Medications Used in Dementia: What Caregivers Should Know | Sarah Mourra MD | UCLAMDChat

[Music] hi I'm Dr Sarah MOA and I'm a bureau of Health Professions fellow in geriatric Psychiatry at UCLA today I'm here to talk to you about medications used in dementia and what caregivers should know so as we go along feel free to ask questions on Twitter using the hashtag UCLA MD chat and we'll be able to answer your questions uh at the end of the lecture so to start off thinking about this topic I wanted to um present this quote which is any symptom in an elderly patient should be considered a drug side effect until proven otherwise and this is a very true true um statement that is important for Physicians to keep in mind and for caregivers to keep in mind when we're taking care of our elders or our loved ones um and they manifest new symptoms uh or um deterioration in terms of their symptoms and we're trying to figure out what might be causing it so why caregivers why is this important for you to know um maybe it's just the Doctor Who should be keeping track of these sorts of things well medication related problems or mrps are more common due to the changes that occur with aging and disability um older individuals are often not able to metabolize medications as well um they may be more vulnerable to uh side effects of medications um due to kind of brains that may not uh have as much cognitive Reserve um for example individuals who may uh have cognitive impairment or stroke um so it's important to keep in mind that they are much more vulnerable uh to medications than individuals in the younger population so why caregivers well caregivers spend the most time with these patients and they are able to play a key role in identifying an actual or potential MRP or medication related problem um that the physician may not be picking up on so why is this important well if it's identified um it has the potential to prevent uh unnecessary nursing home admission hospital admission um it has the potential to prevent Falls and other adverse outcomes um that may result from the medication related uh side effect or problem um in studies that have been done it's been found that caregiver knowledge of their loved ones medications is often greater than that of the Care recipients themselves so it's very important for care givers to really play an active role in this way and we'll also talk about tools that will allow you to do so so what are some red red flags to sort of think about well maybe a medication related problem or MRP is going on here well um one uh a certain category involves sort of mental changes and what we mean by that are symptoms like excessive drowsiness confusion depression um delirium which is a clinical syndrome that's often caused by an underlying medical condition or by a medication that may not be uh working well for that patient or causing these effects uh delirium is a syndrome that we typically um identify with four key symptoms and those are inattention or difficulty to focus um difficulty focusing while having a conversation sort of being distracted um a difficult ulty with alertness so kind of falling asleep in the middle of a conversation rapid onset so very acute onset within days um hours to days a patient can have this come on and thought processes that are really disorganized some of you may be saying well how can I tell if um my elder or the person I'm caring for has an underlying dementia individuals with dementia often will not manifest such a sudden change and also they often will not have difficulty focusing um or paying attention to what you're saying even though they are cognitively impaired um insomnia uh is another um medic potential red flag for a medication related problem so a patient who was uh sleeping very well before and all of a sudden um they're up at night they're not able to sleep um and they're really having difficulty in that regard changes in speech and memory um I know this is challenging especially with uh you know Elders who have advanced dementia but it's very important to keep in mind sort of the time course so is this a change in speech and memory that came about within a few days to weeks versus months to years which we would normally expect in the course of the illness so really the bottom line here is um any of these red flags occurring over a shortened time course should be should raise a red flag for uh looking at potential medication related problems and looking back at okay was a medication increased recently was it taken off recently was it added recently other red flags include in terms of physical U manifestations Parkinson's like symptoms so new onset Parkinson's like symptoms and what I mean by this is shuffling gate new onset Tremor um the patient is less verbal less expressive um their face is less expressive uh they are having more Falls things like that um incontinence so new onset incontinence can also be a red flag for a medication related problem muscle weakness uh so you know if the um if your Elder is all of a sudden not able to sort of um have the same strength that they used to and again on a shorten time course of days to week it's important to really think about could this be due to a medication side effect loss of appetite um we'll talk a little bit about this later but this is a frequent issue with some of the medications we use to treat medication excuse me to treat U mood and cognition in individuals with Dementia or dementing illnesses um Falls and fractures so any new onset Falls or fractures is an indication that um perhaps a medication related problem may be at play so um just to go through an overview of what we'll be talking about today I wanted to cover briefly um the different categories of medications that we use in individuals with dementia and cognitive impairment so those involve medications for mood and this may involve depression um as well as uh irritability or um sort of a bipolar disorder or uh kind of mood fluctuations in addition to treating apathy um we're also going to be talking about memory medications um for dementia behavioral medications that are used to control difficult behaviors including agitation verbal um aggression physical