People with dementia are more likely to be prescribed medications for treatment of cognitive problems, behavioral symptoms, and multiple comorbidities, compared with people without dementia. Most geriatric patients with dementia take five or more medications, commonly defined as polypharmacy (Ruangritchankul et al., 2020).

The use of multiple medications can lead to greater risk of drug-related problems, including potentially inappropriate medications, drug-drug interactions, and adverse drug reactions. This can result in an increased risk of hospital admission, morbidity, mortality, and healthcare burden. These problems tend to occur more frequently—and are more serious—in older adults with dementia than in younger population (Ruangritchankul et al., 2020).

Antipsychotics, anti-epileptics, and antidepressants are the most commonly used medications in older adults with dementia. Older adults, particularly those with dementia, are vulnerable to the adverse effects of these medications. This can include worsening cognitive impairment, aggression, restlessness, sedation, falls, bleeding, and changes in cardiovascular and gastrointestinal function (Jordan et al., 2015).

10.1 FDA Approved Medications for Dementia

There are several FDA approved pharmaceuticals that may temporarily slow cognitive, functional, and behavioral decline, especially in the early stages of cognitive decline:

Cholinesterase Inhibitors

1. Donepezil (Aricept)
2. Rivastigmine (Exelon)
3. Galantamine (Razadyne)

Increase Glutamate Levels

1. Memantine (Namenda)

Combination

1. Namzaric

Anti-Amyloid Antibodies

1. Aducanumab (will be pulled of the market in 2024)
2. Lecanemab

The first three medications are cholinesterase inhibitors, which work by increasing the levels of acetylcholine, a neurotransmitter in the brain involved in learning, alertness, judgment, and memory. Cholinesterase inhibitors do not reverse the progression of Alzheimer’s disease or repair damaged brain cells, and the medications lose their effectiveness over time.

Because cholinesterase inhibitors increase the availability of acetylcholine, they can overstimulate the parasympathetic nervous system. Although side effects can differ somewhat, all three medications can cause nausea, vomiting, gastrointestinal (GI) issues, loss of appetite, and weight loss.

The fourth medication, memantine (Namenda), regulates glutamate, a chemical messenger involved with learning and memory. For people with moderate to severe Alzheimer’s disease, memantine has been shown to improve symptoms related to cognition, function, behavior, and clinical global changes. Side effects include dizziness and headaches.

The fifth medication, Namzaric, was approved by the FDA in 2014. It is a combination of Namenda and Aricept. It is indicated for the treatment of moderate to severe Alzheimer's dementia in patients stabilized on memantine and donepezil. Namzaric is taken as a capsule for once-daily oral administration. To facilitate dosing for patients who may have difficulty swallowing, the capsules can be opened to allow contents to be sprinkled on food (CenterWatch, 2020). Side effects include diarrhea, nausea, vomiting, weight loss, headache, and dizziness.

The approval of the anti-amyloid antibody medications (aducanumab and lecanemab) has caused a great deal of controversy because they were approved by the FDA using an expedited pathway based upon limited data, evidence of significant side effects, and limited benefits (Henry and Pellegrino, 2023). Aducanumab has serious side-effects including brain bleeds and edema in the brain. This medication is being pulled off the market by its manufacturer (Biogen) in 2024. Side effects of lecanemab include infusion-related reactions, amyloid-related imaging abnormalities, and headache.

In 2023, the U.S. Food and Drug Administration announced the supplemental approval of Rexulti (brexpiprazole) oral tablets for the treatment of agitation associated with dementia due to Alzheimer’s disease. This is the first FDA-approved treatment option for this indication (FDA, 2023). Side effects include drowsiness, dizziness, weight gain, restlessness, increased appetite, and shaking.

10.2 Antipsychotics

Antipsychotics are often used off-label to manage behavioral symptoms associated with dementia. These drugs are widely used in people with Alzheimer’s disease and other types of dementia despite only modest evidence suggesting clinical improvement. Because they often have a sedative effect, they can lead to falls, fractures, and excessive sedation.

A study in the United Kingdom indicated that patients who received an antipsychotic for 12 months were significantly more likely to have died by the 24-month and 36-month follow-up periods compared to patients who had received a placebo. Other studies have found a link between the use of antipsychotic drugs in dementia patients and an increase in the risk of acute pulmonary diseases, hip fracture, thromboembolism, and stroke (Guzzon et al., 2023).

The American Geriatric Society (AGS) Beers consensus criteria* for safe medication use in elders recommends avoiding antipsychotics for treatment of neuropsychiatric symptoms of dementia due to the increased mortality and cerebrovascular events risk “unless nonpharmacologic options have failed and patient is threat to self or others”. All atypical antipsychotics now carry a black box warning from the FDA about this risk, and a similar warning applies to conventional antipsychotics.

*Beers Criteria: The Beers criteria are commonly used to identify “potentially inappropriate medications” for older adults, meaning the risk may outweigh the benefit.

10.3 Best Practices in Adult Day Care

Adult day care staff should be aware of the adverse effects of any medications a client is using. For example, some medications increase the risk of falls while others affect cognition. Weight loss, extremely low body fat, and dehydration can also decrease the effectiveness of some drugs. If you notice a change in cognition or behavior, report your observations to your supervisor so a comprehensive evaluation can be completed.

In Florida, adult daycare staff are allowed to “supervise self-administered medication” which means (O’Keeffe et al, 2014, latest available):

1. Reminding participants to take medication at the time indicated on the prescription.
2. Opening or closing medication containers or assisting in the opening of pre-packaged medication.
3. Reading the medication label to participants.
4. Observing participants while they take medication.
5. Checking the self-administered dosage against the label of the container.
6. Reassuring participants that they have obtained and are taking the dosage as prescribed.
7. Keeping daily records of when participants received supervision.
8. Immediately reporting apparent adverse effects on a participant's condition to the participant's physician and responsible person.

If a daycare client is unable to self-administer a medication, a person licensed under Florida law must be available to assist that person. A physician, advanced registered nurse practitioner, dentist, licensed practical nurse, RN, or physician's assistant can administer medications (O’Keeffe et al., 2014).