Hello, everybody.

I'll be talking to you about how we use medications as part of dementia dare.

Here is an overview of my presentation.

I will begin by a few principles that I want to make sure you appreciate.

Then we'll talk about three areas, in relationship to medication use.

One relates to minimizing medication load, especially medications that might be

used for comorbid conditions, like high blood pressure or cholesterol.

I'll then then briefly touch upon medications that are marketed in the US

and other parts of the world for cognitive symptoms, such as memory loss.

And finally, I will be talking about the use of medications for

some of the neuropsychiatric, also known as behavioral symptoms,

associated with dementia.

For example, depression,, delusions, sleep disorders, and so forth.

Here then are the principles.

Perhaps the most important principle is that it is best to use medications

sparingly in people with dementia.

That is because their brains are vulnerable and

they have difficulty tolerating medications.

Medication effects can be additive.

So two meditations, or three medications, or

four medications produce an increasing burden on the brain.

And at some point, it might be too much for it to handle.

The second major principle is that medications should be used for

clear reasons.

If there's not a clear reason with a clear benefit greatly outweighing risk,

medications should probably not be used.

I'll talk a bit more about that in the later parts.

Also, medication monitoring should be happening regularly.

Medication benefits must be monitored, always asking the question,

are these medications producing the benefit that is desired?

Next important principle is to carefully look for side effects.

And keep in mind that side effects might not be typical.

In other words, the side effects listed in the books might not be the ones that we

see in someone with dementia.

A common example is that a side effect where a person might be having

nausea might be weight loss.

And so weight loss, which can also be due to dementia itself,

should often be associated or considered to be the result of a medicine.

Finally, there should be the intent and

plan to stop medications that do not have a clear benefit.

If a medicine is not clearly helping someone with dementia,

it should be stopped.

There are very few instances where a medication cannot be stopped

with a brief period of observation, to make sure that it is producing benefit.

Minimizing medication load is a really critical aspect

of care of people with dementia.

All medications, including over the counter medications,

must be reviewed regularly.

Following the principles I just articulated, they must be reviewed for

benefit as well as side effects.

Of particular attention are medications that have what is known as

an anticholinergic effect.

Those of you who are clinicians can look that term up and read more about this.

In general though, medications that produce anticholinergic effects

are actually quite common and widely used.

And they can really impact the brain by worsening memory and

other cognitive symptoms.

Common examples of anticholinergic medications are those that

might be used for bladder control or incontinence, for pain,

especially narcotics, sleep, as well as gastroesophageal reflux disease.

It's not to say that these medicines should never be used, but

rather it should be appreciated that they are affecting the brain, and

they are affecting cognition, when the risk benefit is being evaluated.

Minimizing medication load ultimately means that the overall number of

medications should be reduced if at all possible.

Examples might be medications for comorbidities.

For example, statins, or other medicines used to reduce cholesterol or

lipids, might not be needed.

In certain ages over age 80 or ages 90, there really are diminishing returns,

and if they are not needed, they should be stop.

The same is true for medications that might be used to manage blood pressure.

In general, as people get older, less intense blood pressure control is needed.

The management of blood pressure for 40 or 50 year olds has a different target,

as compared to management of blood pressure for an 80 or 90 year old.

As a result, if blood pressure medicines are being added or

used to keep blood pressure at a lower than appropriate point,

they should be reduced or discontinued.

Similarly, medications that are used for

unclear indications should be stopped, period.

People with dementia, are often taking as many as seven or

eight prescription medications.

And many times they're taking a number of over the counter medications that can be

stopped.

Another example of over the counter medications that are often used with

adverse effects include those that are used to manage sleep.

Things like diphenhydramine, or other antihistamine medications

sold over the counter to help sleep, can be harmful for people with dementia.

There are alternative approaches to helping improve sleep.

The next discussion of medicines concerns the use of medicines for

what we call the cognitive symptoms of Alzheimer's disease.

These are medicines that have been studied and approved, in the United States and

other countries, for the treatment of memory loss and other cognitive symptoms.

It should be appreciated that as a whole, these are not cures for

Alzheimer's or another dementia.

However, they do have a role to play, and should be considered, although

not necessarily always prescribed, to treat someone with Alzheimer's disease.