aggression um and then we'll also be talking about sleep medications as many of you know sleep can be a major issue in patients with dementia so it's important to also be aware of the side effects associated with the common medications that we use for sleep so starting off I'd like to discuss medications used for mood um so there's a lot of information um and I'm going to try to go through it as uh you know slowly as possible so people kind of understand what's going on but feel free to send any questions our way um so in terms of of the common medications that we use to treat mood symptoms and this is typically depression um in dementia we will often use the anti-depressants um and this involves several classes one being the ssris um up here uh examples of ssris are caline or Zoloft Citalopram or Celexa ESAT talopram or Lexapro fluoxitine or proac per oxetine or paxel um and then we also have snris so more noradrenergic in addition to serotonergic activity uh which involve duotine um or syala venlafaxine or axer and marzipan or Remeron well Butrin or bupropion is a medication that is not considered an SSRI or snri it has a more dopamine um related method of action so in terms of how we uh think about these medications the ssris are typically our first line that we'll use to treat patients with dementia and uh who also manifest um depressive symptoms now um the main thing to keep in mind with the ssris is that they can cause um GI side effects like uh loss of appetite nausea um kind of uh diarrhea issues like that in the first couple days to weeks although this can go on um and if our Elder is having that problem it would be important to readdress whether this medication is the right medication for them um any of the ssris can also contribute to sedation confusion Falls um things like that the more serious um effects of ssris can involve something called serotonin syndrome which typically typically occurs when you're combining multiple ssris or multiple anti-depressants together um this is a very uh dangerous um condition that is characterized by confusion or altered mental status um high blood pressure and high heart rate um high fever as well as uh Tremors or jerking movements of the extremities so it's very important to be aware of this um potential uh adverse effect when thinking about um an individual who is on maybe one or more uh ssris um in general we try not to use proac paxel or Wellbutrin in older adults um mainly for several different reasons proac tends to have a very long halflife it stays around much longer than any of the other SSR and that can really build up um in the body of the patient especially um if they're having bad effects from it it's hard to stop the medication and have those uh effects go away right away so we tend to avoid that um it can also um lead to increased anxiety uh for some patients paxel uh tends to have what we call more anti-cholinergic effects and we can get into that a little bit later um but uh essentially dementia is a condition where there's a lack of a acetal choline in the brain and so any medication that is anti-cholinergic is only contributing to the problem reducing the level of acetylcholine and impairing cognition so even individuals who do not have dementia who suffer from depression who may be started on a medication like paxel with strong anti-cholinergic effects can have cognitive dulling from it um and confusion that can occur um other anti-cholinergic effects can include urinary retention so difficulties with passing urine um as well as dry mouth and constipation which in patients with dementia they're already struggling with many of those issues so we try not to start um that medication to to potentially make those those issues worse um while Butrin tends to be much more activating medication it's not so great for anxiety which we often find is comorbid with depression in patients with dementia so we tend to avoid it um in general additionally while buttin can increase um seizure risk uh which um in many patients with dementia particularly Advanced dementia is something that we're uh concerned about already so we try to avoid that um so in terms of uh other things to watch out for with anti-depressants um sort of more rare uh things that may occur is that in individuals with dementia and depression who may have an underlying bipolar disorder that has not been diagnosed starting any of these medications um in one of those patients can potentiate or cause a switch into a more manic or hypomanic state and this may be characterized by irritability um mood swings insomnia uh things like that um it's important to keep in mind that that individuals with underlying bipolar disorder um may spend uh do spend approximately 75% of the time depressed so someone who may have sort of gone under the radar for some time particularly if they had um uh the less severe form of bipolar dis bipolar disorder called bipolar 2 uh this is something to keep in mind um so second line medications uh for depression in patients with dementia in involve tricyclic anti-depressants um these May these are examples of this include um amitryptiline nor trolene um these are frequently used in patients who have comorbid migraines um or who may be having neuropathic pain however they are considered um dirtier drugs in the sense that they um are less specific uh in terms of The receptors that they target and can have more anticolon or IC side effects uh for example um which we talked a little bit about before as well as higher risk for cardiac arrhythmias um based on their effects on the heart so that's something important to keep in mind um a less used Class of medications that's often used in treatment refractory depression include the monoamine oxidase Inhibitors um this involves uh medications like um tral camine uh we very rarely use uh these medications in patients with dementia um there uh there's a lot of reasons why but they also have high risk of um serotonin syndrome um as well as um hypertensive crisis uh when combined with certain foods so there's a lot of dietary restrictions that go into that and so uh we tend to avoid that class um in this population also anti-choicers are often