Info on anti-dementia drugs, antipsychotics, antidepressants and other medications for treating symptoms of Alzheimer's Disease.
Four cholinesterase inhibitors, tacrine(brand name Cognex), donepezil (brand name Aricept), rivastigmine (brand name Exelon) and galantamine (brand name Reminyl) have been approved by the FDA for use in treating Alzheimer's disease. All produce some limited improvement in the cognitive symptoms associated with Alzheimer's disease, though they do not slow or halt the progression of the disease. The beneficial effects are typically modest and temporary.
This new generation of anticholinesterase drugs was originally developed to improve memory and the ability to carry out day-to-day living activities in people with Alzheimer's disease. Evidence suggests that these drugs also have beneficial effects on behavioral symptoms, particularly apathy (lack of drive), mood and confidence, delusions and hallucinations. Taking anti-dementia drugs may therefore reduce the need for other forms of medication. However, in higher doses these anti-dementia drugs may occasionally increase agitation and produce insomnia with nightmares.
Memantine (Namenda) is the most recent anti-dementia drug to be developed. It works in a different way than the anticholinesterase drugs and is the first drug suitable for those in the middle to later stages of Alzheimer's disease. It is thought to slow the rate of disease progression rather than to have immediate effects on behavioral symptoms.
Commonly prescribed drugs for Alzheimer's Disease
This list includes the names of many (but not all) of the different medications available. New drugs are appearing all the time and you may need to ask your doctor what type of medication is being prescribed. The generic name is given first, followed by some of the common proprietary (trade) names.
Chlorpromazine (Thorazine, Largactil)
Other mood stabilizers
- Memory Loss and the Brain newsletter, winter 2006.
- Alzheimer's Society - UK
Overview of using medications to treat Alzheimer's patients with sleep problems.
Drugs for treating sleep disturbance
Sleep problems, expecially persistent wakefulness and night-time restlessness, can be distressing for the person with dementia or Alzheimer's Disease and disturbing for caregivers. Many of the drugs commonly prescribed for people with dementia can cause excessive sedation during the day, leading to an inability to sleep at night.
Increased stimulation during the day can reduce the need for sleep-inducing medications (hypnotics) at night. Avoiding stimulants like caffeine, being exposed to the sun during the daytime to regulate circadian rhythms, limiting daytime naps and establishing a bedtime routine are other suggestions to improve sleep offered by the Mayo Clinic.
Hypnotics are generally more helpful in getting people off to sleep at bedtime than they are at keeping people asleep throughout the whole of the night. They are usually taken 30 minutes to one hour before going to bed.
Chlormethiazole is generally well tolerated by elderly people, although some cannot take it because it produces an unpleasant itching sensation in the nose. Benzodiazepines (see section on drugs for treating anxiety) such as temazepam are frequently prescribed.
Antipsychotics, used to control the agitated and combative behaviors often associated with Alzheimer's disease, also have sedative properties that help people sleep.
- If excessive sedation is given at bedtime, the person may be unable to wake to go to the toilet and incontinence may occur, sometimes for the first time. If the person does wake up during the night despite sedation, increased confusion and unsteadiness may occur.
- Hypnotics are often best used intermittently, rather than regularly, when the caregiver and person with dementia feel that a good night's sleep is necessary for either or both of them. The use of such drugs should be regularly reviewed by the doctor.
- Alzheimer's: Managing sleep problems, Mayo Clinic, Oct. 19, 2007.
- Alzheimer's Society - UK, Carers' advice sheet 408, March 2004.
Information on antidepressant medication to treat Alzheimer's patients with depression.
Researchers have discovered that treating depression in patients with Alzheimer's disease can have a significant impact on the well-being of these patients. They also found that treatment of depression can reduce caregiver stress.
In Alzheimer's and dementia patients, symptoms of depression are very common. In the beginning stages they are usually a reaction to the person's awareness of their diagnosis. In the later stages of Alzheimer's Disease, depression may also be the result of reduced chemical transmitter function in the brain. Simple non-drug interventions, such as an activity or exercise program, can be very helpful. In addition, both types of depression can be effectively treated with antidepressants, but care must be taken to ensure that this is done with the minimum of side-effects.
