A DICE-Y APPROACH TO TAMING DEMENTIA SYMPTOMS

Treatment for managing dementia depends on its type and severity, but drug therapy often plays a role. Drugs can't cure dementia, but psychotropic medications, which include antipsychotics, antidepressants and anticonvulsants, are used with extreme caution in certain cases to help improve behavioural symptoms such as aggression, agitation, lack of inhibition and depression -- symptoms that caregivers tend to feel are more stressful or difficult to handle than the trademark memory loss associated with dementia.

For many people with dementia, the potential risks of psychotropics outweigh their potential benefits. All antipsychotics, including haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal), significantly increase the risk of death, perhaps because they also increase the risk of stroke, heart attack and falls.

The DICE approach. In exploring ways to improve symptoms without depending on potent psychotropic drugs, experts from the University of Michigan and Johns Hopkins Medicine developed DICE, a strategy designed to minimize problems by changing a patient's behaviour. The acronym DICE stands for describe, investigate, create and evaluate. The DICE approach is a collaboration among a caregiver, a clinician and, if feasible, the individual with dementia. DICE consists of the following four steps:

Describe: The caregiver describes to the clinician specific behavioural problems the patient is exhibiting and the circumstances and environment under which they occur. The person with dementia describes the situation if he or she has the ability to do so. Both the caregiver and patient convey the degree of distress this behaviour causes them.

Investigate: The clinician examines, excludes and identifies possible underlying medical and mental health causes for the patient's actions as well as drugs the patient may be taking that contribute to the behaviour. The clinician reviews the caregiver's handling of the behaviour and advises the caregiver on issues such as appropriate reaction and expectations. Finally, the clinician will examine the environment for possible improvements, such as reducing clutter or noise and improving lighting.

Create: The clinician and the caregiver create a plan to prevent or respond to either a specific action or general behaviour to enhance the environment and improve caregiver skills and well-being.

Evaluate: The clinician evaluates and assesses the patient's and caregiver's compliance with the suggested plan and makes any needed changes if the desired effects aren't achieved.

The Centers for Medicare and Medicaid Services recommend the DICE approach in an effort to reduce the need for psychotropic drugs. The authors caution that doctors should prescribe psychotropics only after they've made other attempts to change behaviour - unless patients have severe depression, psychosis or aggression that poses a risk to themselves or those around them. The study outlining the DICE approach appeared in the Journal of the American Geriatrics Society.

(Source:  Scientific American Health After 50, 30 March 2015)

CALMING ALZHEIMER'S AGITATION WITH CITALOPRAM

A drug intended to treat depression has been found to reduce agitation in people with Alzheimer's disease. The drug, citalopram (Celexa), appears to be a safer alternative to the traditional antipsychotic medicines used for agitation. Doctors typically prescribe antipsychotics after nondrug treatments, such as behavioral therapy, fail to calm patients.

In a randomized clinical trial reported in JAMA (volume 311, p. 683), Johns Hopkins scientists studied 186 people, average ages 78-79, with Alzheimer's who had symptoms of agitation such as emotional distress, irritability, aggressive behavior, verbal or physical outbursts and restlessness.

They gave about half the patients citalopram with gradually increasing doses up to 30 mg. The remaining patients received a placebo. Participants in both groups, and their caregivers, received counseling as well. After nine weeks, 40 percent of the patients in the citalopram group showed marked improvement in agitation symptoms, compared with 26 percent in the placebo group. Caregivers of patients who received citalopram also reported less stress.

The risks - Citalopram, however, does have some risks; the FDA advises people over 60 to avoid doses above 20 mg. Citalopram been associated with abnormal heart rhythms and a mild decrease in cognitive function. Some study participants who took citalopram also reported anorexia, diarrhea, falls and upper-respiratory infections. Yet, lower doses are still thought to be safer than antipsychotic drugs, which have been associated with stroke, heart attack and death.

The study authors say the next step is more research to determine whether the drug is as effective in doses of 20 mg over a longer period. They also recommend that doctors assess patients individually to determine drug doses, based on factors like the patients' severity of agitation, cardiovascular health and cognitive function.

