In people with dementia, like that caused by the progressive brain disorder Alzheimer’s disease, a decline in mental abilities can affect all aspects of one’s life. The advancing changes also profoundly affect how people with dementia interact with their caregivers.
Among older adults with dementia, as it becomes more severe, most experience behavioral and psychologic symptoms of dementia, or BPSD, which can include verbal and physical aggression; agitation; psychosis, like hallucinations; and wandering. “Some patients with dementia develop physically aggressive behavior that becomes difficult for caregivers to manage,” says Dr. David Knopman, chair of the Alzheimer’s Association medical and scientific advisory council, and a clinical neurologist at Mayo Clinic in Rochester, Minnesota.
Research finds that up to 90 percent will experience at least one BPSD and more than 30 percent of those older adults “will have severe symptoms that put themselves and others in danger during the course of their illness,” according to a review published in The Journal of the American Osteopathic Association in July.
The review was focused on ways to reduce off-label use of antipsychotic medications in older adults with dementia who live in the community. These drugs are approved by the Food and Drug and Administration primarily to treat schizophrenia and bipolar disorder. But they’re not approved to treat dementia-related psychosis; in fact, as the agency points out, no drugs are approved for this. The FDA also has a black box warning on antipsychotic medications making clear in boldface that the drugs are associated with an increased risk of death in elderly patients treated for dementia-related psychosis. Although the causes of death vary, most are cardiovascular or infectious in nature, according to the agency — including heart failure, sudden death, like from cardiac arrest, and pneumonia.
[See: 11 Things Seniors Should Look for in a Health Provider.]
The FDA recommends health professionals look for other ways to manage dementia-related psychosis. The Centers for Medicare and Medicaid Services has pushed to reduce the prescription of antipsychotics to patients with dementia who are in nursing homes; and the national effort to reduce prescribing of antipsychotics to those with dementia is now expanding to reach health providers who prescribe the drugs to older adults with dementia who still live at home or in the community.
While noting that the risks, benefits and side effects of individual antipsychotic drugs vary, the review published in July asserts that “a growing body of evidence suggests that antipsychotic use in the management of BPSD is associated with … health risks and only modest benefits.” The review, led by Dr. Rengena Chan-Ting, an assistant professor of geriatric medicine at the Rowan School of Osteopathic Medicine in Stratford, New Jersey, advocated for alternatives to address symptoms of aggression and agitation in older adults with dementia.
These include techniques such as behavior management that seek to better understand what’s triggering the aggressive behaviors and make changes to reduce those behaviors. “They can physically start to hit their loved one, not understanding, as they move into the moderate dementia that their loved one is trying to help them function throughout the day,” Chan-Ting says. Other ways to calm people with dementia include sensory stimulation, she says, such as meditation and massage therapy — holding a shoulder or holding a hand. “Even music therapy has been known to be extremely helpful; if you know what kind of music grandma likes, you can put that music on — it will distract her,” she says.
The Alzheimer’s Association provides various tips to prevent agitation in outlining dementia-related behaviors. Among them, check the environment for stresses, such as too much noise, too many people or bright lights; identifying signs of frustration during certain activities like bathing or dressing and taking a calm reassuring tone; and communicating directly while avoiding expressions of anger or impatience in speaking or movements. “Much of the physically aggressive behavior that occurs in dementia patients in the community is potentially avoidable by the use of greater skill in approaching the patient and in dealing with the patient on a day-to-day basis,” Knopman says.
That said, clinicians say for some patients antipsychotic medication may still be needed. If such aggression isn’t stopped, experts say caregivers at home may become overwhelmed, fear for their own safety and feel that there’s no choice but to institutionalize that person, or put them in a nursing home.
[See: 7 Red Flags to Watch for When Choosing a Nursing Home.]
“Antipsychotic drugs … should be used sparingly and only under the right circumstances when the alternatives have been exhausted for dealing with dementia patients who have agitation,” Knopman says. He adds that it would be appropriate to use antipsychotics to treat physical aggression, where other methods had failed. But for other aggressive behaviors, like a person who’s verbally abusive, Knopman says he would seek to avoid using the medication if possible. “Because that doesn’t threaten the caregiver physically. It may be extremely annoying and very difficult to live with,” he says, adding that could result in the placement of a person into institutionalized care. “But I would try to avoid medication in those situations.” Knopman says he also wouldn’t prescribe antipsychotics to address visual hallucinations if those hallucinations aren’t threatening either to the patient or to the caregiver and aren’t so anxiety-provoking that the person’s quality of life is greatly diminished. “I’d avoid using medications simply because there were hallucinations,” he says.
Neurologist Dr. Doug Scharre, director of the Center for Cognitive and Memory Disorders at the Ohio State University Wexner Medical Center in Columbus, Ohio agreed that there should be a focus on using antipsychotics appropriately in patients with dementia. That includes differentiating when the underlying cause of a person’s agitation is something other than psychosis, such as depression-related agitation, and treating the latter instead with more appropriate medications instead — in that case antidepressants.
But he has pushed back against the broader effort to reduce antipsychotic prescribing for patients with dementia. “If you use it as a last resort what happens is people get so far out of control that they end up in hospitals — emergency rooms,” he says.
Scharre says the drugs work well to treat psychosis in dementia patients, and that using low doses of antipsychotics reduces side effects. Generally speaking, clinicians say it’s important to consider which antipsychotic is used. For example, one that’s used by many doctors, quetiapine, avoids a side effect called parkinsonism, that includes stiffness, impaired gait and potential difficulty swallowing. “What it does cause, though, is sedation, and so one has to be very careful about using it, that you don’t overly sedate a dementia patient,” Knopman says. Other antipsychotics can cause sedation as well, so it’s a matter of looking at risks associated with each individual drug, experts say.
By using lower doses — say 50 to 150 milligrams of quetiapine — versus 300-plus (or well above) that may be used for a patient with schizophrenia, Scharre says, it’s possible to treat dementia-related symptoms while lowering risk. “They don’t have very many side effects, when you use them in appropriate doses,” Scharre says. He says research on the use of antipsychotics doesn’t reflect how effective they can be in those with more severe psychosis. He asserts that’s, in part, because it’s harder to enroll those type of patients in placebo-controlled trials, where they might get the drug or they might get a placebo.
Experts say if patients are placed on an antipsychotic, their caregiver should remain in close, regular contact with the health provider to provide updates on whether the drug is effective and relay if they’re experiencing any side effects. Based upon that and the patient’s symptoms, the dose may be increased or decreased gradually and stopped. It’s also important to talk with a provider about all drugs a patient is taking to guard against potentially dangerous drug-to-drug interactions.
Chan-Ting says the use of any antipsychotic in a person with dementia should be temporary, and caregivers should talk to health providers not only about non-drug alternatives, but when patients might be weaned off the drug. Research highlighted in the review Chan-Ting led shows that commonly older adults with dementia who are prescribed antipsychotics remain on them indefinitely. “Over time the patient will no longer need the antipsychotic because they wouldn’t be strong enough to stand or they would now be wheelchair-bound or they have generalized weakness, and they couldn’t possibly hurt anybody,” she says.
[See: How Music Helps People With Alzheimer’s Disease.]
Experts emphasize that most dementia patients do not become physically aggressive, and fewer still may need treatment for that. In cases where antipsychotics are used, Chan-Ting emphasizes, “This is, if you will, a pill of transition … eventually the behavior stops, because the dementia will continue to progress.”
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Should Antipsychotics Be Used for People With Dementia? originally appeared on usnews.com