Antidepressants may be helpful not only in improving persistently low mood but also in controlling the irritability and rapid mood swings that often occur in dementia and following a stroke.
Once started, the doctor will usually recommend prescribing antidepressant drugs for a period of at least six months. In order for them to be effective, it is important that they are taken regularly without missing any doses.
Improvement in mood typically takes two to three weeks or more to occur, whereas side-effects may appear within a few days of starting treatment.
- Tricyclic antidepressants, such as amitriptyline, imipramine or doxepin, which are commonly used to treat depression in younger people, are likely to increase confusion in someone with Alzheimer's. They might also cause a dry mouth, blurred vision, constipation, difficulty in urination (especially in men) and dizziness on standing, which may lead to falls and injuries.
- Newer antidepressants are preferable as first line treatments for depression in Alzheimer's.
- Drugs such as fluoxetine, paroxetine, fluvoxamine, sertraline and citalopram (known as the selective serotonin re-uptake inhibitors) do not have the side-effects of tricyclics and are well-tolerated by older people. They can produce headaches and nausea, especially in the first week or two of treatment. There is very limited information about the use of other newer antidepressants in people with Alzheimer's, although one large treatment study (M Roth, CQ Mountjoy and R Amrein, 1996) suggests that moclobemide (an MAOI not sold in the U.S.) is an effective treatment. Venlafaxine (Effexor) has many of the side-effects of tricyclic antidepressants, but can be very helpful in people who have not responded to other treatments.
- Lyketsos CG, et al. Treating depression in Alzheimer disease. Efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS. Arch Gen Psychiatry July 2003;60:737-46.
- Schneider LS: Pharmacologic considerations in the treatment of late-life depression. Am J Geriatr Psychiatry 4:S1, S51-S65, 1996.
- Roth, M, Mountjoy, CQ and Amrein, R (1996) 'Moclobemide in elderly patients with cognitive decline and depression'. British journal of psychiatry 168: 149-157.
- Alzheimer's Association: Depression and Alzheimer's
Overview of using medications to treat anxiety in Alzheimer's patients.
Medications for treating anxiety
Anxiety symptoms are fairly common among patients with Alzheimer's Disease (AD). Such symptoms are likely to make patient care more problematic and, therefore, increase the risk of nursing home placement.
Anxiety states, accompanied by panic attacks and fearfulness, may lead to demands for constant company and reassurance.
Short-lived periods of anxiety, for example in response to a stressful event, may be helped by a group of drugs known as benzodiazepines. Continuous treatment in excess of two to four weeks is not advisable because dependency can occur, making it difficult to stop the medication without withdrawal symptoms.
One important thing to remember, benzodiazepines (like Xanax) can reduce anxiety, but they can also create more memory problems and increase the risk of falls since they slow reaction times and disrupt balance. SSRI antidepressant medications (Zoloft, Prozac, Lexapro), though, may help to reduce anxiety for some patients.
Side-effects of anti-anxiety medications
- There are many different benzodiazepines, some with a short duration of action, such as lorazepam and oxazepam, and some with longer action, such as chlordiazepoxide and diazepam. All of these drugs may cause excessive sedation, unsteadiness and a tendency to fall, and they may accentuate any confusion and memory deficits that are already present.
- Major tranquilizers (antipsychotics) are often used for severe or persistent anxiety. If taken for long periods these drugs can produce a side-effect called tardive dyskinesia, which is recognized by persistent involuntary chewing movements and facial grimacing. This may be irreversible, but is more likely to disappear if it is recognized early and the medication causing the problem stopped.
- Anxiety Symptoms as Predictors of Nursing Home Placement in Patients with Alzheimer's Disease, Journal of Clinical Geropsychology, Volume 8, Number 4, October, 2002.
