 Long term care nursing home residents with dementia have usually reached the advanced stage of the disease. These residents are typically frail elderly and compromised in terms of brain and multiple other organ function. The use of any medication in this population should be individualized and judicious, especially given the sensitivity of this group to adverse drug events and drug to drug interactions. Here at Cobble Hill, medications are scrutinized according to risk and benefit; unnecessary medications and polypharmacy are avoided.
A 6 month duration study published in Lancet (April 07,
2006) suggests acetyl cholinesterase inhibitors can improve
cognition and preserve function in patients with severeAlzheimer’s disease. The clinical relevance of acetyl cholinesterase
in bringing about a meaningful change in terms
of quality of life is however questionable. For example, in
a previous study using acetyl cholinesterase on a demented
population only a five point improvement in a seventy point
neuropsychological scale is observed at best. While even
a limited improvement is welcome, it would be prudent
not to ignore the bulk of prior studies from July 1966 to
April 2006 which indicate only a limited benefit at best in individuals with mild to moderate Alzheimer’s dementia. We
might want to consider the small number (fewer than 1%)
of post marketing case reports limited to important or life
threatening events with patients on acetyl cholinesterase
inhibitors as part of the risk to benefit paradigm. I believe
we need more studies to validate the results of the Lancet
study on individuals with moderate to advanced dementia
before we can prescribe these medications on an indefinite
basis to this subset of individuals.
With “The Graying of America” or “The Demographic
Imperative” and a likely increase in numbers of patients with
advanced dementia the question in my mind is who will take
care of these patients and how can we maximize care especially
in institutionalized settings? In my experience a small
change in care provision (e.g. the time of day an individual
is taken out of bed or fed or toileted) may have significant impact on function and behavior of that patient with dementia.
Staff training in care delivery and individualizing that delivery using a
person-centered approach profoundly improves the quality of life of a given
resident with advanced dementia. Social impacts, such as a new nursing assistant
or a new room-mate maybe much more important than dopamine or acetyl
choline deficiency in determining behavior and function and quality of life
of an institutionalized individual with dementia.
To summarize it is my belief that until such time further studies are available
on prolonged use (greater than 6 months) of acetyl cholinesterase inhibitors in
individuals with advanced dementia, our use of these drugs for that segment
of the population should be individualized and cautious. We need to focus on
measures of care provision and quality of life that best improve the situation of
this frail, elderly vulnerable and often minority subset of our population. |
 Alzheimer’s disease (AD) is a chronic disorder that
requires chronic treatment. There are
currently two classes of medications
that can be used to slow the decline in
memory and other thinking abilities
that occurs in AD. Outcome is generally
better when medication is started
without delay and taken persistently.
In my experience, the best results come from starting
treatment very early in the course of AD and continuing
as long as the person has meaningful abilities
to preserve.
There are circumstances in which I believe AD
medications should be stopped - for example, if the
person’s illness has progressed to such an advanced
stage that they have minimal interactions with the
world around them. Obviously, any AD medication
that causes severe and recurrent side effects should be
stopped. In such cases, another approved AD medication
should be considered as a substitute. Rarely, a
medication intended to slow AD instead produces a
more rapid decline than is otherwise expected. If this
is confirmed by careful testing, that medication should
be discontinued and a substitute sought.
It is sometimes necessary to stop treatment temporarily
or decrease the dose of AD medications to
address another illness and during certain hospitalizations.
However, there can be a withdrawal syndrome
when some medications (for example, cholinesterase
inhibitors) are stopped for more than just a few days.
Withdrawal can result an even more dramatic decline
in the space of a few weeks than AD itself causes over
several months. Any interruption in treatment should
therefore be kept as brief as possible. In general, a
physician should be consulted before making any
alterations in prescription medications.
Although current treatments are called “symptomatic
therapies” recent evidence suggests that they may do
more than just provide a “band aid” for AD symptoms.
A number of brain imaging studies
have shown that the available treatments
can slow the rate of shrinkage
of the brain in AD and may help to
preserve the health of brain cells that
would otherwise have died as a result
of the illness. Accordingly, treatment
for AD should be started without delay
once symptoms become evident and
continued without interruption as long
as there are meaningful abilities to be
preserved. |