used for augmentation of treatment of depression um in patients uh in patients with and without dementia so that's something important to keep in mind um I should ALS I should also mention uh that any of the ssris that we spoke about or snris also have a um uh effect of um increasing bleeding times um this has uh not necessarily been borne out for individuals who are not already at risk for gastrointestinal bleed but for individuals who are at risk for bleed bleeding or have already had a gastrointestinal bleed um this is important to keep in mind in terms of um potential effects uh caused by medication okay um I should also mention with uh well Butrin and any of the snris like Duloxetine and venlafaxine and merapen um there is a risk for increased blood pressure uh for patients who um may already um you know struggle with that as a problem okay so I'd like to move on to talk about memory medications um so these are medications that we use to um not to cure uh the Dementia or to um improve necessarily uh the cognition um but these medications have been shown to slow the decline um the inevitable decline that occurs um when patients uh have dementia um so the common ones that we use are Denzil or AOSP galantamine or Radine rivastigmine or the excalon patch um or oral form um these are all considered acetal Colin estras Inhibitors and essentially going back to the idea that um uh dementia uh particularly Al alimer dementia can be a state of um deficient acetylcholine essentially the mechan the mechanism of action of these drugs is that they um stop the enzyme that breaks down acetylcholine thus increasing the level of acetylcholine um in the brain and uh with the presume presumed idea that it improves um cognition or at least prevents further decline um so in terms of important uh medication related problems that can come from acetyl colon estra Inhibitors the main thing to consider is that all of these medications do have adverse effects in terms of loss of appetite nausea or GI symptoms like diarrhea um so patients can feel when they're started on these medications as though they've lost their appetite they may begin losing weight um for patients who may be more nonverbal uh this may manifest as um you know simply more irritability uh refusing meals um and sort of mood changes so it's important to really be aware of the timing of these medications and when they're started and to be monitoring um your loved one or Elder's um sort of eating habits and schedule uh following initiation of these medications often times um RI rivis stigmine is actually um one of the the worse offenders uh when it comes to um the GI side effects uh which is part of the reason that the patch can also be helpful the patch does not have um the risk of GI side effects the same way the other oral forms do um so moving on I wanted to um also talk about excuse me actually I just want to go back for a second the second major thing to look out for with acetylon estras inhibitor is that they can actually lower the pulse so um what this means is that for individuals who may already have a low heart rate uh the medication May lower their heart rate further putting them at risk of passing out or falling um from decreased uh blood flow to the brain oh excuse me I think I did something sorry about that okay we're back up um due to decrease blood flow to the brain so um it's important uh to monitor also your loved one for any symptoms of dizziness or falling that occur after uh starting these medications and to monitor the heart rate typically if somebody's heart rate is in the 50s um 50 beats per minute uh we will usually um not start one of these medications um until the heart rate uh reaches a more kind of regular level above UH 60 beats per minute due to this risk so the next medication I wanted to talk about is mim Mantine or nenda um this is a medication that has a completely different method of action uh from the acetylon estra Inhibitors um it is an nmda antagonist um so it essentially um works on a different neurotransmitter called glutamate in the brain um and works with the hypothesis that uh dementia is a state of um excitotoxicity or overstimulation from an excitatory neurotransmitter like glutamate so essentially memantine will lower um will work against uh that issue essentially lowering glutamate uh toxic level to lowering glutamate levels and hopefully improving um that uh that potential toxicity so um essentially the important thing to keep in mind with uh MIM Mantine is that it can also cause um some mood symptoms um it can cause fatigue um it can also in patients who have kidney issues um it's metabolized through uh the kidney or the renal system so any impairment of the kidney can also lead to very high levels of nenda or memantine um and that can uh cause confusion um and delir as we talked about before um and um it also can uh increase the risk of seizures um when it can get to when it gets toxic but this is very rare um so I'd like to move on to medications used for Behavioral symptoms um I should probably uh mention that um it's very important when a patient has behavioral symptoms to really understand where that change in behavior is coming from so for example untreated pain can manifest as behavioral symptoms um also there's a full range of Behavioral symptoms so wandering uh verbal um you know just speaking verbally uh constantly or verbal aggression um and then on the other range physical aggression which actually threatens the safety of caregivers so before starting any medication PA s we will often try to manage um behavioral symptoms with non-pharmacologic interventions however when safety becomes an issue and caregivers um are at risk we will uh often need to use uh medications to try to control the behavior um often times when the behavior is not um physically threatening or threatening safety um but medication is desired um some of the anti-depressants that that we spoke about as well as the cognitive um medications that we spoke about can sometimes have an improved effect on behavioral issues um on the more mild behavioral issues um however when it comes to physical aggression we we obviously take that very seriously and we