(Source:  John Hopkins Health Alert, 30 June 2014)

Medical News / Treatment Articles: Drugs In Dementia - Everything You Wanted to Know

VIDEO - Watch Dr Frank Molnar's brilliant presentation on "Drugs in Dementia - The Good, The Bad, The Ugly" at the October 2011 Alzheimer Society of Ottawa and Renfrew County education seminar. Learn the best use of Namenda, Antipsychotics and Cholinsterase Inhibitors like Aricept. See what distinguishes Alzheimer's, Frontotemporal Lobar, Lewy body, Parkinson's, PPA, Semantic and Vascular Dementias. Understand the side-effects and interactions of antibiotic, antidepressant, heart, narcotic and other medications in dementia. Whether patient, caregiver or neurologist, you'll get many answers.

Recommend to read:

1. Charts Comparing Medications to Treat Alzheimer's Disease and Related Dementias

This brief summary does not include all information important for patient use and should not be used as a substitute for professional medical advice. Consult the prescribing doctor and read the package insert before using these or any other medications or supplements. Drugs are listed in alphabetical order.

TECHNICAL FACTS

BRAND NAME	GENERIC (Int'l) NAME	STAGE OF ILLNESS	DRUG TYPE	HOW IT WORKS	LOGO
ARICEPT®	donepezil	Mild to moderate & Moderate to severe	Cholinesterase inhibitor	Prevents the breakdown of acetylcholine in the brain.
EXELON®	rivastigmine	Mild to moderate	Cholinesterase inhibitor	Prevents the breakdown of acetylcholine and butyrylcholine (a brain chemical similar to acetylcholine) in the brain.
NAMENDA®	memantine	Moderate to severe	N-methyl D-aspartate (NMDA) antagonist	Blocks the toxic effects associated with excess glutamate and regulates glutamate activation.
RAZADYNE®	galantamine	Mild to moderate	Cholinesterase inhibitor	Prevents the breakdown of acetylcholine and stimulates nicotinic receptors to release more acetylcholine in the brain.

PRESCRIPTION FACTS

BRAND NAME	MANUFACTURER’S RECOMMENDED DOSAGE	GENERIC VERSION?	FORMAT	COMMON SIDE EFFECTS	MORE INFORMATION
ARICEPT®	.  Initial dose: 5-mg tablet once a day .  May increase dose to 10 mg/day after 4-6 weeks if well tolerated.	No	Tablet	Nausea, vomiting, diarrhea	Visit www.fda.gov/cder. Click on “Drugs@FDA,” search for ARICEPT®, and click on drug-name links to see “Label Information.
EXELON®	.  Capsule: Initial dose of 3 mg/day (1.5 mg twice a day). .  May increase dose to 6 mg/day (3 mg twice a day), 9 mg (4.5 mg twice a day), and 12 mg/day (6 mg twice a day) at minimum 2-week intervals if well tolerated. .  Patch: Initial dose of 4.6 mg once a day; may increase to 9.5 mg once a day after minimum of 4 weeks if well tolerated. .  Also available as oral solution; same dosage as capsule.	No	Capsule Patch Oral Solution	Nausea, vomiting, diarrhea, weight loss, loss of appetite, muscle weakness	Visit www.fda.gov/cder. Click on “Drugs@FDA,” search for EXELON®, and click on drug-name links to see “Label Information.”
NAMENDA®	.  Initial dose: 5-mg tablet once a day. .  May increase dose to 10 mg/day (5 mg twice a day), 15 mg/day (5 mg and 10 mg as separate doses), and 20 mg/day (10 mg twice a day) at minimum 1-week intervals if well tolerated. .  Also available as oral solution; same dosage as above.	No	Tablet Oral Solution	Dizziness, headache, constipation, confusion	Visit www.namenda.com. Click on “Prescribing Information” to see the drug label.
RAZADYNE®	. Tablet: Initial dose of 8 mg/day (4 mg twice a day). .  May increase dose to 16 mg/day (8 mg twice a day) and 24 mg/day (12 mg twice a day) at minimum 4-week intervals if well tolerated. .  Extended-release capsule: Same dosage as above but taken once a day. .  Also available as oral solution; same dosage as above.	Yes	Tablet Once-A-Day Extended Release Capsule Oral Solution	Nausea, vomiting, diarrhea, weight loss, loss of appetite	Visit www.razadyneer.com. Click on “Important Safety Information” to see links to prescribing information.

2.  Introduction To Medications

Learn about the 4 prescription drugs  currently approved by the U.S. Food and Drug Administration (FDA) to treat people who have been diagnosed with Alzheimer’s disease (AD). Treating the symptoms of AD can provide patients with comfort, dignity, and independence for a longer period of time and can encourage and assist their caregivers as well.

