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Medications
Dementia remains a difficult, and poorly understood, area of medicine. I present my experience here in the hope that this will begin a discussion of drugs that may help dementia patients. This is simply my professional perspective, developed after a review of the medical literature and years of practicing geriatrics. I work to minimize all medications. I also try to identify medications that may be causing problematic symptoms. I believe that activities and compassionate communication should always be used to alleviate the worries and confusion of my patients who suffer from dementia. Yet sometimes, medication may be the best choice: A few drugs may help delay or decrease the progression of dementia. Others may give relief to some of the behavioral symptoms of dementia that can make life intolerable. Caregivers may have tried myriad interventions—stress relief, activities, compassionate work-arounds—but the dementia patient may still believe he is being poisoned. Or, she may refuse to wash, or fight back when being helped to bathe. He may become very angry over small incidents during the day. Life can be better than this. In these cases, medications may be part of the solution. "Goals of care" should underlie the process of deciding whether to use drugs, and which ones to use: Should the focus be upon avoiding all the medical consequences of aging? Or, should we try to improve the days remaining to each dementia patient? Nothing written here should be interpreted as a prescription for any particular patient. No use of these medications is without some risk. Therefore, a physician with an ongoing relationship with the patient should determine what course of treatment makes sense. We can not be responsible for any outcome of any use of these medications. The treating physician is responsible for deciding which medications are indicated for their particular patient. I am interested in your comments. Please get in touch via the email link in the "Contact Us" section of this website. Thank you for your interest. Dementia MedicationsThe most direct drug treatments for dementia seek to improve the supply of key brain chemicals, or to improve cardiovascular health that will avoid the mini-strokes that can cause vascular dementia. Anti-cholinesterase InhibitorsThe most focused drug for dementia is Donipezil, or Aricept®. This medicine is one of several "anti-cholinesterase inhibitors." These drugs increase the production of "choline." This chemical forms one of the building blocks of "acetylcholine," a key "neurotransmitter," the scientific name for a substance that helps brain cells signal each other. This class of drugs can help keep the nursing home at bay for an extra six to nine months. However, the drugs only help 10 to 30 percent of dementia patients. Unfortunately, it's impossible to know which 10 to 30 percent. Therefore, it's common to give these medicines to all patients with declining brain function. While these medications cannot reverse delirium (the sudden confusion of time and events), they may take the edge off angry reactions. Empirically, some patients' behavior may improve somewhat with these drugs. Donipezil is by no means a cure-all. While the drug is perhaps the best-studied of the dementia drugs, it remains controversial in many medical circles. The medication is expensive and the benefits are modest. In fact, there is no definitive proof that the drug alters the course or the progression of Alzheimer's. Further, the FDA has not approved it for use in other kinds of dementia. (However, it is commonly prescribed "off-label" for these conditions.) The side effects may be uncomfortable: insomnia, or sedation, nausea, diarrhea, decreased blood pressure and heart rate. Occasionally, the drug causes behavioral problems. Still, Donepezil is certainly worth trying. If the patient's function remains stable, it may even be working. Several similar drugs also affect choline uptake:
Blood ThinnersOne of the major types of dementia is "vascular dementia," in which little strokes damage small parts of the brain. These little strokes may not show up on a head CAT scan, but rather as small "white matter changes," or little scars. Patients who have suffered from little strokes like these may exhibit increased confusion, or loss of abilities. These problems may improve slightly, but rarely improve to the level of function before the stroke. Thinning the blood can help avoid the damaging strokes.
To prevent strokes, baby aspirin generally should not be used with clopidogrel/Plavix™, a drug that prevents blood clots. (However, if a patient has a stent keeping a heart artery open, both aspirin and Plavix™ may be prescribed.) Make sure to discuss these issues with your doctor. Studies have not shown that baby aspirin and Plavix™ prevent recurring stroke better than Plavix alone. However, it will increase the bleeding risk. Yet, when a patient who is already taking baby aspirin has a stroke, the evidence indicates adding Plavix™ or Aggrenox®, rather than just increasing the dose of aspirin. Recent studies have also suggested that patients with irregular heart rhythms ("atrial fibrillation"), Plavix may be a good second choice to reduce stroke risk. Unfortunately, the major side effect is bleeding, something that cannot be reversed quickly.