think about um other medications that can effectively essentially control um that behavior a little bit better so um one of the classes that we frequently use are the anticho U medications or dopamine antagonist um medications um these involve medications such as quene or cakil olanzapine or Zyprexa resperidone or risol aripiprazol or Abilify and zedone or Geodon um there's a couple other ones that are on the market but these are um the most commonly used ones at this point in time um so what are the the most important side effects to look out for when using a uh anticho medication um well the antis psychotic medications range um in terms of their potency so you have very low potency uh anticho discs as well as very high potency anticho and depending on whether something and potency relates to um the way in which the medication binds to the receptor so how quickly and um and how tightly it binds to the the uh dopamine receptor which is what it acts on now U medications that are low potency so that involves a medication for example like cakil um they tend to have more effects involving sedation um or over sedation um effects involving uh low blood pressure when going from a sitting to a standing position uh which we call orthostatic hypotension so this may manifest as um the patient uh saying that when they get out of bed in the morning they feel dizzy their head is kind of spinning and they sort of have to catch themselves um or when they go from a sitting to standing position um feeling as though the room is spinning or they feel a little bit laded so um and this you know at its very worst can lead to Falls or passing out which is very important um to be mindful of especially if one of these medications were started recently um essentially uh higher potency medications um one of those uh I guess resperidone on this list would be an example of that um they tend to have more effects along the lines of um potentially creating uh Parkinson's like symptoms so um reductions in the ability to walk normally so sh more of a shuffling gate a Tremor um involuntary movements uh of the face or mouth um as well as stiffness uh and rigidity um in the muscles and uh in the muscles of the usually the um upper extremity but can occur um anywhere else as well um the higher potency agents um can also C cause sedation um higher risk for Falls as well um uh in terms of the overall class of antipsychotics um important things to keep in mind um involve the fact that uh currently there is a blackbox warning on all of these medications um indicating that in studies it's been found um that they all increase the risk of stroke or um cardiac uh mortality um now uh this definitely was done in a much um more ill population a much older and much more ill population however it's an important um issue to keep in mind when thinking about the risks and benefits of starting one of these medications um other uh important considerations for the entire class of antis psychotics involve the fact that um especially the second generation or atypical antipsychotics which we are are sort of our default um in this population um which are all listed here uh there is the risk of um uh increased risk essentially of um glucose uh or excuse me insulin resistance um and veloping U metabolic side effects so weight gain um hyper lipidemia so high cholesterol um so this is uh very important for elders who may suffer already from a metabolic syndrome or diabetes um and these medications may actually cause a worsening of some of those issues so blood sugars that are much higher and this can manifest in multiple um issues further down the line so you know um mood changes that come from the sugar fluctuations etc etc um so other uh medications that we um don't use don't uncommonly use in patients for whom the behavioral issues have really gotten to the point where there is physical um aggression and safety uh may be an issue um or um you know mood is really um kind of extremely irritable and leading to lashing out uh episodes um we will often use a medication called valproate or valproic acid also known as depote um this is a medication that um is an anti-convulsant so it's used um typically in high doses for uh seizure disorders however um in lower doses it can be very helpful uh with individuals um who suffer from dementia who may be having a lot of these behavioral problems important things to keep in mind in terms of um uh side effects or adverse effects from depote involve um rash uh bleeding risk um dizziness or confusion that can occur when levels go above or become toxic for example um so for this reason blood levels of this um medication are frequently monitored um to make sure that they are not uh reaching toxicity and actually with older adults we'll tend to keep um keep them sort of at the lower range whatever is working for the behavior we follow the behavior not the drug level um it's important to also uh know that um uh essentially sedation can be part of what can happen with this medication as well as changes in liver enzymes um which uh you know the physician will frequently be monitoring while on this medication um but uh in rare cases um it can affect um liver function and that in itself can cause confusion and other issues um somewhere down the line so it's just important to really keep in mind if your older adult is um experiencing new onset confusion and depote has been something that's been started to really bring that to the attention of the physician sooner rather than later um so I'd like to move on to a group of medications that are frequently used um in patients with uh dementia um usually by non-geriatric psychiatrists so um these are benzo diazines these involve medications like lorazapam or Adavan Alprazolam or xanax Kazaam or clonin um ask any geriatric psychiatrist and they will tell you we avoid these medications in our older adult patients particularly our patients with dementia at all costs clearly there are sometimes that you do need to make an exception but in general for Behavioral issues these are not um the first line medications that we will go to um the main reason is that benzo dipene medications um are associated with increased risks