Treatment of dementia using medications mostly focuses on symptom management. There are no therapeutic interventions that have been found to stop the progression or reverse the deterioration caused by Alzheimer’s disease.
Antipsychotics, anti-epileptics, and antidepressants are the most commonly used medications in older adults with dementia. These medications are used in the hope of treating or slowing the progression of symptoms associated with dementia, to manage neuropsychiatric symptoms of dementia, and to treat other health conditions. 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).
Whether to manage symptoms of dementia or co-morbidities:
- 25 to 50% of people with dementia receive antipsychotics
- One-third of care home residents receive antidepressants
- 10 to 20% of people with AD require anti-epileptics (Jordan et al., 2015)
FDA Approved Medications for Dementia
There are five FDA approved pharmaceuticals currently prescribed, which may temporarily slow cognitive, functional, and behavioral decline:
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Razadyne)
Increase Glutamate Levels
- Memantine (Namenda)
The first three medications are cholinesterase inhibitors, which work by increasing the levels of acetylcholine, a neurotransmitter in the brain involved in learning and memory. Cholinesterase inhibitors are generally used for the treatment of individuals in the mild-to-moderate stages of Alzheimer’s disease (DeFina et al., 2013).
The fourth medication, memantine (Namenda), increases levels of glutamate, another neurotransmitter involved with learning and memory. Memantine is indicated for the treatment of moderate to severe Alzheimer’s disease. Overall, the benefits of these drugs are limited. They are effective for about one year and in only about half of individuals to whom they are prescribed (DeFina et al., 2013).
The fifth medication, Namzaric, was approved by the FDA in 2014. It is a fixed-dose combination of memantine (Namenda) and donepezil (Aricept). It is indicated for the treatment of moderate to severe Alzheimer’s dementia in patients stabilized on memantine and donepezil. Namzaric is supplied as a capsule for once-daily oral administration. The capsules can also be opened to allow the contents to be sprinkled on food, to facilitate dosing for patients who may have difficulty swallowing (CenterWatch, 2014).
There is particular concern over the use of antipsychotics in people with dementia, with only modest evidence suggesting clinical improvement but increased risk of adverse health outcomes and mortality (Jordan et al., 2015). Although people with dementia are more susceptible to adverse drug events, as well as falls, fractures, and excess sedation, these drugs remain widely used in people with Alzheimer’s disease (Gnjidic et al., 2014).
Several large clinical trials have demonstrated an increased risk of mortality when atypical antipsychotics are used by people with dementia. All atypical antipsychotics now carry a black box warning from the FDA about this risk, and a similar warning applies to conventional antipsychotics. Atypical antipsychotics are also linked to a two- to three-fold higher risk of cerebrovascular events (Steinberg & Lyketsos, 2012).
The 2012 American Geriatric Society (AGS) Beers consensus criteria* for safe medication use in elders recommend 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” (Steinberg & Lyketsos, 2012).
*Beers Criteria: In 1991 Beers and colleagues published an expert consensus document that attempted to establish criteria for identifying medications that are inappropriate for use in older adults. The Beers criteria are commonly used to identify “potentially inappropriate medications” for older adults, meaning the risk may outweigh the benefit.
For people with dementia, antipsychotics may reduce aggression and psychosis, particularly among those most severely agitated. However, in older people, antipsychotics are associated with increased overall mortality, worsening cognitive impairment, hip fracture, diabetes, and stroke (Jordan et al., 2014).
Several studies have emphasized the need to avoid drugs that affect cognition or cause delirium in clients with dementia. The use of drugs to treat non-dementia illnesses in older adults with dementia may lead to serious adverse effects, even when clearly beneficial drugs recommended by clinical guidelines are prescribed (Colloca et al., 2012).
Article: Risks Run High When Antipsychotics Are Prescribed For Dementia
Source: Scott Hensley, March 18, 2015
Best Practices in Adult Day Care
Adult day care staff should be aware of any medications a client is using that may affect cognition or lead to an adverse event. Older adults with dementia are susceptible to dehydration, which can affect drug absorption rates. Some medications can increase the risk of falls while others affect cognition. Weight loss and extremely low body fat 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 day care staff are allowed to “supervise self-administered medication” which means:
- Reminding participants to take medication at the time indicated on the prescription
- Opening or closing medication containers or assisting in the opening of pre-packaged medication
- Reading the medication label to participants
- Observing participants while they take medication
- Checking the self-administered dosage against the label of the container
- Reassuring participants that they have obtained and are taking the dosage as prescribed
- Keeping daily records of when participants received supervision
- Immediately reporting apparent adverse effects on a participant’s condition to the participant’s physician and responsible person (O’Keeffe et al, 2014)
Supervision of self-administered medication must not be construed to mean that a center shall provide such supervision to participants who are capable of administering their own medication (O’Keeffe et al., 2014).
No client who requires medication during the time spent at the center and who is incapable of self-administration can be admitted or retained unless there is a person licensed according to Florida law to administer medications. A physician, advanced registered nurse practitioner, dentist, licensed practical nurse, RN, or physician’s assistant can administer medications (O’Keeffe et al., 2014).