Don’t overlook nonpharmacologic interventions
Families caring for a loved one with Alzheimer’s disease face many decisions. Regardless of when in the course of the disease the diagnosis occurs, its pronouncement is followed by a complex and often emotional negotiation process that includes identifying community resources, making care arrangements, and legal and financial planning. This work may take place concurrently with the exhausting physical care that often comes with the job of a caregiver. As the disease progresses, the physical, emotional, and financial stress on the family increases.
Because they may be pressed for time, have limited staff support, or have limited knowledge of community resources, physicians unfamiliar with the treatment of Alzheimer’s disease may focus on prescribing pharmacologic interventions rather than providing education, resources, and referrals. This approach may lead caregivers to unrealistic expectations of medications in lieu of beneficial environmental and behavioral interventions for NPS. For a family attempting to provide home care for a patient with Alzheimer’s disease, improved behavior may lead to improved quality of life—both for those with dementia and their caregivers. Further, environmental and behavioral interventions could also slow the speed of functional decline and decrease NPS.
Despite the quality of the small studies we examined, without replication in diverse populations that reflect patients seen in everyday clinical practice, it is difficult to know which patients will benefit from combination therapy. The goal of evidence-based medicine is to use evidence gathered from patients who are similar to those that the physician is treating. To evaluate the evidence base around the use of dementia-specific medications and the impact on patients with dementia, additional RCTs, longitudinal data, and secondary outcomes are needed. However, even without this evidence, currently available data should not be ignored. This is part of the evolution of the evidence base.
Bottom Line
For treatment of neuropsychiatric symptoms (NPS) in patients with dementia, evidence supports monotherapy with a cholinesterase inhibitor for patients with mild to moderate dementia, and memantine for those with moderate to severe dementia. The use of these agents results in moderate improvements in NPS. Combination of a cholinesterase inhibitor and memantine increasingly appears to offer benefit.
Related Resources
- Steffens DC, Blazer DG, Thakur ME. The American Psychiatric Publishing textbook of geriatric psychiatry, 5th ed. Arlington, Virginia: American Psychiatric Association; 2015.
- Jacobson SA. Clinical manual of geriatric psychopharmacology, 2nd ed. Washington, DC: American Psychiatric Publishing; 2014.
- Fitzpatrick JL. Cruising through caregiving. Austin, Texas: Greenleaf Book Press; 2016.
- Snow T. Positive approach to care. Techniques and training for families and professionals working with persons with cognitive impairment. www.teepasnow.com.
Drug Brand Names
Aripiprazole • Abilify
Carbamazepine • Tegretol
Citalopram • Celexa
Donepezil • Aricept
Donepezil/memantine • Namzaric
Fluoxetine • Prozac, Sarafem
Galantamine • Razadyne
Lithium • Eskalith, Lithobid
Memantine • Namenda
Olanzapine • Zyprexa
Risperidone • Risperdal
Rivastigmine • Exelon
Sertraline • Zoloft
Trazodone • Desyrel, Oleptro
Valproate • Depakote