of Falls in this population increased confusion um and essentially uh increased mortality overall so it's um it's very um seductive very very often to just use one of these medications because they really calm the patient right down um you know they may actually sedate them um and they seem less anxious but these medications can also stick around in the body for quite some time um and in older adults who may not be able to necessarily metabolize the medication as well um it can build into levels that cause delirium confusion Falls um and essentially adverse outcomes so we really try to avoid that group of medications um so I'd like to move on to sleep medications um this is a very common complaint in patients with dementia um they're not sleeping well um they're wandering at night um they go to bed very very early and then they're up you know early in the morning um I would like to reiterate that essentially the first line treatment for sleep problems in patients with dementia is nonpharmacologic so really looking at you know um are they is the reason that they're up at night is because they're sleeping during the day um they need a little bit more activity or more structure um are they having disregulation of their um sleep cycle in which case would it make sense to expose them to sunlight late in the afternoon so um their uh melatonin is suppressed and they are not as sleepy earlier in the night and thus not waking up early in the morning so they're kind of going to bed a little bit later and able to sleep through the night um so it's important to really identify and understand when an older adult is having with a dementia is having sleep disturbance um what is that coming from but you know a lot of times we'll sort of try to address things non-pharmacologically and if that doesn't work it's very important to consider um whether medications can be helpful so commonly used medications um for sleep in individuals with dementia um do involve a couple different classes of medications um one being the anti psychotic medications which we talked about earlier um which do carry all of their side effects uh you know and adverse effects that we talked about um usually if the problem is only sleep and there's no comorbid depression no behavioral symptoms um no um anxiety Then we typically try to stay away from the antis psychotic so um we will often use the antis psychotics for sleep when there's another issue that the antipsychotic is potentially treating but um in general it's not the first line that we will go to for Sleep um often times we will use anti uh depr sedating anti-depressants um for Sleep issues in individuals um with uh dementia um a very common one is trazodone or desil um this is a medication that came out um kind of uh you know over 10 years ago um in the 1990s as an anti-depressant but was so sedating um that really was found to be better as a sleep medication um side effects from from trazadone do include over sedation confusion Falls as any of these sleep medications can um but it tends to be less of an offender than for example the benzo dipene class or a couple other classes we'll talk about later merapen Remeron is a frequently used medication for sleep in individuals with dementia who often have comorbid depression um so you know it can often sort of be helpful for those two issues and minimizes needing to use two separate medications for those issues um however it does have the risk of orthostatic hypotension or low blood pressure when going from a sitting to standing position thus increasing Falls it can affect blood pressure so that's important to be monitored um and in that sense it can also like any of these medications um cause confusion if too high of a dose for example or if the patient is just very sens sensitive um I should also mention that rron does have the effect of increasing appetite which often uh is helpful in individuals with dementia who may be frail or losing weight um however for patients for whom uh diabetes or obesity is a problem that is something that is important to keep in mind so um medications for Sleep um that tend to be less safe uh involve actually um the most accessible one so over-the-counter uh benadrilina effects which we talked about before so um Dien hydramine or Ben Benadryl has it's an it's a potent anti-histamine but it also has significant anti-cholinergic effects which can lead to increased confusion increased sedation increased risk for Falls um and increased delirium so we really try to stay away from that and we try to educate uh caregivers about that um again uh benzodiazapines are frequently used frequently um prescribed in the primary care setting for Sleep however in this population can be very unsafe and can really lead to increased risk of fall confusion um Etc um some people have asked well what about uh ambian or zadam um kind of the benzo diazene like sedative hypnotics so these are medications that are used for sleep they are related to um benzodiazapines and have a similar method of action however they do not have as much of a potential for example for abuse um or tolerance necessarily um so you know they're frequently used as sort of a safer alternative now unfortunately in our population so individuals with dementia cognitive impairment older adults who may be more frail um these medications can actually be fairly um dangerous in terms of also increasing risk for confusion increasing risk for Falls um we tend to stay away from them um as the first line treatment for um individuals uh with dementia who are having sleep disturbances okay so um I'm going to briefly talk a a little bit about um Herbal Remedies or vitamins that are frequently um you know uh used uh in individuals with dementia um oftentimes caregivers uh do bring in um their Elders or loved ones and they mention well you know we started this um and for the most part you know for example coconut oil has been very hot right now um for the most part uh interventions like that despite um not having a a lot of evidence behind them are not necessarily uh harmful however uh there are certain ones that do have significant um adverse effects or could potentially cause medication related