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Medications and Treatments

Articles about the medications and treatments for Alzheimers

Using Namenda

The recent approval of Namenda (memantine) for use in moderate or severe Alzheimer disease has raised some questions about the use of this new medication with other previous AD drugs.

The studies documenting some efficacy for Namenda were performed in patients also taking Aricept (donepezil), which is in the class of acetylcholinesterase inhibitors (AChE-I).

Current practice guidelines for pharmacological treatment of AD call for use or attempted use of AChE-I's and high dose vitamin E.

Current Practices

Our current practice pattern at the Bryan ADRC Memory Disorders Clinic is to consider the addition of Namenda in patients with moderate or severe AD.

We would add Namenda to the AChe-I drug (Aricept, Reminyl or Exelon) that they were currently taking. This mimics most closely the actual study design approved by the FDA.

We have some concern and caution about using Namenda in patients who are agitated or hypervigilant.

In addition, if the patient is not taking AChE-I medications, we would probably start or restart AChE-I's before adding Namenda.

Q&A About Namenda

What is it?

Memantine (Namenda, Forest Labs) is a recently approved treatment for moderate to severe Alzheimer's disease (AD).

Why "moderate to severe" Alzheimer's disease?

Studies of memantine have consistently demonstrated it to be effective in the middle and later stages of AD. By contrast, studies of memantine in "mild to moderate" AD patients have had mixed results.

Should other drugs used to treat AD be stopped before trying memantine?

Cholinesterase-inhibitor drugs (donepezil or Aricept, rivastigmine or Exelon, and galantamine or Reminyl) are approved for treating symptoms of "mild to moderate" AD. One recent study of memantine used in conjunction with donepezil showed the combination to be more effective than donepezil alone.

Other studies have shown that combining memantine with cholinesterase-inhibitor drugs does not significantly increase side effects. These data suggest that combining memantine with a cholinesterase inhibitor drug is appropriate for "moderate" AD patients.

Although memantine is not specifically indicated for use in mild AD patients, and cholinesterase-inhibitors are not approved for use in severe AD, both pose little risk and may, in some circumstances, offer some benefit on an individual basis.

How does memantine work?

The mode of action is thought to involve blocking N-methyl d-aspartate (NMDA) receptors, which are normally activated by the brain chemical glutamate.

In AD, too much or not enough glutamate can have very different effects. Too little glutamate is associated with impaired learning and memory, which is the core clinical feature of AD.

On the other hand, excessive glutamate can trigger a chain of events that leads to the death of brain cells (excitotoxicity). Memantine may moderate the effects of too little or too much glutamate.

Although there is evidence from laboratory studies suggesting that memantine may have a neuroprotective effect in slowing the underlying disease, this has not been proven.

Both memantine and cholinesterase-inhibitor drugs have been shown to slow the rate of clinical or functional decline over time.

In both cases, however, it is not clear if underlying disease processes are being slowed down or not. Slowing clinical decline without altering the overall progression of the disease refers to a symptomatic treatment effect.

How is it dosed?

The recommended dosing of memantine is as follows: 5 mg one/day for one week, then 5 mg twice/day for one week, then 15 mg/day (5/10) for one week, then 20 mg/day (10/10) maintenance dose.

Are there significant side effects or drug interactions?

Memantine has remarkably few side effects overall. Headaches and confusion were reported only to be modestly higher in subjects on memantine + donepezil compared to donepezil only in one large study. No clinically significant drug interactions have been identified to date.

Is it available now?

Yes, many pharmacies stock it now and samples should be available in physician's offices soon.

Medication and Falls

Falls can be a life changing experience - for the person who falls and for their care partners. Falls are most often the consequence of combinations of factors, internal and external. Internal factors involve the person and external factors involve the environment.

Internal factors can include the aging process, health conditions, sensory changes (vision and hearing), problems with walking and moving (gait and balance), difficulties with doing self care, depression and cognitive impairment.

External factors might include physical restraints, a move to a new location, slippery or shiny floors, cluttered pathways, unsteady furniture, inappropriate, misused or damaged equipment and poor lighting (glare or too low).

Past History is Key Indicator

Despite all these potential contributors, one key indicator of high risk of future falls is clear - past history of falls; the more falls the greater the risk of falling. Once an older person has fallen, especially if the fall resulted in an injury or seems to be more than a simple trip that could have happened to anyone in the specific circumstances, considering the contributing factors and possible strategies to reduce risk of future falls is a good idea. Simply accepting that "older people are prone to falls" or "she falls all the time" sets the person up for continued falls and injury.