There are two general groups, one are known as cholinesterase inhibitors.

What these medicines do is increase the level of acetylcholine in the brain.

Acetylcholine is a chemical that is important to the functioning of memory,

and that chemical is lost early in Alzheimer's disease.

Cholinesterase inhibitors boost, albeit temporarily,

the amounts of acetylcholine in the brain.

In the US, the three marketed medicines go under the trademark names of Aricept,

Exelon, or Razadyne.

They each are pretty equivalent in whether they are likely to help or harm.

So that decisions should be made in careful consultation with a physician

who's familiar with their use and who's familiar with the patient.

It is not clear to me that one of these should be preferred over the others.

Generally speaking, choices should be made based on the particular circumstance.

Why use these medicines?

Well, 10 to 15% produce a modest benefit.

These are patients who come back after starting the medicines and

look better by all accounts.

Patient thinks that their mentation is better,

families and caregivers agree, and the clinical teams notice that.

Since this occurs 10 to 15% of the time and can be substantial improvement,

it's a good idea to consider trying these medicines if they can be used safely.

Otherwise though, the benefits of these medicines can be small, so

that it's important, before starting them,

to have a detailed conversation about what expectations there are around their use.

So that if they are not being helpful,

the decision can be made ahead of time to try a trial off them.

In other words, to stop them, to see if they have been helpful.

While side effects from these medicines are, in general,

uncommon, if they occur, they can be significant.

More common side effects include stomach upset, nausea,

occasionally vomiting, loose bowels, diarrhea.

More concerning side effects can be muscle cramps, falls,

a slow heart rate, and occasionally fainting spells.

There are, in fact, in the literature, some links between use of these medicines

and sudden death, although this is probably very, very rare.

The other group of medicines, with really only one medicine in the class,

are known as NMDA antagonists.

What they do is they limit the toxicity of a brain chemical called glutamate.

Namenda, as it's marketed in the US, or Ebixa, as it's marketed in

many other parts of the world, is the best example of this medicine.

The evidence is quite good that this medicine is not very helpful

in mild dementia.

So it is primarily indicated in moderate or

more severe stages of dementia for people with Alzheimer's disease.

The effects here are also small, typically improvements in functioning or

perhaps slowing of the progression of functional and cognitive loss.

Side effects again are uncommon, but they also can be quite substantial and

important, such as dizziness or falls, or

even brief periods of significant agitation.

The final group of medications relates to the treatment of neuropsychiatric,

also knows as behavioral and psychological, symptoms of dementia.

It's important to retaliate that these are universal.

Over time, almost everybody with dementia develops one or more of these symptoms.

With the most common ones being conditions like depression,

agitation, psychosis, referring really to delusions and

hallucinations, as well as sleep problems or apathy.

If these arise newly, the first step is to make sure that they are not the result

of a comorbid medical problem, like a bladder infection, dehydration, pain,

or another fairly common problem like, that could go unnoticed and

manifest only because of the new behavioral change.

Assuming medical problems are not found to underlie these neuropsychiatric symptoms,

it is critical that non-medication treatments be tried first.

There is a wide array of such options, and they can be quite effective.

It is rare that the situation is emergent enough, where there's not enough time to

try these non-medication treatments, where use of medication is absolutely critical.

As I've been emphasizing all along,

it's critical to use these medications very carefully.

These almost all have anticholinergic effects that I talked about earlier.

And so they should be used when the benefit is likely to be very clear and

with careful monitoring.

They should also be used with a backup plan.

What I mean by that is that they should be used on an outpatient basis, cautiously.

And if there is uncertainty about whether they are helping,

if the behaviors are getting worse, or if there are other safety concerns,

the backup plan might consider a higher level of care, such as a chronic or

acute hospitalization, or more intense home-based care.

There are three groups of medicines that are commonly used to treat

behavioral symptoms.

The first group are the antipsychotics, these come as conventional,

and what are also referred to as atypical antipsychotics.

In 2015, there really is no reason at all to use conventional

antipsychotics to treat people with dementia.

And that is because they clearly have worse side effects, and are either less or

equally effective as the atypicals.

So that if antipsychotics are considered, then atypicals are the way to go.