problems that I feel is important to really um discuss briefly so in terms of alternative medication or herbal um medications um for mood or depression uh two of the most frequently uh used ones are St John's wart and idental seal methionine or Sam e um often available in uh health food stores however um it's very important both of these have been found to to have efficacy in treatment of depression not necessarily treatment of depression in dementia um but they do have e e efficacy in um sort of younger age groups that don't have that comorbidity um however there are very important considerations uh with both of these agents so um I'm going to just start with St John's wart which um despite its efficacy for depression does have significant liver interaction and what this means is is that it can interfere with the metabolism of a multitude of medications um that our older adults specifically our older adults with dementia may already be on so either decreasing levels or increasing levels based on the way it inhibits the liver uh enzymes that are in charge of metabolizing um or getting rid of other medications so um so some of those uh interactions involve um medications like um essentially dexin so it can lower levels of dexin um it can also um essentially decrease the level of warin warin which people take um for clotting disorders uh so putting them at risk for you know developing another clot um it can decrease levels of HIV medications um which is you know the protease Inhibitors which can be very significant um this uh medication as well as es adenos es adenos methionine um they both work serotonergically so that means that they're working on serotonin so for example um if a patient is also on another serotonergic medication like an anti-depressant and the physician is not aware that they are taking one of these supplements it can increase their risk for serotonin syndrome which we talked about earlier which is a medical emergency um so in terms of um memory medications that are herbal that are frequently used um two of the most uh recent ones um sort of talked about have been Geno Boba vitamin E um unfortunately as of a 2009 study Geno Boba has not been found to be um significant in terms of um essentially slowing the course of uh cognitive decline in dementia um however U many individuals continue to use it it's important because this medication can interact um with other medications um including uh essentially um increasing risk of bleeding when combined with warin Hein or nids like non-steroid steroidal anti-inflammatory um medications like um aspirin or excuse me um El um aspirin um Motrin any of those medications so it's important to exercise caution there um so in terms of uh side effects um from Geno Boba uh other than that there isn't um there isn't that much uh vitamin E has recently been found to be promising in slowing the decline of um cognition in individuals with dementia um however it does carry the risk of GI side effects uh which may manifest as um losing weight or lower appetite um patients can have uh more fatigue uh with uh vitamin E even though it is a vitamin you would think well you know how harmful could it be it definitely has effects especially when it gets to very high levels so uh lastly I'd like to talk about um sort of alternative remedies for sleep um we actually do use melatonin um quite a bit in this population particularly when it's found that the Sleep issue is really kind of a reversal of sleep cycles um and melatonin can be helpful in doses from 3 to 6 milligrams however um you know no uh supplement or medication is without um its side effects and one of the main things with melatonin is essentially sedation over sedation uh which can lead to um Falls Etc um and uh P some patients actually will experience sort of a paradoxical insomnia um on melatonin so it's important to keep an eye out for that okay so I wanted to just briefly go over other considerations when it comes to medications being used in this population um and one of those considerations is the idea of poly Pharmacy so poly Pharmacy is essentially defined as the use of multiple medications and more recently it's been defined as the use of five or more medications um that essentially can have potential interactions with each other um so it's important uh many of our patients in this uh population so patients with dementia will be on more than five medications and um it's important to work with the physician to make sure that uh all of these medications are actually indicated and needed and that includes vitamins and Herb Herbal Remedies as well um so poly Pharmacy um when a patient is on more than five medications multiple different medications um has been associated with increased Frailty so um losing weight um weakness uh exhaustion um sort of when doing very small things or small activities um increased mortality increased disability and and increased Falls and so you know how much does it increase the fall risk well um it's been found that if the patient is on 5 to nine medications um it increases the risk of Fall by four times uh the amount um if they're on more than 10 medications it actually increases their risk six times so risk of falling is increased by six times a factor of six so it's really important to really in this population less is more um really seeing about uh whether um really reassessing medications is it really important uh for this person to be on all these medications or are there ways of simplifying this medication regimen so that we can decrease uh poly Pharmacy so other considerations in this regard is that teamwork is crucial um it's important for the caregiver the pharmacist The Physician psychiatrist if they're involved um to really work together and function as a team to avoid these medication related problems the caregiver is the eyes and the ears of the physician and the pharmacist um if you're not uh you know seeing it essentially it's very unusual for the physician to notice or to be able to to become aware of some of these things so um so it's important uh because it contributes to better outcomes for these patients and improve daily functioning um so what can you do as a caregiver