Tuesday, March 9, 2010

Medications for Alzheimer’s behavioral symptoms treatment

If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches.

It is extremely important to understand that these medications do not cure the disease or reverse someone's symptoms. However, these medications can help some people function at a higher level for a longer period of time.

Some caregivers that using an Alzheimer's medication will only be prolonging a loved one's suffering. In other words, caregivers sometimes fear that their loved ones will live longer with a terrible disease if they use these medications. However, there is no evidence that life is actually prolonged by taking medications for Alzheimer's Disease.

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Medications should target specific symptoms so their effects can be monitored. In general, it is best to start with a low dose of a single drug. Effective treatment of one core symptom may sometimes help relieve other symptoms. For example, some antidepressants may also help people sleep better. Individuals taking medications for behavioral symptoms must be closely monitored. People with dementia are susceptible to serious side effects, including stroke and an increased risk of death from antipsychotic medications.

Sometimes medications can cause an increase in the symptom being treated. Without careful evaluation, some medical providers will increase rather than decrease the dose, putting the person at greater risk. Risk and potential benefits of a drug should be carefully analyzed for any individual.

When considering use of medications, it is important to understand that no drugs are specifically approved by the U.S. Food and Drug Administration (FDA) to treat behavioral and psychiatric dementia symptoms. Some of the examples discussed here represent “off label” use, a medical practice in which a physician may prescribe a drug for a different purpose than the ones for which it is approved.

The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.”

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The analysis states that while risperidone and olanzapine are useful in reducing aggression and risperidone reduces psychosis, both drugs are associated with severe side effects. Despite some efficacy, these drugs should not be used routinely with dementia patients, unless the person is in severe distress or there is a marked risk of harm.

Risks and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms of Alzheimer's disease, listed in alphabetical order, include the following:

Antidepressant medications for low mood and irritability:
  • citalopram (Celexa)
  • fluoxetine (Prozac)
  • paroxeine (Paxil)
  • sertraline (Zoloft)
  • trazodone (Desyrel)
Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance:
  • lorazepam (Ativan)
  • oxazepam (Serax)
Benzodiazepines should not be considered first-line therapy for management of chronic behavior disorders of dementia, even in patients with prominent anxiety. However, community surveys show that these drugs are commonly used in these patients.  No published studies support the routine use of benzodiazepines for the management of psychotic symptoms of dementia. Chronic benzodiazepine use may worsen the behavior abnormality because of the amnestic and disinhibitory effects of these drugs. In clinical practice, benzodiazepine use should be limited to management of acute symptoms that are unresponsive to redirection or other agents. A short-acting benzodiazepine with prompt sedative effects may be useful to empower the caregiver or nursing facility during an episode of acute agitation that fails to respond to reassurance or removal of the precipitant. Short-acting benzodiazepines should be discontinued after the symptoms are controlled with other agents. Benzodiazepines with short half-lives, no active metabolites, and little potential for drug interaction are recommended.

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Antipsychotic medications for hallucinations, delusions, aggression, agitation, hostility and uncooperativeness:
  • aripiprazole (Abilify)
  • clozapine (Clozaril)
  • haloperidol (Haldol)
  • olanzapine (Zyprexa)
  • quetiapine (Seroquel)
  • risperidone (Risperdal)
  • ziprasidone (Geodon)
Research evidence as well as governmental warnings and guidance regarding the use of antipsychotics indicate that individuals with dementia should only use these medications when:
1) Their behavioral symptoms are due to mania or psychosis
2) The symptoms present a danger to the resident or others
3) The resident is experiencing inconsolable or persistent distress, a significant decline in function or substantial difficulty receiving needed care.

Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring.

Although antipsychotics are the most frequently used medications for agitation, some physicians may prescribe a seizure medication/mood stabilizer, such as:
  • carbamazepine (Tegretol)
  • divalproex (Depakote).
 These drugs are recommended as second-line agents in patients with inadequate response to antipsychotic agents. Multiple small, relatively short-term trials have proven anticonvulsants to be effective and well-tolerated. In practice, however, side effects, drug interaction, and a narrow therapeutic window may limit the use of carbamazepine. Data suggest that patients taking divalproex have continued symptomatic improvement on a stable dosage over time, although this effect may reflect the natural history of behavior disorders. Sedation is a common side effect of these agents and may limit their use. Most of the data on gabapentin (Neurontin) has been anecdotal.

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