- Haupt M, Karger A, Janner M. Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers. Int J Geriatr Psychiatry 2000;15:1125-9.
- Treatment of agitation in older persons with dementia. The Expert Consensus Panel for Agitation in Dementia. Postgrad Med 1998 Apr;Spec No:1-88.
- Alzheimer's Society - UK - Carers' advice sheet 408, March 2004
Neuroleptics - antipsychotics are used to treat behavioral symptoms in Alzheimer's patients, but their effectiveness is in question and there are some side-effects to be aware of.
Major tranquilizers (also known as neuroleptics or antipsychotics) are drugs that were originally developed to treat people with schizophrenia.
The use of major tranquilizers in people with dementia remains controversial and clinical trials are in progress to better determine their effectiveness. At the moment, none of these treatments are specifically licensed to treat people with dementia, although they are frequently prescribed to treat symptoms including agitation, delusions (disturbed thoughts and false beliefs), hallucinations (seeing and hearing things that are not there), sleep disturbance and aggression.
Effectiveness of Antipsychotics in Treating Alzheimer's Behavioral Symptoms
The extent to which these medications benefit patients is unclear, and opinions vary as to whether they are safe for this population. The results of phase 1 of the CATIE-AD NIMH (National Institute of Mental Health) study provide a first set of real-world effectiveness data where little existed before. Overall, data from this trial suggest:
- Although some atypical antipsychotic medications are modestly helpful for some patients, they are not effective for the majority of Alzheimer's patients with psychotic symptoms.
- Good clinical practice requires that medical or environmental causes for Alzheimer's-related agitation and aggression be ruled out and that behavioral interventions be considered before turning to antipsychotic medications.
- If an antipsychotic medication then is warranted, clinicians should closely monitor their Alzheimer's patients for intolerable side effects and potential safety concerns.
- Clinicians should be mindful of the limitations of these medications and weigh the risks against potential benefits.
Side-effects of neuroleptics and antipsychotics
- Side-effects include excessive sedation, dizziness, unsteadiness and symptoms that resemble those of Parkinson's disease (shakiness, slowness and stiffness of the limbs).
- Major tranquilizers may be particularly dangerous for people with dementia with Lewy bodies, possibly causing sudden death. If a person with dementia with Lewy bodies must be prescribed a major tranquilizer, it should be done with the utmost care, under constant supervision, and should be monitored regularly.
- A new generation of major tranquilizers may be less prone to produce troublesome side-effects, although some of these drugs (risperidone and olanzapine) have been determined to be unsuitable for use in people with dementia because of the high risk of stroke. So far, there is very little information about the possible risk of stroke with other drugs in this class, such as quetiapine; therefore, their use is not recommended at the moment.
- Whichever drug is used, treatment with major tranquilizers should be regularly reviewed and the dose reduced or the drug withdrawn if side-effects become unacceptable.
- Excessive sedation with major tranquilizers may reduce symptoms such as restlessness and aggression at the expense of reducing mobility and worsening confusion.
- Evidence is also beginning to accumulate to suggest that major tranquilizers may accelerate the rate of decline and disease progression in people with Alzheimer's, so there are particular concerns about the long term use of these drugs.
Anticonvulsant drugs, such as sodium valproate (Depakote) and carbamazepine, are sometimes also used to reduce aggression and agitation, as is the antidepressant drug trazodone.
- Devanand DP, Jacobs DM, Tang MX, et al. The course of psychopathologic features in mild to moderate Alzheimer disease. Archives of General Psychiatry 1997;54:257-63.
- The Quality of Antipsychotic Drug Prescribing in Nursing Homes, Becky A. Briesacher; M. Rhona Limcangco; Linda Simoni-Wastila; Jalpa A. Doshi; Suzi R. Levens; Dennis G. Shea; Bruce Stuart, Arch Intern Med. 2005;165:1280-12.
- NIMH: NIMH Perspective on Treating Alzheimer's Patients with Antipsychotic Medications, October 12, 2006.