Risks and benefits need to be weighed carefully with this drug; thinning someone's blood comes with very real downsides. If a patient remains quite functional—walking, communicating, eating well—then the goal is to preserve that function and reduce the risk of stroke. Coumadin®, Plavix® or Aggrenox® may be the answer in that case. However, if a patient has already become confused, and falls frequently, then the risk of increased bleeding is probably more of a danger than the risk of stroke. In that case, it might be best not to use these drugs. Some Drugs Make Dementia WorseMost drugs specifically developed to improve dementia seek to increase the levels of "choline," a chemical that brain cells need to communicate with each other. Yet several common medicines are "anti-cholinergic," that is, they decrease levels of choline. Thus, these drugs can make dementia worse, resulting in more confusion and agitation. They can also cause dry mouth, constipation, and difficulties urinating. These include:
Various steroids — medicines commonly used to reduce inflammation of various sorts — may also pose a problem for a person with dementia:
Treating Dementia's Behavioral SymptomsDementia commonly makes people anxious, paranoid, angry, depressed, even delusional. They may become compulsive, or obsessed with repeating some task. They may ask the same question over and over. A person may become convinced that people are stealing from them. They may come to believe that their spouse is an imposter or cheating on them (often a difficult delusion to treat). They become angry and paranoid with visitors and doctors. They may misinterpret social cues and become convinced that caregivers and staff want to become romantic with them. It's key to investigate whether behavioral problems stem from practicalities. Anger, paranoia, inappropriate action can grow from a wet Depends™, from hunger or from fatigue. The patient may be developing a bedsore from sitting or lying in the same position for more than two hours. They may have suddenly acute arthritis pain. They may be annoyed about a neighbor's yelling, or a bladder that will not empty, or serious constipation that hurts. All these issues should be considered and addressed before proceeding with more involved intervention. Activity is CrucialIt's crucial for both families and caregivers to understand that the lack of something to do can actually make behavioral problems worse. All dementia patients need meaningful activities to fill their days. What this means is different for everyone. One may like gardening, while another may spend hours on puzzles or manipulating simple gears. The trick is to find the right balance for each person, to allow them to enjoy what capacities they still retain. The key point is that it's not enough to park someone in front of a TV. If someone sits at home all day with a caregiver who just looks at them, she may get into trouble, acting out from frustration or boredom. Meaningful activity becomes even more important as the condition progresses, and the patient's connection to reality becomes ever more tenuous. For instance, if an elder with advanced dementia watches a news report about flooding, he may become convinced that he is in danger but unable to communicate this. The resulting anxiety may lead to distressing behavior. When Medication for Behavior Makes SenseIf the behavioral problems do not interfere with medical and personal care, then it may be best to ignore them as much as possible. But often, behavioral issues make caring for patients difficult or impossible. In these cases, it makes sense to discuss the risks and benefits of treating behavioral/psychological issues with medication. Controversy over MedicationTreating the behavioral symptoms of dementia remains controversial, largely because there's a sense that it's an insoluble problem with little evidence for effective treatment. For instance, a recent review of many studies of medications for behavioral symptoms concluded that nothing works. Paradoxically, this has resulted in the common prescription of drugs like Lorazepam/Ativan®, a common anti-anxiety medicine. While drugs like these may yield short-term results, they are highly addictive. And, if used for more than a couple days, they may actually increase behavioral problems, rather than decreasing them. Some studies have concluded that Citalopram/Celexa® decreases agitation, but it doesn't work for all patients. Still, it's a better choice than Lorazepam, unless a patient really needs to be sedated or restrained. Just as most drugs are not tested in children under six, fewer drug studies focus on complicated medical patients over 65, or patients with dementia. Behavioral Symptoms CAN Be TreatedNevertheless, geriatricians, geriatric -psychiatrists and I have found empirically that the behavioral symptoms of dementia can be treated. It's important to focus on the goals of care for dementia patients. Are we trying to treat every disease, prevent every side effect and prolong life despite the patient's possible suffering? Or, are we trying make the patient as functional as possible with a minimum of distress? Treating behavioral symptoms can improve patients' lives. (Done incorrectly, it can also make things worse.) But, when relieved of anxiety, delusion, compulsion, paranoia and anger, dementia patients can live more fully in the moment. When behavior symptoms are treated, loved ones and caregivers do not need to be on edge, accused of being jailers, wondering when the next outburst or crisis will come. Patients can enjoy their friends and family. They can make the most of the time left to them. I have seen these medicines for behavioral problems make a huge difference in the lives of my patients. They have brought comfort to families. Still, these drugs cannot be interchanged like various tranquilizers, or like the statins used to lower cholesterol. All drugs have pluses, and minuses. While it's important for patients, or their families, to know medication basics, be sure to discuss these options in detail with your doctor. Guidelines for TreatmentThe challenge in formulating guidelines for the treatment of behavioral issues is that dementia patients are