A Cautionary Note On Cox
The discovery that COX-2 is a factor that generates inflammation, as opposed to COX-1, has set off a frenzy by drug companies to invent drugs that selectively inhibit COX-2. Potentially, these drugs will be free of the side effects caused by blocking both forms of cyclooxygenase. So-called COX-2 inhibitors are expected to become a $10 billion dollar product within the next decade, and have already spawned a major lawsuit over the patent.
However, data is beginning to appear that suggests that COX-2 inhibitors may not be as great as everyone originally thought. Nature Medicine published research by scientists at the Veterans Affairs Medical Center in Long Beach, California that challenges the notion that COX-2 inhibitors wont harm the gastrointestinal tract. That research shows that the line dividing COX-1 and COX-2 is not so neat, and that COX-2 also has potential to affect the gut.
Other research goes even further. It suggests that when cyclooxygenase is inhibited, a different inflammatory product, lipoxygenase is increased. LOX-induced leukotrienes are as dangerous to brain cells as COX-induced prostaglandins.
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 they can improve mood and wellbeing.
Find out how to live well with dementia and more useful information in the NHS Dementia Guide.
Page last reviewed: 05 July 2021 Next review due: 05 July 2024
Do Medicines For Dementia Work
Alzheimer’s disease: medicines can’t cure Alzheimer’s disease, but they may slow it down for a while and make it easier to live with.
- Cholinesterase inhibitors may be used in people with mild to moderate Alzheimers disease or mixed dementia. These may give temporary help with memory, motivation, concentration and daily tasks.
- Memantine may be useful in the moderate or severe stages of Alzheimers disease, to help with attention and daily tasks, and possibly ease distressing or challenging behaviours.
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Sedating Antihistamines: Sedatives And Sleep Aids
Some sedatives or hypnotics, such as benzodiazepines and barbiturates, can cause drowsiness, confusion, increased cognitive impairment, slowed reaction, and worsening balance leading to falls. Sleep aids usually have the same effects. Examples of sedatives to avoid include the benzodiazepines diazepam , lorazepam , temazepam, triazolam , and sleep aids zolpidem , eszopiclone , and zaleplon .
- Worsens Benign Prostatic Hyperplasia
Memory Loss Caused By Commonly Used Medications
Many over-the-counter drugs and prescription drugs have been linked to memory loss and mild cognitive impairment. Mild cognitive impairment is a common condition associated with aging that can also be an early sign of Alzheimers disease with the main symptom being short term memory loss.
Drugs that cause MCI and related memory loss have a property known as anti-cholinergic, that means the drugs slow the neurotransmitter acetylcholine which plays a large role in memory retention. However, very few drugs are labeled or classified as anti-cholinergic drugs.
Other than the officially classified anti-cholinergic drugs, there are 17 additional drugs that have anti-cholinergic properties. Many doctors are unaware of the anti-cholinergic properties in commonly prescribed medications, which can be problematic for people at risk for MCI.
Additionally, several studies have shown a higher rate of cognitive decline for people who regularly use anti-cholinergic drugs. In one specific study, a research team observed nuns and clergy from the Rush Religious Orders for an eight year period and concluded that those who used medications with anti-cholinergic properties experienced a faster rate of cognitive decline.
Dr. Jack Tsao, a researcher on the study and an associate professor of neurology at Uniformed Services University, addressed the American Academy of Neurology stating:
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Medications For Alzheimers: Insomnia
Alzheimers often causes changes in sleep patterns, resulting in insomnia.
Chronic insomnia can significantly decrease quality of life for both the person with Alzheimers and their families.
Belsomra is currently FDA-approved to treat insomnia in mild to moderate Alzheimers disease.
Side effects include impaired alertness and coordination, worsening of depression or suicidal thinking, complex sleep behaviors, sleep paralysis, or compromised respiratory function.
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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Safe Storage And Organization
People with dementia can often forget to take their pills. They can also forget that they have already taken their pills, which could lead to them taking a double dose. Sometimes, people with dementia can mix up pills, take incorrect dosages, or ingest the wrong medications. Proper organization and storage of medication can help prevent these incidents.
If the care team agrees that the person living with dementia is still able to manage their medication regimen, you may not have to take extreme measures to safekeep medications . In that case, the person living with dementia can have full access to their medication, so they can take what they need at the necessary time. This lessens the burden on caretakers since they wont have to be present to administer every medication.
However, as the disease begins to affect the persons cognition, lax storage habits could become dangerous. It is wise to put strict storage measures in place before a potentially dangerous accident happens. If disease progression is severe, you may need to limit the persons access to medication altogether.
The safest storage place is usually a locked box or cabinet that can only be accessed by the caretaker. You may need a second lockbox for medications that have to be refrigerated.
Types Of Dementia Medications
Several prescription medications are approved by the Food and Drug Administration to treat symptoms of dementia caused by AD. These drugs can provide short-term relief from cognitive dementia symptoms. Some can also help slow the progression of AD-related dementia.
While these drugs are approved to treat symptoms of AD, theyre not approved to treat symptoms of other types of dementia. However, researchers are exploring off-label uses of these medications for people with non-AD dementias.
OFF-LABEL DRUG USE
Off-label drug use means that a drug thats been approved by the FDA for one purpose is used for a different purpose that hasnt been approved. However, a doctor can still use the drug for that purpose. The FDA regulates the testing and approval of drugs, but not how doctors use drugs to treat their patients. So, your doctor can prescribe a drug however they think is best for your care.
According to the Alzheimers Association, some AD medications may benefit people with Parkinsons disease dementia and vascular dementia.
Some of the most commonly prescribed medications used to treat symptoms of AD are cholinesterase inhibitors and memantine.