It is important to understand that none of these medications stops the disease itself.

Treatment for Mild to Moderate AD

Medications called cholinesterase inhibitors are prescribed for mild to moderate AD. These drugs may help delay or prevent symptoms from becoming worse for a limited time and may help control some behavioral symptoms. The medications include: Razadyne® (galantamine, formerly known as Reminyl® and now available as a generic drug), Exelon® (rivastigmine), and Aricept® (donepezil). Another drug, Cognex® (tacrine), was the first approved cholinesterase inhibitor but is rarely prescribed today due to safety concerns.

Scientists do not yet fully understand how cholinesterase inhibitors work to treat AD, but research indicates that they prevent the breakdown of acetylcholine, a brain chemical believed to be important for memory and thinking. As AD progresses, the brain produces less and less acetylcholine; therefore, cholinesterase inhibitors may eventually lose their effect.

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No published study directly compares these drugs. Because they work in a similar way, switching from one of these drugs to another probably will not produce significantly different results. However, an AD patient may respond better to one drug than another.

Treatment for Moderate to Severe AD

A medication known as Namenda® (memantine), an N-methyl D-aspartate (NMDA) antagonist, is prescribed to treat moderate to severe AD. This drug’s main effect is to delay progression of some of the symptoms of moderate to severe AD. It may allow patients to maintain certain daily functions a little longer than they would without the medication. For example, Namenda® may help a patient in the later stages of AD maintain his or her ability to use the bathroom independently for several more months, a benefit for both patients and caregivers.

Namenda® is believed to work by regulating glutamate, an important brain chemical. When produced in excessive amounts, glutamate may lead to brain cell death. Because NMDA antagonists work very differently from cholinesterase inhibitors, the two types of drugs can be prescribed in combination.

The FDA has also approved Aricept® for the treatment of moderate to severe AD.

Dosage and Side Effects

Doctors usually start patients at low drug doses and gradually increase the dosage based on how well a patient tolerates the drug. There is some evidence that certain patients may benefit from higher doses of the cholinesterase inhibitors. However, the higher the dose, the more likely are side effects. The recommended effective dosages of drugs prescribed to treat the symptoms of AD and the drugs’ possible side effects are summarized in the table (see below).

Patients should be monitored when a drug is started. Report any unusual symptoms to the prescribing doctor right away. It is important to follow the doctor’s instructions when taking any medication, including vitamins and herbal supplements. Also, let the doctor know before adding or changing any medications.

3.  How Do Alzheimer's Medications Differ?  

Which Alzheimer's medications are best? To help answer this question, the ACP/AAFP Committee issued guidelines on the five available medications for Alzheimer's.

An American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) committee issued a clarifying guideline on drug treatment of dementia. Their advice? When trying to decide which medicine is best for a person, the most important considerations are:

    Side effects

    Ease of Use

    Cost

There's no proof that any one of the five drugs available in the United States to treat dementia in general, and Alzheimer's in particular, is more effective than the others.

The committee reviewed published studies for outcomes such as cognition, global function, behavior/mood, and quality of life/activities of daily living. They found only limited high-quality scientific evidence of the effectiveness of the drugs and therefore developed the following cautious recommendations:

·  The decision to use approved drugs for dementia should be based on an individualized patient assessment.

·   The choice of drugs should be based on tolerability, adverse effect profile,ease of use, and cost.

·     There's an urgent need for more clinical research to improve knowledge about the clinical effectiveness of drugs used to treat dementia.

The committee recommended the following kinds of research:

·         Evaluate the effectiveness of drug therapy for dementia and assess whether treatments affect key outcomes, such as institutionalization.

·         Evaluate the appropriate duration of therapy.

·         Head-to-head testing of drugs.

·         Test drugs in combination therapy.

The guideline was published in the Annals of Internal Medicine.

Currently, there are five FDA-approved drugs for treatment of dementia. These include four acetylcholinesterase inhibitors - donepezil (Aricept®), galantamine (Razadyne®, Reminyl), rivastigmine (Exelon®), and tacrine - and one neuropeptide-modifying agent - memantine (Namenda®).

While these drugs may improve symptoms or slow disease progression, they don't cure dementia or repair brain damage.

"Doctors, patients and family caregivers desperately want information on how to treat this disease," Dr. Amir Qaseem, senior medical associate in the ACP's Clinical Programs and Quality of Care Department, said in a prepared statement.