highly variable. Two people may look the same, have the same level of dementia, and have similar symptoms. Yet these two patients may respond very differently to the same medication. Thus, treating these symptoms requires trial-and-error medicine. I am upfront about this with the families of my patients. As I always state at the beginning, there is no way to be absolutely sure we can find the right combination of activities, behavioral intervention, pain management and medications that will lead to calm engagement without side effects. While working several years as a fellow in geriatrics at Mt. Sinai Hospital in Manhattan, as an assistant professor of medicine at University of California-San Francisco, at the Veterans' Administration Hospital in San Francisco and as a hospice director in the North Bay, I have collaborated for years with geriatric psychiatrists, geriatricians and neurologists. I have handled a wide variety of cases in which we have enjoyed excellent results treating behavior problems. (There are a handful of patients that medications could not help calm without severe side effects, but they are rare.) It's a matter of balancing treatment for agitation with loss of abilities like walking. Treating Behavior is an ArtThat said, the Food and Drug Administration has not approved the drugs described below to treat dementia. These medications have serious side effects. Neuroleptics may increase the absolute risk of stroke by approximately 3 percent. They may increase the absolute risk of sudden death by approximately 1 percent. Medical practitioners, families and caregivers should closely monitor patients who are using these medications. even if the patient is calm. It can be very easy to miss further decline or over-sedation. Remember that geriatric behavioral medicine, is more of an art—and is more about trial and error—than most doctors would like to admit. Physicians often write prescriptions "off-label." That is, they use a drug to treat symptoms and illnesses not outlined in that drug's FDA-approved "label". This happens most often in the treatment of behavioral symptoms of dementia, since the studies do not clearly indicate what to do. That said, it's important to only use "evidence-based" medicine, proven effective by studies. This area is just incredibly difficult to study. We cannot wait 10 to 20 years for definitive direction when so many of our loved ones need help today. Hire a Board-Certified Geriatric SpecialistThe problems of behavior in dementia have not been emphasized in medical schools until recently. Therefore, if behavioral symptoms become an issue, it's important to seek out a geriatrician, a geriatric psychiatrist or a neurologist with a focus on dementia. A geriatrician has had training above the standard internal medicine or family practice residency. Those extra years of training focus on what changes in older individuals lead to specific problems, or "syndromes" such as becoming frail, falling, developing osteoporosis or dementia. Geriatricians use extra caution when prescribing medications. Drugs can often cause symptoms that made the medical appointment necessary in the first place. First, Do No HarmMy first rule of coping with the behavioral symptoms of dementia is this: Don't prescribe any medication that will likely make the patient less inhibited. Many anti-anxiety drugs like Lorazepam/Ativan® or Alprazolam/Xanax®, sleeping pills like Temazepam/Restoril, or Zolpidem/Ambien®—act very much like a couple shots of vodka, or whiskey. They make patients less inhibited, which often worsens the problems of dementia. Careful with the TranquilizersAll too often, the disturbing behaviors of dementia patients are treated with tranquilizers of the "benzodiazepine" class. When starting, or if stopped too quickly, these medications have been shown to contribute to delirium, and to decreased brain function. This may lead to agitation and falls. Paradoxically, tranquilizers and anti-anxiety medications may actually make a patient more agitated, or less socially inhibited. Tranquilizers have their place for emergencies, such as when a patient becomes violent. Short-term use in a hospital may sometimes make sense so that test or procedure may be done to treat a medical issue. However, if used for more than a day or so in patients with dementia, they can lead to oversedation, disinhibition, and paranoia. This increases the danger of falls. If stopped abruptly, the symptoms may become even worse: Insomnia, hypervigilence (an inability to "turn off" mental activity), paranoia, or delirium may result. Alternatives for Behavioral ProblemsSeveral other classes of drugs and treatment may be used more effectively to treat behavioral symptoms. These include anti-psychotics ("neuroleptics"), antidepressants, and anti-seizure medications. Electro-convulsive therapy, known popularly as "shock treatment," has evolved considerably since it earned its bad name. It now can be much more humanely administered, and it really can help some patients. Everyone an IndividualThe challenge is this: Everyone's body chemistry is slightly different. Everyone has a different situation, and a different history. The key is to know where to start and then be available to hear feedback and adjust strategy. Only then can behavioral symptoms be eased, so that life "in the moment" can be pleasant. Anti-Psychotics (Neuroleptics)All anti-psychotics may increase the absolute risk for stroke by approximately 3 percent. They may increase the risk of sudden death by 1 percent. They should not be used for garden-variety agitation. Several antidepressants—Citalopram®, Remeron® or Zoloft®—make much better choices in cases of anxiety or aggression. However, if a patient is paranoid, delusional or hallucinating and has extreme anxiety brought on by these delusions, anti-psychotics can be very helpful. First, delirium, infection, new medications need to be ruled out. In rare cases, ischemia, decreased blood flow, may be the issue. Each medication has a different effect. If one fails, another may work. However, all can affect walking and lead to further decline. I try to use the minimum amount necessary for the shortest time possible, to allow safe care.
