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by Angela J. Massey
The use of medications to manage dementia and its associated behaviors is a very important aspect of managing the disease. Compliance can be challenging in patients with dementia because of the number of medications, side effects, monitoring requirements, cost, potential for drug interactions, and other factors that influence the responsibility for the administration of the medications. There are several issues that should be considered for optimal benefits from medications in this area.
Dementia Medications
The memory enhancers primarily provide an opportunity to slow the progression of the disease, increase the functional ability of the patient, and minimize caregiver burden. Aricept® should ideally be administered in the morning with a full breakfast to minimize sleep interruption and GI distress. All of the memory enhancers should be administered with food, and their dosing, except for Aricept®, should be spaced 10-12 hours apart to minimize the expected gastric distress. Clinicians should not expect to see any clinical results for four to six weeks after initiating treatment and subsequently should moderate the rate of step-by-step dosage increases or "titrations" to ensure tolerability. A trial period of the individual agents should be attempted for three to six months, with the realization that the rate of response varies between agents, and cross-titrations are needed when switching between agents. Compliance should be emphasized, because data suggest that the full initial benefits may not be experienced with interruptions in treatment. The cost of these agents is at least $100 per month, so clinicians should be instrumental in utilizing patient assistance programs that are available for all of the memory enhancers and numerous other medications.
As psychotropics are needed to manage the psychobehavioral symptoms associated with dementia, clinicians should be careful in their selection and dosing of these agents. If sedating psychotropics are utilized, nighttime administration is recommended to minimize daytime sedation and confusion. Many of the antidepressants (particularly the selective serotonin reuptake inhibitors such as Prozac® or Zoloft®), and some of the older anticonvulsants like carbamazepine (which may be used to address agitation or aggression), can affect the metabolism of other medications. Antidepressants should also be selected based on their potential to cause sedation, increase attention or appetite, and address anxiety. The use of benzodiazepines for longer than three months can cause anterograde amnesia, which may further complicate the dementia. The benzodiazepines also cause terminal and/or rebound insomnia and psychological dependence with long-term use. Cross-titration of psychotropics is also necessary to minimize rebound symptoms, withdrawal reactions, and to allow the most recent medication time to work.
Cognitive impairment caused by medications that are not used to enhance memory is also a major challenge in treating patients with dementia. As previously mentioned, the long-term use of benzodiazepines (i.e., Xanax®, Ativan®) may interfere with the ability to learn new information. Anticholinergic medications (i.e., Artane®, Cogentin®, Atropine®) and antihistamines (i.e., Benadryl®, Dimetapp®, Chlortrimeton®) may cause sedation and contribute to confusion. The incontinence medications (i.e., Detrol®, Ditropan®), motility medications (i.e., Levsin®, Bentyl®), pain medications, and sedating psychotropics can also cause these problems. Since avoiding the total use of these medications is sometimes not possible, attention to time of administration may minimize their cognitive-impairing effects.
Herbals and Vitamins
Another challenge in managing medication use in patients with dementia is the liberal use of herbals and vitamins for the prevention and/or treatment of dementia. Herbals like ginkgo, ginseng, and Huperzine A may in fact have some benefits, but due to the lack of regulations by the U.S. Food and Drug Administration, their use may be more appropriate in the case of treatment resistance from the available prescription products and should be supervised by knowledgeable clinicians. The limited availability of scientifically sound evidenced-based medicine ensuring the safety and efficacy of these products is another reason why clinicians should be cautious about their use. Subarachnoid hemorrhages, blood sugar fluctuations, and bruising are but a few of the side effects reported in the literature about some of these products. Clinicians should also encourage consumers not to exceed the recommended daily allowances of the individual vitamins because of risks like neurologic toxicity, excessive urinary excretion, and drug-nutrient interactions that can occur with their use. For example, megadoses of vitamin E may increase the likelihood of bleeding and/or gastric distress. Megadoses of Vitamin C also have been associated with gastric distress, particularly diarrhea, and may even affect the absorption of other medications. Because some nutrient deficiencies require extra supplementation, are caused by prescription medication use, and are even associated with the cause of dementia, clinicians should be closely involved in the dosing and management of vitamins for these purposes.
In closing, the appropriate use of medications for managing dementia requires the collective involvement of prescribers and professionals like pharmacists and nurses so that the appropriate medications may be utilized to ensure their benefits.
Angela J. Massey is a pharmacist who is board certified in psychiatry. She is an associate professor of pharmacy at Florida A&M University School of Pharmacy. Massey has taught therapeutics in the areas of psychiatry and neurology, alternative medicine, patient counseling, and has trained pharmacy students clinically for the past 12 years. Contact her by e-mail at angela.massey@famu.edu.
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