you know um you're probably saying well you know what am I supposed to do how am I supposed to uh do this and I don't want to put all the burden on you but um there are certain tools that can be helpful um to being able to play an active role in identifi in identifying medication related problems and essentially nipping them in the bud so um practical tips uh here are a couple um important questions that um providers uh you know it's important to ask the provider um and we are open to this because a lot of times you know um especially Specialists there may be there may be not looking at the entire picture or the um you know the appointment is rushed and so having the caregiver as an active participant is very important uh for us to really collect all the information to make a decision that's going to be a healthy one for the patient so questions like is this medic a really needed um is this medication the most appropriate for the medical condition being treated will the medication be a problem with other medical conditions that are occurring at the same time is the medication being prescribed at the right dose does the medication interact with other medications so um finding ways of getting this information from The Physician during the visit can really um help you be aware of you know what this medication can potentially do and the way that it interacts with a very complex system which is an older individual with dementia with multiple medical problems already on multiple other medications so other practical tips involve um really being organized keeping uh as much as you can um keeping track of medications and the content of physician visits uh with a caregiver handbook so um there's this uh there's a great um link here and a website that's listed in my references um for caregivers that can really be helpful um this particular uh document is a uh essentially a PDF um that helps sort of keep track of the medications um and when they've been increased or decreased because a lot of times too um there may be multiple different providers um sort of increasing medication taking off medication adding medication and it's important to sort of have a place to consolidate that me that uh information particularly if the individual is not being treated within one Health Care System um so if suspicion is high for a potential um medication related problem it it's very easy to just go to um a drug interaction Checker um and so I also listed a link for that at the bottom of this slide um simply type in the names of the medications and the um the uh drug interaction Checker will give you a list of the medications that may or may not be a problem um so here are my references I would uh like to draw your attention to the family and caregiver Alliance uh website which is a really excellent resource to use um and again I'd like to remind you to please feel free to ask questions via Twitter uh using the hashtag UCLA MD chat and so um we'll go ahead and take questions at this time okay great Okay so we've got a couple questions here um okay all right so I'll start off with um can certain medications make my dementia worse um and uh so this is a really um excellent question um and frequently a patient will be started on um a medication and feel as though their dementia is getting worse or their cognitive impairment is getting worse um now now uh I would argue there there isn't any medication that necessarily um makes dementia worse as in accelerates the course of Dementia or worsens the dementia um causing kind of a steep decline for example however there are medications that can cause cognitive impairment so even in somebody who is for example um you know 50 years old without any uh cognitive impairment or dementia if they take certain medications they will feel as though they're not remembering things well um and they're cognitively impaired and when you discontinue that medication they go back to their Baseline so um to answer your question there aren't necessarily any medications that will accelerate the course of Dementia or make dementia worse but there are medications that cause cognitive impairment and the key word with those are any medications that have anti-cholinergic effects so things like Benadryl um any of the uh benzo diazines can make cognition worse based on the way they're sort of um working or acting um you know any of the benzo oene like sedative hypnotics um a lot of times uh some patients can experience cognitive dulling on medications that are frequently used um for neurological conditions uh so for example um some patients may have cognitive delling on a medication like Topamax um so uh I would say that absolutely there are medications that can make it feel like um your thought processes are worsening or not uh are are getting worse um but I would uh say that once you discontinue those medications um you typically see uh an improvement um there recently was an article that uh implicated uh benzodiazapines um as uh being more associated with developing dementia um that uh article obviously requires further research um however it was unclear whether um the benzodiazapines were being used more in people who had sort of the premorbid signs of dementia so uh sort of a sorry the pro uh prodrome of dementia and they happen to be more medicated with those medications to treat the prodrome or the um the signs the behavioral and mood issues that come before dementia uh versus the medication actually causing dementia so um it's important to keep uh that in mind um so I'm looking here uh my Dad recently um lost more weight uh our mental issues from PTSD a cause of quote unquote wasting away and steady physical decline um this is a a great question I you know I think it would be tough to really say for sure in the individual situation um obviously I haven't uh interviewed your father um or worked with him but um absolutely untreated um other other mental health conditions that are not adequately treated can certainly lead to social withdrawal loss of appetite depression depression in itself can cause a wasting away if it is untreated um so frequently we call these the neurovative signs of depression patients don't want to eat um