AntidepressantsDepression in dementia takes many forms. For those with early dementia, anxiety about their fate and loss of abilities can lead to depression. As dementia progresses, changes in the brain may lead to depression, but this may have less to do with conscious sadness than with physiology. Dementia patients may be irritable and edgy, without the ability to explain their bad mood. They may eat and sleep too much or too little. Recent studies have shown that patients with moderate dementia may be upset by a disagreement, and quickly forget the cause of the argument. Yet the resulting irritable mood may continue independently. Just a few decades ago, treatment for depression was limited. Luckily, we live in an age where there are many drug options for easing depression. Most work by affecting the supply, or the absorption of, key brain chemicals. The largest group of these new antidepressants are "selective serotonin reuptake inhibitors" (SSRIs). These drugs work on "serotonin," a chemical that helps transmit brain messages. The drugs block nerve cells from absorbing serotonin, thus increasing the supply of this important nerve transmitter. Others drugs may affect the supply of "norepinephrine," a brain chemical that helps control attention, and "dopamine," a chemical key to muscle control. But not all anti-depressants are created equal. All SSRIs may cause stomach upset, diarhhea, or decrease the sodium levels necessary for health. They may affect walking. Thus, for dementia patients, older medications like Citalopram®, Zoloft®, and Remeron® often result in better outcomes than the more complicated new drugs. Here are some of the most common anti-depressants:
Electroconvulsive TherapySometimes a patient's depression may become so deep that it does not respond to medications. When suffering from severe depression, a person may not move, eat, or speak. Or they may become combative, or severely confused. In these cases, electroconvulsive therapy (ECT) may be a safe and effective way to improve their symptoms. Brief-pulse currents are administered to the brain while the patient is under anesthesia. It's important to control hypertension and make sure there are no brain lesions before pursuing this treatment. In my practice, I saw one 83-year-old woman diagnosed with advanced dementia. When she was younger, this patient had had an episode of severe depression and had responded well to ECT. We tried this treatment again. The woman did so well after ECT that she was able to move from a dementia unit to a structured, assisted living facility. Mood-Stabilizing MedicationsSometimes the person just gets very angry, not so much delusional, but with quick change of mood and resistance, or is sexually inappropriate. Using antidepressants is often the best way to address these symptoms. Dr. Volicer, who had done research in this area also suggests to use the neuroleptics, if the antidepressants are not effective. However, if the person has just anger, then an alternative to using the Neuroleptics, that have the increased stroke risk would be the mood stabilizers. This class were originally used for seizure control, then for use in manic depressive disease. There is controversy in the use of these medications. However, this would be an option, especially if the option was to use a benzodiazepine, which will lead to more disinhibition or agitation when used regularly.
While I was UCSF working in long-term care, I treated many patients who had abused the medications commonly used to calm people, such as opiates. I found that Gabapentin® avoided addiction issues and helped calm a wide variety of these patients: a man with post-traumatic stress disorder who had to stay in the hospital for antibiotics, another who terrible sciata, another with spinal pain. Likewise, I have found that Gabapentin® can effectively calm some dementia patients. It may decrease anger and anxiety for some, but for others it may do little but make them sleepy. Again, the starting dose should be very small, say 50 milligrams administered by a reliable caregiver. ConclusionThis information is intended to start a dialog of the effects of medications for those with dementia. However, it is not a complete list of side effects, or interactions. It should intended be used independently of the direction of a physician who knows the person well. Elder Consult cannot be responsible for any outcomes of these medications that have not been evaluated by myself or one of my clinicians. We present this summary to give practitioners and the public some information about medications that have been important in the care of our patients. In this challenging area of medical care, we hope that it is of use.
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