Cholinesterase inhibitors work by increasing acetylcholine, a chemical in your brain that aids in memory and judgment. Increasing the amount of acetylcholine in your brain may delay dementia-related symptoms. It may also prevent them from worsening.
The more common side effects of cholinesterase inhibitors include:
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Prevagen Has Been Clinically Shownto Safely And Effectively Improve Memory*1
¹Based on a clinical study of subgroups of individuals who were cognitively normal or mildly impaired.
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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.
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Dealing With Side Effects
Always report side effects to your doctor. Some side effects are known to be dangerous and may require switching to a new medication. Others are simply bothersome and unpleasant.
Sometimes side effects lessen over time as the body adjusts to the medication. Other times, side effects can be related to non-medication issueslike stomach upset being caused by a spicy dinner rather than a new medication.
If a person experiences side effects, they can write them down in the medication list and discuss them at the next doctors visit.
Some side effects might be worth accepting if the benefits of the medication outweigh the impact of the side effect. The person with dementia and their caregivers are the ones who get to make that choice.
Treating The Accompanying Symptoms Of Dementia
Dementia often causes a number of behavioural and psychological symptoms which can be very distressing.
These may include depression, anxiety, sleeplessness, hallucinations, ideas of persecution, misidentification of relatives or places, agitation and aggressive behaviour. These symptoms may respond to reassurance, a change in the environment or removal of the source of any distress such as pain. However, sometimes medication may be required for relief.
Major tranquillisers
Major tranquillisers, also known as neuroleptics or anti-psychotics, are used to control agitation, aggression, delusions and hallucinations. Haloperidol is one commonly used drug. In modest doses this drug tends to cause symptoms similar to Parkinsons disease such as stiffness, shuffling gait and shakiness, and older people are very prone to these side effects. Some are unable to tolerate even low doses of Haloperidol.
Newer tranquillisers such as Risperidone have fewer Parkinsons like side effects and have been studied more intensively in people with dementia than Haloperidol has. Risperidone appears to be helpful for the treatment of aggression and psychosis, but may be associated with a slight increase in risk of stroke.
Olanzapine and Quetiapine are sometimes used, but have been less comprehensively studied in the treatment of dementia, and there is some evidence that Olanzapine may also be associated with increased risk of stroke.
Drugs for treating depression
Drugs for treating anxiety
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No Easy Solutions But Improvement Is Usually Possible
As many of you know, behavior problems are difficult in dementia in large part because there is usually no easy way to fix them.
Many probably too many older adults with Alzheimers and other dementias are being medicated for their behavior problems.
If your family is struggling with behavior problems, I know that reading this article will not quickly solve them.
But I hope this information will enable you to make more informed decisions. This way youll help ensure that any medications are used thoughtfully, in the lowest doses necessary, and in combination with non-drug dementia behavior management approaches.
To learn about non-drug management approaches, I recommend this article: 7 Steps to Managing Difficult Dementia Behaviors
And if you are looking for a memory care facility, try to find out how many of their residents are being medicated for behavior. For people with Alzheimers and other dementias, its best to be cared for by people who dont turn first to chemical restraints such as antipsychotics and benzodiazepines.
This article was first published in 2016, and was last updated by Dr. K in May 2022.
When To Get Help From The Medical Team
Hopefully, these tips are helpful in creating a safe and successful environment for taking medication at home. But there are times when its important to reach out to medical professionals. Here are four situations where you should contact your care team.
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People Should Not Stop Their Therapy But Talk To Their Health Care Provider
Prof. Gray urges people not to stop their therapy based on the findings of this study they should talk to their health care provider, and also tell them about all their over-the-counter drug use.
Health care providers should regularly review their older patients drug regimens including over-the-counter medications to look for chances to use fewer anticholinergic medications at lower doses, she says.
If providers need to prescribe anticholinergics to their patients because they offer the best treatment, then they should use the lowest effective dose, monitor the therapy regularly to ensure its working, and stop the therapy if its ineffective, she adds.
Although the link between raised risk of dementia and anticholinergics has been found before, the new study uses more rigorous methods including over 7 years of follow-up to establish the strength of the link. By accessing pharmacy records, the researchers were also able to include non-prescription use of anticholinergics in their data.
It is also the first study to show a dose-response effect, note the authors. That is, the higher the cumulative amount of drug taken, the higher the risk of developing dementia.
And another first for the study, is that it also shows that dementia risk linked to anticholinergics may persist long after people stop taking the drugs.
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
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
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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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.
Tips For Taking Medicines For Dementia
The person with dementia may need support to manage their medications. You may find it helpful to do the following:
- Develop a routine for giving the medication: ask the pharmacist if medications should be taken at a certain time of day or with our without food. Then create a daily ritual. This might involve taking medications with breakfast or right before bed.
- Pill boxes or blister packs: ask your pharmacist about aids to help you to give medication as prescribed, eg, using pill boxes or blister packs. Read more about remembering to take your medicine.
- Swallowing difficulties: if swallowing is a problem, talk to your pharmacist or doctor. Read more about difficulty swallowing medicines.
- Side effects: ask your doctor or pharmacist about what side effects might occur with the medication and what you should do if you get them. Some dementia medicines may make the symptoms worse, so it’s important to be aware of this and let your doctor know. Read more about medicines and side effects.
- Get the treatment reviewed regularly: a medicine which is useful may not continue to be effective indefinitely because of the progressive changes to the brain caused by dementia.
- Keep a record of all medications, including over-the-counter medicines such as pain relievers, cold medicines and antacids. Also include creams or eye ointments, vitamins, herbal supplements and complementary medicines. Take this record to medical appointments.
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