they're you know they're not sleeping terribly well or they're sleeping all the time um they're kind of uh refusing to kind of interact sort of um deconditioning so it's it's very important to um obtain a consultation with a geriatric psychiatrist where you can effectively tease out how much is the untreated PTSD for example leading to um depression or withdrawal um or you know um disengagement or loss of appetite um how much is that contributing uh versus the um dementia which in itself um in the end stages can uh lead to that so so I think it would be very um key to sort of parse that out um especially you know with with your father's situation um let's see so um are there medications that can prevent dementia this is an excellent question um so it's a it's a very multifaceted question in the sense that the overall answer is as of now we do not have any medications that have been proven to prevent uh dementia there's also um it's important to consider though that there are many different types of dementia so there's dementia associated with Alzheimer's disease there's dementia associated with vascular um dementia so for example vascular changes in the brain um lead to a dementia so similar to um the way that plaques in the vessels of the heart can cause heart disease plaques in the vessels of the brain can cause inflammation um and uh cause a dementia that we call a vascular dementia there's um Park uh dementia associated with Parkinson's disease um Etc um so in terms of medications that prevent dementia we don't have something across the board that can really prevent it however we do know that physical activity um good diet um um some have argued that uh mental kind of mental stimulation and Novelty can be very helpful um in sort of uh you know working with uh patients not converting into dementia when they have cognitive decline um however um it would be also important for example in somebody who has vascular risk factors like um high blood pressure or uh high cholesterol or diabetes if keeping those things under control with medic medications um can actually with medications and lifestyle I should say can actually improve kind of the course especially vascular dementia um is is what we're talking about here so it's important to keep that in mind um as of now there there are some promising I think vitamin E recently there was a study that came out about patients who already have dementia vitamin E improving sort of the decline there was a recent study that just came out out this month about Celexa the anti-depressant being helpful in preventing decline but in terms of preventing onset um unfortunately we uh do not have anything at this point that can do that um unfortunately in this field our Diagnostics our ability to diagnose and image and look at what's going on in the pathology are far ahead um than our ability to really um necessarily treat the the condition so um our ability to diagnose it our ability to look at prognosis much better than where we are in terms of medications to treat it and I hope that that changes in the future um let's see uh so I think we talked about uh can medications cause mental decline um or dementia um how long does does it take uh for a medication for dementia to work um so this is uh this is certainly challenging because there really haven't been um studies that uh kind of quantify exactly you know um when the medications start to work or don't start to work but I would say within I would say within a two one to two Monon period of starting the medication uh these medications do take time to titrate up to the appropriate dose so it's a sort of a slow um you know titration that occurs but um you know I think that it really depends I've had patients say you know within a couple weeks they they sense kind of a difference in their loved one um just in terms of energy and engagement and interest um and sometimes improvements in behavior um I have not had any patients who really when we're talking about the the Improvement cognitively for the cognitive symptoms it's not a dramatic um Improvement at all if anything it's essentially working to just keep the person where they're at for a longer period of time so um you would expect it to work within about a month or two of being on it but the idea is that the medicine is keeping the person where they're at for a longer period of time rather than um the decline that uh in inevitably will occur um occurring sooner so uh that's essentially you know the idea about how the medication works and I think it it leads to challenges because a lot of family members often are left wondering well is the medication actually working or not and there will be maybe some subtle changes that they see but um for the most part it's a question of uh to know whether the medication's actually working is to look at another reality where the person was not on the medicine and how far they declined um or how quickly they declined uh in that sort of situation compared to being on the medicine so it's very challenging we do know though that there are situations where the patients come off medications for a few weeks and they really um caregivers May notice a steeper decline at that point so that's where it's important to really follow up with the physician um if the decision is made to stop the medications if it's that they're not doing anything and really monitor the patient closely um so I think that's the questions that we have for today um I'm happy to take other questions that have come in or okay thank you so much for letting me participate in this webinar today um feel free to uh contact me um through my information on the website um and uh the the video of this presentation is also available on YouTube um and uh can be watched um there as well thank you very [Music] much

Channel: UCLA Health

Views: 81,980

Keywords: Dementia (Disease Or Medical Condition), Caregiving, Caregivers, Sarah Mourra MD, Geriatrics, Psychiatrist (Profession), UCLA Alzheimers and Dementia Care program, Pharmaceutical Drug (Medical Treatment), Caregiver (Profession), Health (Industry), Medicine (Field Of Study)

Id: 05scoNjlGmw

Length: 64min 18sec (3858 seconds)

Published: Fri Nov 20 2015