"More research is warranted, because the available evidence concerning these pharmaceuticals' effects on quality of life is mixed, and the clinical significance of many of the findings is questionable," Dr. Kenneth G. Schellhase, an AAFP representative on the committee, said in a prepared statement. "In addition, the duration of existing trials was usually less than one year, providing insufficient information to determine the optimal length of treatment, and few trials compare one drug directly with another."

Most existing studies of the five approved dementia drugs focused on statistical significance of changes, but clinically important improvement is what matters to patients, caregivers and doctors, the committee noted. Many studies measuring clinical improvements are currently in progress throughout the world.

4.  Behavioral Benefits of Alzheimer's Medications

People with Alzheimer's and other dementias often take medications called cholinesterase inhibitors.

Medical research has demonstrated they are also a safe alternative to antipsychotics for the behavioral and psychological symptoms of dementia.

This is according to a study that appears in the December 2008 edition of Clinical Interventions in Aging.

Currently, the main cholinesterase inhibitors that are offered for Alzheimer's and other dementias are:

Brand Name	Generic Name
Aricept	donepezil HCL
Exelon	rivastigmine
Razadyne®	galantamine HBr

Investigators from the Indiana University School of Medicine, the Regenstrief Institute and Wishard Health Services reviewed nine randomized, double-blind, placebo-controlled clinical trials evaluating the effectiveness of three popular cholinesterase inhibitors in managing behavioral and psychological symptoms displayed by patients with Alzheimer's disease.

The researchers report that the trial results indicate cholinesterase inhibitors led to a statistically significant reduction in behavioral and psychological symptoms such as aggression, wandering or paranoia when using the same dosage as administered for improving cognitive impairment.

Nine out of 10 Alzheimer's disease patients display behavioral and psychological symptoms of their disease. The review of the clinical trials revealed that cholinesterase inhibitors are safe, producing no major side effects.

"There is a need for safe alternatives to the anti-psychotic drugs currently used to manage the behavioral and psychological symptoms of Alzheimer's disease. The results of the studies we analyzed are encouraging and suggestive that cholinesterase inhibitors are safe and effective alternatives. However, they are underutilized and typically prescribed for less than three months and for less than 10 percent of patients with Alzheimer's disease. Our findings might provide clinicians with useful data to justify the appropriate use of these medications," said Malaz Boustani, M.D., corresponding author of the Clinical Interventions in Aging paper. Dr. Boustani is assistant professor of medicine at the IU School of Medicine, a Regenstrief Institute research scientist, a research investigator with the IU Center for Aging Research, and chief research officer of the Indianapolis Discovery Network for Dementia.

In Alzheimer's disease there is a decrease in acetylcholine, a chemical in the brain that assists memory, thought and judgment. Cholinesterase inhibitors raise acetylcholine levels. Increased concentrations of acetylcholine in the brain leads to increased communication between nerve cells and may improve or stabilize the symptoms of Alzheimer's disease in the early and moderate stages of progression.

Noll Campbell, PharmD, a clinical pharmacy specialist in geriatric psychiatry with Wishard Health Services and corresponding author of the paper, said that, "This class of medications has already been approved by the Food and Drug Administration to manage symptoms of Alzheimer's-type dementia, although their potential benefits on behavioral symptoms are not frequently identified by many prescribers. Clinical trials of cholinesterase inhibitors have shown benefits in several domains of cognitive function as well as behavioral symptoms associated with dementia, and may improve the management of behavioral problems while reducing the use of more harmful medications that are needed to control behaviors."

Dr. Boustani noted that the vast majority of busy primary care physicians, the doctors who see the majority of patients with Alzheimer's disease, are unaware of the details of the studies analyzed in the Clinical Interventions in Aging paper and he hopes that this new paper, which reviewed the studies, will encourage them to prescribe cholinesterase inhibitors, with its benefits for both cognition and behavior symptoms to their Alzheimer's disease patients. 

5.  Moderate Your Medications

Almost 190,000 Australians have dementia and as Australia's population ages, dementia becomes a bigger challenge for doctors, their patients and carers.

According to the National Prescribing Service Limited (NPS), there are limited benefits to using cholinesterase inhibitors and memantine in the treatment of patients with dementia drug therapy.

Research indicates that the benefits of cholinesterase inhibitors and memantine are small, some people will not respond and adverse effects are common, says NPS clinical expert, Education and Quality Assurance Program Manager, Ms Judith Mackson.

