Drugs to treat symptoms may worsen Alzheimer’s disease

UEF Bulletin 2016

In Finland, most people with Alzheimer’s disease get the recommended medication – and then some.

 “Our problem is not a lack of treatment, but a liberal use of psychotropic drugs in the treatment of behavioural symptoms of dementia. Excessive use may cause more damage than benefit,” says Sirpa Hartikainen, Professor of Geriatric Pharmacotherapy (in the photo above).

According to the Current Care Guidelines, pharmacotherapy with cholinesterase inhibitors or memantine is part of the comprehensive care package of Alzheimer’s disease. “In Finland, 96% of people with Alzheimer’s disease start the recommended medication. The available drugs don’t stop or significantly slow down memory loss, but they help to maintain functional capacity.”

Finland is also an exemplary country in Alzheimer’s diagnostics. Older people with cognitive impairment get expertly diagnosed by geriatricians and neurologists.

“However, the extensive use of psychotropic drugs is a cause of concern.”

According to results from the MEDALZ study led by Hartikainen, 53% of people with Alzheimer’s disease who live at home used psychotropic drugs during the year following the diagnosis. Some 29% used benzodiazepines and related drugs, 28% used antidepressants and 20% used antipsychotics. People with Alzheimer’s disease were six times more likely to use antipsychotics and three times more likely to use antidepressants compared to controls, and they were often initiated before the diagnosis.

Psychotropic drugs are mainly used to treat behavioural and psychological symptoms of dementia, such as aggression, anxiety, wandering, delusions, hallucinations and depression. Almost all patients experience these symptoms at some point, but Hartikainen points out that drugs should not be prescribed as a first resort. “Non-pharmacological approaches should always be tried first, and psychotropic medication only temporarily when necessary.”

Both the use of benzodiazepines and antipsychotics can accelerate cognitive decline and predispose the patient to falls and injuries. Antipsychotics can have especially harmful side effects in frail older people, including blurred vision, hypotension, parkinsonism and urinary retention, which in turn can lead to urinary tract infections and delirium. The use of antipsychotics has also been linked to increased risks of stroke and mortality.

“Sometimes it can be asked whether these drugs are prescribed more to relieve the burden of caregivers and nurses than to help the patient.”

In Finland, 30% of people with Alzheimer’s disease using benzodiazepines and 57% of those using antipsychotics are long-term users. “This is not in line with treatment guidelines. The need for medication should be reassessed as symptoms subside. In any case, the harm caused by psychotropic drugs outweigh the benefits in long-term use.”

“For example, benzodiazepines don’t help you sleep after several months’ use, but they are addictive and difficult to stop taking. Many patients get their first prescription when they are hospitalised and unable to sleep in an unfamiliar environment.”

The use of benzodiazepines is common among older people both with and without Alzheimer’s disease, even though they have been linked to an increased risk of dementia. “One possible explanation is that they inhibit the intellectual activity needed to maintain cognitive function in old age.”

Hartikainen admits that behavioural symptoms can be hard to treat without drugs. “It requires good interaction skills, patience and knowledge of the patient’s history and interests. It’s easy to upset a demented person, but calmness, friendliness and negotiation go a long way.”

Patients live with Alzheimer’s disease for an average of 12 years. “Their pharmacological needs change over time, so their medication must be assessed on a yearly basis, and sometimes even more often.”

Weight loss is common in dementia, and the dosage of many drugs has to be altered accordingly. Better yet, weight loss, muscle loss and malnutrition should be prevented to preserve daily functions and delay institutionalisation. “People with dementia often forget to eat. We need home care models to ensure that they get enough energy, proteins and other nutrients from meals at all times, as well as exercise.”

“An emerging challenge is the fact that many patients with dementia now have their own teeth instead of false teeth. They need more help in maintaining oral health, the worsening of which may lead to malnutrition and even systemic infections.”

World’s largest Alzheimer’s register study

The Finnish Medication Use and Alzheimer’s Disease Study, MEDALZ, is the world’s largest Alzheimer’s register study, with a cohort of 70,000 patients and unique access to their prescription register, hospital discharge registers and socioeconomic data from Statistics Finland. Controls included, more than 300,000 people are involved. The study assesses persistence and changes in medication use, as well as health status after AD diagnosis, drugs and diseases as risk factors for AD, the associations of medication use with mortality, hip fractures, cardio- and cerebrovascular events, and the use of social and healthcare services.

Text: Ulla Kaltiala Photo: Raija Törrönen