rather than any medical benefit, motivating the use of antipsychotics. Antipsychotic drugs are used sometimes almost by default, for the convenience of the facility, including to control people who are difficult to manage.
Did You Know?
Even worse: Reports have found residents were often given these drugs without their knowledge. Because a company may have marketed itself as effective for dementia when it isnt, and because the sedative effect makes residents easier to care for, and because side effects like the acceleration of cognitive decline are happening internally and thus not apparent by the patients actions, staff may be unaware of the harm theyre committing.
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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Who Are These Medications For And What Are The Benefits
These medications are prescribed for people with mild to moderate Alzheimers disease. Studies show that between 40 70% of people taking the drugs benefit from them with symptoms improving temporarily for between 6-12 months.
The impact of taking cholinesterase inhibitor medications can include: reduced anxiety, improvements in memory and concentration daily activities such as personal care, dressing and shopping.
Trials to determine if these drugs also bring benefits for behavioural changes such as agitation or aggression are inconclusive, with mixed results. Unfortunately the impact of these medications gradually reduces with symptoms then gradually worsening.
Reminiscence And Life Story Work
Reminiscence work involves talking about things and events from your past. It usually involves using props such as photos, favourite possessions or music.
Life story work involves a compilation of photos, notes and keepsakes from your childhood to the present day. It can be either a physical book or a digital version.
These approaches are sometimes combined. Evidence shows that they can improve mood and wellbeing. They also help you and those around you to focus on your skills and achievements rather than on your dementia.
You’ll find more details about these treatments in the Alzheimer’s Society’s dementia guide.
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The Devastation Of Alzheimers Disease
With all this said, we are extremely aware of the gradual and cumulative devastation that Alzheimers disease causes, as patients lose their memory and cognitive functioning over time. In late-stage disease, people can no longer hold a conversation or respond to their environment. On average, a person with Alzheimers disease lives four to eight years after diagnosis, but some patients can live up to 20 years with the disease.
The need for treatments is urgent: right now, more than 6 million Americans are living with Alzheimers disease and this number is expected to grow as the population ages. Alzheimer’s is the sixth leading cause of death in the United States.
Although the Aduhelm data are complicated with respect to its clinical benefits, FDA has determined that there is substantial evidence that Aduhelm reduces amyloid beta plaques in the brain and that the reduction in these plaques is reasonably likely to predict important benefits to patients. As a result of FDAs approval of Aduhelm, patients with Alzheimers disease have an important and critical new treatment to help combat this disease.
Alternatives To Antipsychotics For Alzheimers / Dementia
Physically abusive behavior can be dangerous, but verbally abusive behavior is probably not an actual threat to anyones well-being. This is an important distinction. The side effects of antipsychotics can be so strong, and the benefit so marginal, that a caregiver should consider whether problematic behavior is actually threatening. Caregiver stress can be brutal, and it is possible to become so sensitive to outbursts, particularly if theyre cruel, that pharmaceutical fixes are sought even though that may not be necessary.
The reactions of caregivers due to caregiver stress may be triggering physically aggressive behavior, and therefore the troubling symptoms you think warrant antipsychotics could be entirely avoidable. Along those same lines, be sure to check for environmental stressors, like too much noise too many people, or frequent visits from disagreeable people bright lights or even an uncomfortable temperature or climate in your loved ones living space. Dementia affects a persons ability to communicate, so your loved one may be unable to express that something very basic is causing problems.
Before turning to antipsychotics, try these non-pharmaceutical strategies:
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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.
Who Is The Drug For And What Are The Benefits
The NICE guidance recommends use of Memantine for people with severe Alzheimers disease, and for those with moderate Alzheimers who may suffer significant side effects from cholinesterase inhibitor drugs.
For those in the middle and later stages of the disease it can slow down the progression of symptoms such as disorientation, as well as difficulties with daily activities .
There is some evidence that memantine may also help with symptoms such as aggression and delusion.
How Is Aducanumab Administered
To take the drug, you need an intravenous infusion every four weeks for as long as you live. This means going to a hospital or a clinic where an intravenous tube is inserted, and the monoclonal antibody is slowly infused over several hours. The other monoclonal antibody, Gantenerumab, can be administered below the skin, and one may be able to administer the drug at home however, this technique does require some skill and supplies.
Medicines To Treat Related Conditions
There are some conditions, such as heart problems, that can affect symptoms of dementia, particularly vascular dementia. It’s important that these are diagnosed and treated.
These conditions include:
These changes in behaviour can be very distressing, both for the person with dementia and for the person caring for them. However, there are coping strategies that can help.
If coping strategies do not work, antipsychotic medicines such as risperidone or haloperidol may be prescribed for those showing persistent aggression or extreme distress.
These are the only medicines licensed for people with moderate to severe Alzheimer’s disease and vascular dementia 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 can be used only if other treatments have not helped.
The decision to prescribe a medicine should be taken by a consultant psychiatrist.
Antidepressants may sometimes be given if depression is suspected as an underlying cause of anxiety.
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What The Data Show
The late-stage development program for Aduhelm consisted of two phase 3 clinical trials. One study met the primary endpoint, showing reduction in clinical decline. The second trial did not meet the primary endpoint. In all studies in which it was evaluated, however, Aduhelm consistently and very convincingly reduced the level of amyloid plaques in the brain in a dose- and time-dependent fashion. It is expected that the reduction in amyloid plaque will result in a reduction in clinical decline.
We know that the Peripheral and Central Nervous System Drugs Advisory Committee, which convened in November 2020 to review the clinical trial data and discuss the evidence supporting the Aduhelm application, did not agree that it was reasonable to consider the clinical benefit of the one successful trial as the primary evidence supporting approval. The option of Accelerated Approval was not discussed by the Advisory Committee. As mentioned above, treatment with Aduhelm was clearly shown in all trials to substantially reduce amyloid beta plaques. This reduction in plaques is reasonably likely to result in clinical benefit. After the Advisory Committee provided its feedback, our review and deliberations continued, and we decided that the evidence presented in the Aduhelm application met the standard for Accelerated Approval. We thank the Advisory Committee for its independent review of the data and valuable advice.
Anxiety And Insomnia Medications
Benzodiazepines, a class of medications used to treat anxiety or insomnia, comprise another group that has been linked with cognitive difficulties. Although these medications are truly a blessing for some individuals immobilized by anxiety, their use can be accompanied by sedation and mental slowing. A recent study even suggested that prolonged use of benzodiazepines might be a risk factor for later dementia, although experts have questioned the significance of this finding and clinicians continue to prescribe anti-anxiety medications such as lorazepam or sleeping pills such as temazepam and consider them very beneficial when used properly.
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When Antipsychotics Are Necessary For Alzheimers / Dementia
Antipsychotics, including those listed above, still have a role to play in treating people with Alzheimers and related dementia. They should not be used, however, unless the person exhibiting extreme behaviors has failed to respond to non-drug management strategies. For more on those strategies, see below.
If your loved one is exhibiting behaviors that are dangerous, and other avenues have been attempted and, in accordance with a doctor, you have decided to go ahead with antipsychotic medication, there are strategies for safely administering the drugs.
Use the lowest possible doses for the shortest amount of time to decrease risk from side effects . Halving a pill, for instance, will make the drug less risky and it still may have some effect. Caregivers are advised to start with the lowest possible dose and then monitor behavior. If troubling symptoms persist, then you can slightly up the dosage. Repeat this pattern consistently to find the right balance between effectiveness and side effects.