Because the response rate is low and the effects of cholinesterase inhibitors and memantine are small, if these medicines are to be used, it is imperative that they are monitored in order to objectively assess their effectiveness for the patient.

Antipsychotics have a very limited role in some of the challenging behaviours of dementia and the risk of cerebrovascular events and all-cause mortality increases. Consequentially if there are no clear beneficial effects, a trial withdrawal should be attempted because for many patients symptoms will NOT worsen on withdrawal.

A planned, regular and also opportunistic approach to reviewing medications is recommended not only for people with Alzheimer's disease, but all older people using medicines, Ms. Mackson said.

She says health professionals need to encourage the use of non-pharmacological strategies at all stages of dementia. We know that non-pharmacological strategies can help promote and maintain independence, cognitive function and manage the behavioural and psychological symptoms of dementia.

Carers may see medication as the only option, so they will need support and information to help manage their expectations on the effectiveness of medication, she said. "Appropriate counseling for carers from health professionals on the limited benefits of drug therapy is key to best practice. In addition, carers may need information about the process of withdrawal if there are no clear beneficial effects of the medication."

To learn more about how to make informed decisions when working with patients with dementia, the new NPS education program, Treating the symptoms of dementia may be of interest. To obtain a copy,or to find out about the education program, visit the NPS website www.nps.org.au.

(Source: Alzheimer's & Dementia Weekly, 2 January 2012)

Medications and Patients with Alzheimer’s Disease – What to Avoid

Doctors are often asked whether there are any medications that someone with Alzheimer’s disease should avoid. Patients with Alzheimer’s disease may need medicines to treat symptoms of the disease, as well as for other health problems such as bladder incontinence, mood disturbances, high blood pressure, etc… However, when a person takes many medications, there is an increased risk of adverse effects, including confusion, mood swings, sleepiness, and worsening memory problems. Some medications can worsen symptoms of Alzheimer’s disease and should be avoided, if at all possible.

Sedatives and Sleep Aids:
Some sedatives or hypnotics, such as benzodiazepines and barbiturates, can cause drowsiness, confusion, increased cognitive impairment, slowed reaction, and worsening balance leading to falls. Sleep aids usually have the same effects. Examples of sedatives to avoid include the benzodiazepines diazepam (Valium), lorazepam (Aivan), temazepam(Restoril), triazolam (Halcion), and sleep aids zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata).

Antidepressants:

Certain antidepressants, such as the older tricyclic antidepressants amitriptyline (Elavil), nortriptyline (Pamelor), andimipramine (Tofranil), can cause sedation and worsening cognition. The tricyclic antidepressants have anticholinergic effects, meaning that they can further suppress the activity of acetylcholine, one of the main brain cell messenger chemicals whose activity is reduced by Alzheimer’s disease. For low mood and irritability in patients with Alzheimer’s, the SSRI (selective serotonin reuptake inhibitor) antidepressants including citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and the SARI (serotonin antagonist reuptake inhibitor) such as trazodone (Desyrel) can be considered instead.

Antipsychotics:

Antipychotics are sometimes given to treat behavioral symptoms such as agitation, aggressiveness, hallucinations and delusions. However, both the older antipsychotic drugs such as haloperidol (Haldol) and the newer atypical antipsychotics such as resperidone (Risperdal), olanzepine (Zyprexa) can cause serious side effects including sedation, confusion, and sometimes Parkinsonian-like symptoms. Studies have shown that both atypical and older antipsychoticsare associated with increased risk of death in elderly dementia patients. These drugs should not be used routinely, and if needed, the minimum dosage should be used for the minimum amount of time, under careful supervision of an experienced clinician.

Patients and caregivers should also be cautious of over the counter medicine containing diphenhydramine (Benadryl). Diphenhydramine is an antihistamine that tends to make people drowsy. It also has anticholinergic effects that may result in confusion and worsening cognition. Diphenhydramine is found in sleep aids such as Compoz, Nytol, Sominex, Unisom, and also in “night time” or “pm” version of popular pain relievers, cold and sinus remedies.

In essence, patients with Alzheimer’s disease are particularly vulnerable to side effects from various medications. It is best to consult with your doctors and pharmacists to learn about the benefits and potential adverse effects of any new treatment therapy, including seemingly benign over the counter remedies.

Source: Gaby T. Thai, M.D., 19 April 2011
http://www.alz.uci.edu/medications-and-patients-with-alzheimer%E2%8...