Antipsychotics such as risperidone, olanzapine or

quetiapine, the ones that in the US are commonly used in this setting,

do seem to help with certain types of behavioral symptoms.

In particular, agitation, delusions, and hallucinations.

Therefore, they can be used in targeted ways.

It's important, though, to remember that they can have fairly catastrophic side

effects, including strokes, potentially heart attacks, and

they are also associated with a higher risk of death.

Because of the latter, in the United States, use of antipsychotics in people

with dementia carries what is known a black box warning by the Food and

Drug Administration.

So the risk-benefit equation has to be very clear.

In fact, there are emerging options that are non-antipsychotic medications,

that we'll talk about in a moment, referring to some antidepressants.

On balance, therefore, antipsychotics should be used very uncommonly,

after other medical problems as causes of behavioral symptoms have been clearly

ruled out, and after non-medication therapies have been tried first.

If it appears that an emergency is present, and it's necessary to use these

antipsychotics, it's critical to try and discontinue them as soon as possible.

It's also probably a good idea, if possible,

to always involve a specialist when a behavioral symptom is so

severe that any kind of medication use is being considered.

Antidepressants, in other words medicines that

have been developed to treat depression and

other forms of mood disorders, are, in fact, a fairly good emerging option.

The challenge here is that they have not been very well studied.

And that in fact, there is some evidence they don't work as well for

classical presentations of depression,

like major depression, in people with Alzheimer's disease.

However, there is some evidence now that one of the marketed SSRI, or

selective serotonin reuptake inhibitor antidepressants,

the one known as citalopram or it's cousin escitalopram,

appear to be a pretty good emerging option to treat agitation.

In fact, in some quarters, for milder or even more severe forms of agitation,

even in the presence of delusions and hallucinations,

citalopram or escitalopram might be a reasonably good first line option.

There is evidence that there are previously unknown cardiac effects

related to citalopram, so that they should be carefully monitored if used.

In general, however, most clinicians agree that if effective,

they are more safe or safer than antipsychotics.

The other group of medications that I'd like to mention are anticonvulsants.

Divalproex, also known as Depakote or carbamazepine, in the past known as

Tegretol, are also medicines that I have seen prescribed in people with dementia.

In general, however, they should be avoided.

There's pretty good evidence, with Divalproex in particular,

that it's harmful and is not likely to help behavioral symptoms.

Of course,

if either one of these is needed to treat seizures, that's a different story.

But for the treatment of behavioral symptoms, in my personal view,

anticonvulsants should be avoided.

I do want to briefly mention a group of medicines known as benzodiazepines.

For example, Diazepam or Valium, Clonazepam,

Lorazepam also known as Klonopin or Ativan,

are used not infrequently in the US for agitated people with dementia.

Their use is pretty common in nursing homes and other institutions.

It's pretty clear, though, that the risks almost always outweigh the benefits.

So use of benzodiazepines, should be greatly limited or

restricted, because they are not likely to be helpful, and

can lead to very serious or catastrophic side effects.

In summary, therefore, the treatment of behavioral symptoms in people with

dementia should minimally use medications.

And if medicines are needed, it is critical, as much as possible, to involve

specialists who are quite familiar with their use in people with dementia.

Let me summarize, then, my key point.

Medications are, in fact, a key part of dementia care.

If used carefully, and if used you systematically,

they provide great benefits both for patients and caregivers.

Used carelessly, however, these medicines,

especially if more than one are used, can have catastrophic outcomes, even death.

It's therefore very important, to carefully monitor risks and

benefits of every medication over time for people with dementia.

One of my favorite quotes in this setting actually comes from one of my firm

beliefs, which is that while we can't cure dementia, we can make a huge difference

in the lives of patients and caregivers by simply applying what we already know.

Dementia care is a mature set of practices that make great differences and

improvements in life quality for people and caregivers in all settings.

And so I'm a big advocate of using systematic

dementia care as widely as possible.

I'd like to thank you for your attention.

I am more than happy to take any questions that you may have.

I can be reached at the email that you see on this slide.

Thank you very much.

Medication Use in Dementia Care

Living with Dementia: Impact on Individuals, Caregivers, Communities and Societies

Meet the Instructors