November 24, 2020
Nearly three quarters of people with Alzheimer’s disease or other forms of dementia are on medications that were not specifically designed to treat their illness, according to a new report. While many of these drugs may help, some may do harm, and all have side effects and carry potentially serious risks. Those risks are further increased when several drugs are taken in combination. The findings underscore the importance of regularly reviewing medications with a physician and adjusting dosages and prescriptions as needed.
Doctors commonly prescribe drugs to treat agitation, aggression, apathy and other behavioral symptoms that accompany the disease. Among these drugs are antipsychotics, antidepressants, anxiety medicines, seizure medications and pain-relieving opioids.
These drugs act on the brain and nervous system, but they were not designed to treat dementia specifically, nor were they often tested for that indication, and there is little proof that they provide benefits for those with dementia-related behavioral problems. Furthermore, they may lead to potentially serious physical problems and worsen memory and thinking skills.
For the study, researchers at the University of Michigan looked at Medicare records of 737,839 older Americans with Alzheimer’s disease or other forms of dementia who were living at home. The study, published in JAMA, is the first extremely large-scale study of prescription-filling patterns for psychoactive medications outside of nursing homes and other long-term care facilities.
They found that 73.5 percent of dementia patients had filled at least one prescription for an antidepressant, opioid painkiller, seizure medicine, or anti-anxiety or antipsychotic drug in a one-year period.
All of these drugs are associated with special risks in older people, and not just those with dementia. Most are included on the list known as the Beers criteria (named for Dr. Beers, who created the first such compilation about three decades ago), a list now updated by the American Geriatrics Society of drugs often unsafe for the elderly.
One of the most common drug risks is ‘falls’, which can lead to broken hips, long hospital stays, confusion or even death. These drugs are often also prescribed for long periods, leading to dependence that could lead to withdrawal symptoms like agitation that further complicate the management of people with Alzheimer’s disease.
Antidepressants were among the most commonly prescribed drugs for those with Alzheimer’s disease. Nearly half of those in the study had taken an antidepressant, which doctors often prescribe to counteract the apathy and social withdrawal that accompany Alzheimer’s disease. That rate is three times higher than for the older population in general.
Unfortunately, antidepressants often don’t effectively ease the apathy of dementia, said Dr. Donovan Maust, a geriatric psychiatrist at the University of Michigan and VA Ann Arbor Healthcare System. “Apathy and withdrawal, and a tendency to get agitated, are common symptoms of dementia,” he said. “And as much as health care providers want to help these patients and their family caregivers, these medications are just not helpful enough to justify this amount of prescribing.”
In addition, antidepressants, like all drugs, have side effects. Some people starting a new antidepressant, for example, may experience nausea or feel a little “jittery.” Unfortunately, a person with Alzheimer’s disease might have difficulty articulating such side effects to a loved one who takes care of them. Instead, they may appear more agitated, leading to another prescription medication to calm them.
Dr. Maust did note that someone who had depression before they developed dementia might benefit from staying on a drug that worked for them in the past. But “clinicians and caregivers may need more support to provide non-drug based approaches to prevent or address the symptoms that these medications are probably being prescribed for,” he said.
Research has shown that massage, touch therapy, exercise, music therapy and other non-drug treatments can be an effective way to reduce aggression and agitation in people with Alzheimer’s disease. These non-drug treatments are far safer than medications and, in many cases, should be given priority in treating disruptive behaviors in people with dementia, experts say.
One bright spot in the data, Dr. Maust said, is that only one in five of the dementia patients studied had filled a prescription for an antipsychotic medicine such as Abilify, Seroquel or Risperdal. Because of the safety risks associated with antipsychotics, including even an increased risk of death, they have received a lot of regulatory attention, and professional guidelines urge caution in their use.
On the other hand, this class of drugs has more evidence than the others that it actually helps some patients with behavioral problems such as aggression. “So it is worrisome that all the other classes — which have less evidence of benefit — are all prescribed more widely,” said Dr. Maust.
Taking these drugs for months on end is especially risky, he said. “A brain that has dementia is doing its best to function as well as it can,” he explained. “If we add a psychotropic medication into the mix it may not be a helpful thing — and it comes with risks.”
Even drugs specifically designed to treat Alzheimer’s disease carry risks. Cholinesterase inhibitors such as donepezil (marketed under the brand name Aricept), used to treat early Alzheimer’s, for example, may cause urinary incontinence, which may then be treated with another drug that can worsen the patient’s confusion.
Finally, this problem has been recognized at the highest levels, and the Food and Drug Administration, the agency responsible for approving drugs, is well aware of serious problems relating to medications. To take this into account, “boxed warnings” or “black-box” warnings are now added more and more often on various classes of drugs to educate patients about the potential risks. Therefore, it is very important for patients with Alzheimer’s disease and their caregivers to be aware of potential problems, to read carefully the boxed warnings, and to discuss possible issues with their doctor before starting a new treatment.
By ALZinfo.org, The Alzheimer’s Information Site. Reviewed by Marc Flajolet, Ph.D., Fisher Center for Alzheimer’s Research Foundation at The Rockefeller University
Source: Donovan T. Maust, MD, MS; Julie Strominger, MS; Julie P. Bynum, MD, et al:Prevalence of Psychotropic and Opioid Prescription Fills Among Community-Dwelling Older Adults With Dementia in the US. JAMA, Research Letter, Aug. 18, 2020
