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Good prescribing in
dementia: a brief guide
Daniel Harwood explains how certain medications
prescribed for older people are especial y likely to cause
troubling side effects for people with dementia
People with dementia have impaired cognitive concentration, poor memory, drowsiness and speech
function, they are more likely to be older problems. The cognitive-enhancing cholinesterase people, and they frequently have other medical problems requiring the prescription of multiple rivastigmine) work by increasing the levels of medications. These three factors predispose them to acetylcholine. But acetylcholine is also a key the cognitive side effects of commonly used drugs.
neurotransmitter in the autonomic nervous system, In addition, the person may lack the capacity to which controls the bodily functions not under understand his or her medication regimen, and may conscious control such as breathing, digestion, heart be unable to communicate the presence of side function and sweating. So acetylcholine-blocking effects. Frequent transitions in care, the onset of new drugs prescribed to al eviate symptoms arising in medical problems and multiple practitioners the autonomic nervous system, such as bowel or involved in the care of a patient may also contribute bladder spasm, can also reduce the activity of to difficulties in ensuring safe prescribing in people acetylcholine-containing nerve cel s in the brain.
This in turn can cause confusion and drowsiness.
Given al this, it is important for al staff working These drugs can also interfere with the action of with people with dementia and their carers – not cognitive-enhancing drugs. Anti-muscarinic drugs just doctors – to have a basic understanding of the impair cognitive function even in healthy older principles of good prescribing in dementia and to especial y likely to cause side effects. An alert Many commonly used drugs have a degree of practitioner can avert a serious complication by anti-muscarinic activity, but there are some that are spotting a potential problem and suggesting a review of medication by the GP or psychiatrist. This brief paper has been written to support al Tricyclic antidepressants such as amitriptyline, healthcare staff who work with people with clompramine and nortriptyline. One of the newer dementia. I have concentrated on common pitfal s antidepressants such as sertraline or citalopram is a and errors and how to avoid them – this is not safer option if drug treatment is needed for meant to be a comprehensive review of a complex depression in a person with dementia. Sometimes topic. Readers are referred to the references below tricyclic antidepressants are used for the treatment for more detail, and unless staff are qualified doctors of insomnia and bladder spasms. There are now or nurse prescribers, they should of course always many safer alternatives for treatment of these seek advice from a doctor or pharmacist before prescribing. The British National Formulary (2013) Anti-spasmodic drugs used for urinary frequency and is the standard reference for information on incontinence such as darifenacin, oxybutynin, medication, including indications, interactions and fesoterodine, propiverine, solifenacin and trospium.
Drugs which act mainly on M3 receptors (the most In this paper I am focusing on certain categories of important receptor in bladder muscle), such as drugs which are particularly likely to cause adverse darifenacin, or drugs which cross into the brain in effects on cognitive functioning or other significant low concentrations, such as trospium, may be less likely to cause cognitive side effects (Kay et al 2005).
Drugs with a different mode of action can be Antimuscarinic (anticholinergic) drugs
helpful for some urinary symptoms, for example This is the name given to drugs which block the duloxetine for stress incontinence. Urinary action of acetylcholine. Acetylcholine is one of the symptoms are often multi-factorial in people with most important neurotransmitters in the brain. In al three of the common types of dementia – pharmacological approaches such as managing Alzheimer’s disease, vascular dementia and fluid intake and regular prompting to go to the dementia with Lewy bodies – the neurones toilet. Unless there is convincing evidence of containing acetylcholine in the brain are damaged.
improvement of symptoms anti-muscarinic drugs This leads to the characteristic symptoms of poor are best avoided in people with dementia. ‰ Vol 21 No 4 July/August 2013 The Journal of Dementia Care 23
‰ Anti-spasmodic drugs used for irritable bowel Antihypertensive drugs
and gut symptoms: These include dicycloverine, Hypertension is an established risk factor for hyoscine and propantheline. There are other dementia, but there is also evidence that low blood anti-spasmodics without an anti-muscarinic pressure is associated with cognitive decline and dementia (Maules et al 2008). Blood pressure can fal peppermint oil which are safer options for as the course of dementia progresses, due to weight loss and other physiological changes.