Review and Modification

While falls are one of the most complicated and difficult syndromes to evaluate, one fairly concrete truth exists: the more medications an older person takes, the higher the risk of falling. Research consistently shows that taking more than 3-4 medications per day significantly increases risk for falling. Reducing the numbers and doses of medications is associated with reduction in falls. Thus, including review and modification of drug regimens is an important component of evaluating falls. This doesn't mean automatically and arbitrarily stopping medications; it does mean that careful review and modification is indicated.

While almost all medications, even over the counter drugs, have potential to contribute to falls, research has shown that certain groups of drugs are associated with much higher risk and need special consideration.

  • Any central nervous system/psychotropic medications
  • Sedative/hypnotics (sleeping medications)
  • Antidepressants (especially the tricyclics)
  • Antipsychotics/neuroleptics
  • Benzodiazapines ("nerve pills")
  • Certain cardiovascular drugs
  • Diuretics
  • Antiarrhythmics
  • Cardiac glycosides
  • Medications used to treat diabetes

Steps to a good medication review

  • Create a list of all medications the person takes and exactly (how?) he/she takes them (remembering that the reality may be quite different from what's written on the bottle).
  • Prescription
  • Over-the-counter
  • Vitamins and other supplements
  • Herbs and other "natural" remedies
  • Evaluate the medication regimen
  • Current health conditions
  • Potential medication benefits
  • Possible adverse reactions
  • Identify potential problems and possible alternatives
  • Medications that could be stopped (condition resolved)
  • Medications that could be replaced with a similar drug with potentially fewer problems
  • Final note: don't forget the alcohol or "recreational" drugs

Trivia Questions

Question 1: What group of people is most likely to fall?

Answer: Children

Question 2: In a research study at a VA Alzheimer's Special Care Unit, which group of medications was most likely to be associated with night time falls?

Answer: Laxatives

Update on Anti-Psychotics and Older Adults with Dementia

Caregivers should know about two recent reports involving the use of anti-psychotic medications for people with dementia. Anti-psychotics are drugs that were initially developed and tested on adults with schizophrenia, bipolar disease, and other serious mental illnesses. The drugs were helpful in treating in behavioral problems.

The symptoms they were designed to help control symptoms of emotional distress, motoric agitation, physical and verbal aggression, hallucinations, and delusional thinking. The drugs helped individuals calm down, control reactions and responses to others, see and hear more normally without hallucinations or delusions, and focus and concentrate better.

Since many similar behavioral symptoms are experienced by people with dementia, the "off-label" use of these medications became popular and common.

Early Medication

The earliest medications used were called typical anti-psychotics and are known by the trade names of Haldol, Thorazine, and Loxitane (generic names are haloperidol, chloropromazine, loxapine).

With increased use, however, it was discovered that negative side-effects were frequently seen. These effects included tardive dyskinesia (writhing tongue movements, uncontrolled tremors or movements in thumb and fingers, shuffling or scissoring gait), loss of ability to move, increased incidents of falls, eating and swallowing problems, weight loss, and loss of continence.

There were also incidents where people seemed to have the opposite of the expected response (paradoxical effect). In these cases the medications worsened their symptoms. If additional amounts of the medications were given in an effort to "give enough" the individuals sometimes became toxic and very seriously ill or died. After these effects were discovered to be much more common in older adults, the use of these medications were greatly reduced, more selectively used and monitored more carefully for side effects.

A New Generation of Drugs

There was also development of a new generation or anti-psychotics that were designed to be safer and more effective. Again, these medications were developed and tested on adult psychiatric patients. These medications were labeled as atypical anti-psychotics and include medications with the trade names of rispirodone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), and olanzapine (Zyprexa).

In April 2005, the FDA looked at the safety issues associated with using these medications on older adults with dementia, reviewed data and issued a new warning about the use of these drugs in the management of dementia. This report indicated that atypical anti-psychotics increase the risk of death for older adults from 2.6% to 4.5%. Most deaths were caused by heart problems or pneumonia.

This fifty percent increase resulted in a change in labeling of these medications. They now have a "black label" which indicates they are not designed to be used on older adults with dementia.