Antihypertensive drugs can cause postural Anti-histamine drugs especial y chlorpheniramine.
hypotension which increases the risk of dizziness and fal s. In summary, treating hypertension in Anti-muscarinic drugs used to treat Parkinson’s disease, patients with dementia needs extra care. It is good especial y orphenadrine, procyclidine and clinical practice for anyone with hypertension and trihexyphenidyl. There are now many other safer dementia to have their blood pressure monitored alternatives for people with Parkinsonian closely, with dose adjustment of antihypertensive agents according to their blood pressure reading. There are many drugs used to treat hypertension, Hyoscine is licensed for the treatment of motion but common ones are bendroflumethiazide, beta- sickness and hypersalivation. This is a powerful blockers such as atenolol (and other drugs with anti-muscarinic drug which should be avoided in names ending in “ol”), the angiotensin-converting enzyme inhibitors (ACEIs) such as lisinopril and ramipril (and other drugs with names ending in Benzodiazepines especial y alprazolam, although al “pril”), newer ACEIs such as candesartan, alpha blockers such as doxasosin, and calcium channel diazepam) wil cause sedation and put patients at Sometimes antihypertensives are added to a patients’ regimen in order to treat apparently Bronchodilators used in the treatment of asthma such as treatment-resistant hypertension, when the real problem is simply that the patient is forgetting to take their tablets. When the patient is admitted to Opiate analgesics especially codeine (opiates can hospital or residential care, they col apse with exacerbate cognitive function due to their opioid hypotension as they are now taking al their blood effect). Although sometimes tolerated with no pressure lowering medications! So always check problems, opiates can have an unpredictable and with a relative or carer before assuming a drug isn’t dramatic effect on cognitive impairment and the new prescription of opiates should always be considered as a potential cause of an acute Antipsychotic drugs
confusional state. Opiates also cause constipation The potential dangers of using antipsychotic drugs which in turn can worsen cognitive function in in patients with dementia wil be familiar to most readers of this journal, and were highlighted by Professor Banerjee in his report for the Department If at all possible, these drugs should be tailed off of Health, Time for action (2009), which summarised or substituted with a safer alternative if someone the results of a meta-analysis of trials of working with has dementia. Of course, sometimes people with antipsychotic drugs in dementia. Banerjee’s report dementia need to be prescribed one of the drugs said that treating 1000 patients with behavioural and above because of distressing physical symptoms, psychological symptoms of dementia with an but in these cases, cognitive function should be antipsychotic drug for 12 weeks would result in: dementia – not monitored closely, the drug prescribed at a • 91-200 patients showing a clinical y significant minimum dose, and the use of the drug reviewed As noted above, a surprisingly common mistake • an additional 18 cerebrovascular events is the prescription of an anticholinergic drug for a • an additional 58–94 patients with gait disturbance. person who is also taking a cholinesterase inhibitor (donepezil, rivastigmine or galantamine) to treat These drugs can be very helpful for a smal number of people with dementia who have co- understanding There is evidence that this practice may have morbid psychotic disorders such as schizophrenia, adverse effects on cognition in the longer term (Lu in people with chorea due to Huntington’s disease, & Tune 2003). In these cases, it is important that and in people with severe psychotic symptoms and the patient’s GP is contacted, as there is no point in other distressing behaviour disorders. But because prescribing two drugs whose effects cancel each of the risks of these medications, their use should be initiated and monitored by specialist dementia psychiatrist, needs to make a decision with the services. The common practice in the past of the patient and his/her family as to which symptom is almost routine prescription of these medications in prescribing in the most troublesome (that is, the cognitive care homes and for people with delirium in general problem or the physical symptom such as urinary frequency), stop one of the two drugs, and If you are asked about the use of these drugs by GPs or general hospital doctors, the simple advice is: 24 The Journal of Dementia Care July/August 2013 Vol 21 No 4
off the antipsychotic drug or makes an onward referral to a specialist dementia service. Drugs causing falls
A recent systematic review of drugs associated with fal s in nursing home residents showed that the use of more than one type of medication, antidepressant drugs and anti-anxiety drugs were al associated with an increased risk of fal s (Sterke et al 2008). The older tricyclic antidepressant and antihypertensive drugs can cause fal s by leading to postural drops in blood pressure. The newer (SSRI) antidepressants and mood stabilisers such as sodium valproate can be associated with a risk of fal s as they can cause Parkinsonian symptoms and postural instability.