Once this report was released many doctors and health care providers decided to reconsider the use of haloperidol, since the change in safety did not indicate that the typical anti-psychotics posed the same risk. In December of 2005, however, a report in the New England Journal of Medicine reviewed data to determine the impact of typical anti-psychotics on older adults with dementia. NPR reported on December 1, 2005 that Dr. Wand reviewed data on 23,000 elderly Pennsylvanians and found the death risk was increased by 37% with the used of the traditional anti-psychotics.

These findings make it clear that the use of these medications for people with dementia is not without risk and should not be undertaken without significant efforts at using other strategies, environmental modifications, and staff and family education and training. There are certainly no easy answers.

Off-label Use of Drugs

At times, the behavioral symptoms the person with dementia is experiencing are very severe and problematic and need treatment. If the person becomes inconsolably distressed, is extremely physically or verbally agitated without provocation, sees or hears things that are not there and becomes very frightened, or angry, or believes that others are trying to hurt or kill them then "off-label" use of these medications might be considered.

They should always be used as a last resort and the amounts should be kept as low as possible, and monitoring should be done carefully. If these medications are considered, experts recommend very careful use with very low dosages. It is also important to note that other medications which are sometimes considered for helping to manage these symptoms can be dangerous to older people with dementia. This is because anti-anxiety drugs, sleep medications, and some mood altering drugs typically linger in the system and can cause a "hangover." These effects can include increased confusion, falls, problems with continence, drowsiness, and more agitation.

If you have any questions or concerns, contact the Alzheimer's Association Help Line for more information, (800) 228-8738.

 

Hospital Care for People with Dementia

Going to the hospital is often a traumatic experience especially for people with dementia and their caregivers. Using this three-step process will improve the stay for everyone: the person with dementia, family and loved ones and hospital staff.

Step One

Plan ahead. Start with these questions — should we even go to the hospital; under what circumstances would going to hospital be the right choice; when would it not be the right choice.

Prepare advanced directives ahead of time to avoid having to make spur of the moment decisions. For example, decide on the health care power of attorney, complete a living will (including what types of technology to use and not to use, under what circumstances and for how long) and discuss "code" status (use of CPR) while the person is still able to express opinions and wishes. Have copies of legal documents and medical forms completed and convenient.

Divide the potential workload. Decide who will be the family spokesperson, who will stay at the hospital when and how to fill in the blanks. Expect people with dementia to need someone with them 24/7. If family can't do this, develop a back up plan of paid agency or other caregivers. Interview and establish a relationship with these people ahead of time.

Prepare an emergency bag, similar to a maternity bag. Include comfort items such as clothing, pillows, snacks, and toiletries for the person with dementia and the attending caregiver.

Develop a Personal Information Sheet and medication log. Include health information, helping strategies and routines. Examples of these are available through the Alzheimers North Carolina, Inc. office.

Finally, consider registering the person with Safe Return. The bracelet can serve to identify the person as someone who has special needs.

Step Two

Implement your plan. Present your prepared documents as you walk in the door but keep a back up copy. Highlight the most important aspects of care with each staff person, especially how to deal with behaviors. Expect to repeat yourself often and clearly. Implementing the positive physical approach, streaming interactions through one spokesperson, using good manners — Is this a good time for me to ask some questions? and saying "Thank you," will improve care and outcomes.

Offer to help with procedures, exams and personal care if you think this will help the person with dementia and if you feel comfortable with this role. But, keep focused on your job, advocating for the person with dementia. You can do this by staying true to previously made decisions, asking questions and for clarification of answers and making informed decisions. Choose your three priority issues and let go of minor concerns. One important advocacy is monitoring the person closely for changes in thinking, abilities or behaviors that occur suddenly and notifying hospital staff immediately of any changes. Be prepared to explain specifically how this change is different for this person.

Try to keep your self calm and centered — other people will take their cues from you. Be polite and patient, at least in public. Then find a way to let off steam: ventilate to a friend, take a walk, write in a journal. Make sure you take breaks and get away.

Step Three

Evaluate the process. What things are going well and what needs to change? What is the next step: home, hospice, short term or long term placement? Work with the discharge planning team to identify any resources that may be available on discharge, such as home health, equipment, etc.

Finally, remember &mdas;l this too shall end. By using these strategies, you can influence the care of the person with dementia and reduce the trauma for everyone involved.

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