do NOT start antipsychotic drugs in people with Carbamazepine, sometimes used for the treatment dementia if the doctor can possibly avoid it, and if of mood disorders, epilepsy and behavioural (s)he is considering use of these drugs, the patient disorders, can cause problems with balance (ataxia). should be referred to specialist dementia services. Staff in care homes and on general hospital wards should be encouraged to fol ow the guidance in This article is no more than a very brief summary of Optimising treatment and care for people with behavioural and psychological symptoms of dementia troublesome side effects in dementia. But I hope the (Alzheimer’s Society 2011) which documents a step- paper wil encourage staff to consider medication as wise approach of prevention, simple first line a potential cause of an increased level of confusion interventions, ongoing assessment and watchful in someone with dementia, and to increase your waiting, before considering more specialist confidence in asking questions of carers and doctors interventions and antipsychotics. A recent briefing about potential y risky prescribing practices which document written by an expert reference group of the British Psychological Society (2013) describes an prescribed because the prescriber has not thought approach based on a similar model of stepped care, through the problem which is being presented to with a thorough discussion of the evidence-based him or her. Asking some questions to open up a alternatives to antipsychotic medication. Both creative and person-centred approach is part of documents outline a person-centred approach, good basic dementia care, and can lead to better care encouraging carers to ask the simple but crucial and fewer prescriptions of unnecessary drugs for question “Why is the behaviour occurring?” before As 21 per cent of care home residents in England and Wales may be on antipsychotic drugs (Shah et al 2012) it is likely you wil come across patients with References
dementia on antipsychotic medication in your daily Alzheimer’s Society (2011) Optimising practice. It is worth checking whether they are being treatment and care for people with dementia Antimuscarinic drugs for overactive bladder monitored and reviewed according to good practice with behavioural and psychological (Barnes et al 2012). Here are some questions it might symptoms of dementia. London: Alzheimer’s function in older patients. Journal of the American Geriatrics Society 53 2195-2201.
• Have the risks and benefits of the drug been Ancelin ML, Artero S, Portet F, Dupuy AM, discussed with the patient (if he or she has the anticholinergic medications adversely af ects degenerative mild cognitive impairment in capacity to be involved in the decision), relatives the course of Alzheimer’s disease. American elderly people and use of anti-cholinergic Journal of Geriatric Psychiatry 11(4) 458-461.
drugs: longitudinal cohort study. BMJ 332, Maules S, Caserta M, Bertel o C, Verhovez A, • Are the carers aware of the target symptom(s) for Banerjee S (2009) The use of antipsychotic Cognitive decline and low blood pressure: • Is there a system in place for monitoring response medication for people with dementia: time for the other side of the coin. Clinical and to the target symptom? (for example using simple action. London: Department of Health.
Experimental Hypertension 30(8) 711-19.
charts completed by nursing staff or carer) Barnes TRE, Banerjee S, Col ins N, Treloar A, • Is there a system in place to monitor and record McIntyre SM, Paton C (2012) Antipsychotics Cook DG (2012) Quality of prescribing in care side effects closely? (sedation, low blood pressure, blood sugar, muscle stiffness, tremor, mobility antipsychotic drug prescribing in UK mental Wales. British Journal of General Practice 62 health services. British Journal of Psychiatry • Is there someone (preferably from the local Sterke CS, Verhagen AP, van Beeck EF, van specialist dementia service) responsible for (2013) Alternatives to antipsychotic medication: psychological approaches in home residents: a systematic review.
• Is the patient known to the local memory service managing psychological and behavioural International Psychogeriatrics 20(5) 890-910.
distress in dementia. Briefing paper for the If the answer to any of these questions is “no”, British Psychological Society. London: BPS. you might suggest to the care home manager that a GP reviews the patient and either considers tailing Pharmaceutical Society (2012) BritishNational Formulary. London: BNF.
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