Understanding medication and dementia

The Right Prescription

Are you, or somebody you know, prescribed antipsychotic medication for dementia? Then ask your GP or clinician about a medication review, to check you are on the right prescription.

to get the

Right Prescription With all of us in mind

What is this booklet about? People with dementia may develop mood disorders such as depression, behavioural problems such as restlessness or aggression, or psychiatric problems such as psychosis (delusions and hallucinations). This booklet describes the different types of medicines that may be prescribed to treat these problems. It is important to try to understand and address the causes that may have triggered a person’s problems. However, when behavioural or psychiatric problems are severe, extremely distressing, or causing risk to the person or others, and if psychological treatments have not worked, it may be necessary to prescribe medication. The treatment of depression is slightly different, as depression has a major impact on people’s functioning and quality of life. Mild depression can be treated with psychological treatments, but more severe clinically significant depression should be treated with antidepressant medication.

When should medicines be used?

What do medicine names mean?

Medicines should be avoided unless they are really necessary. Before any of the medicines mentioned in this booklet are prescribed, it is essential to ensure that the person with dementia is physically healthy, comfortable and well cared for.

All medicines have at least two names - a generic name, which identifies the substance, and a proprietary (trade) name, which may vary depending upon the company that manufactured it. (For example, Aricept is the trade name for the Alzheimer’s medicine donepezil hydrochloride.) This booklet uses generic names, but the section ‘Commonly prescribed medicines’, later in the booklet, lists medicines in common use, giving both the generic and proprietary names.

Whenever possible, the person should be helped to lead an active life, with interesting and stimulating daily activities. In this way it is often possible to avoid the use of medicines altogether. Some problems should always be treated, including:

Speak to your GP or clinician for more information and a review of your medication.

• pain, and any underlying medical conditions (such as infections), as these can often cause or worsen behavioural problems. •

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problems with eyesight or related medical problems, such as cataracts, as these can contribute to the development of visual hallucinations and can increase their vulnerability.

• hearing difficulty, as if left untreated this can make a person more confused.

Possible effects Medicines will be more effective if they are taken exactly as prescribed by the doctor, in the correct dose, and are monitored regularly for side-effects. 1. If problems are difficult to control, the GP may refer to a specialist from the hospital for further advice. 2. Do not expect immediate results. Benefits may take several weeks to appear, particularly with antidepressants and antipsychotics. 3.

Some medicines, such as antidepressants and antipsychotics (often called major tranquillisers or neuroleptics), need to be taken regularly to have an effect.

4. These medicines are not helpful when given on an as-needed basis. This should only be done after discussion with the doctor. 5.

All medicines have side-effects that may worsen problems. Side-effects may occur early or late in the course of treatment, so it’s important to ask the doctor what to expect.

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Side-effects are usually related to the dose. The doctor will usually ‘start low and go slow’, gradually increasing the dose until the desired effects are achieved.

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Bear in mind that certain combinations of medicines may counteract each other. Remind your doctor if other medications are being taken. All medications should be taken to clinic and hospital appointments.

8. Don’t assume that a medicine that has proved to be useful at one time will continue to be effective. 9. Dementia is a degenerative condition, so the chemistry and structure of the brain will change during the course of the illness. 10.

Once treatment has been established, it is important that it is reviewed regularly. In most circumstances, medicines for behavioural problems should not be prescribed for more than three months without a trial of stopping the treatment.

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Remember that many of the medicines taken to treat mood problems, behavioural problems and psychiatric problems can be dangerous if accidentally taken in large quantities, so make sure medicines are kept safe and secure.

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Antipsychotics Antipsychotics (also known as neuroleptics or major tranquillisers) are medicines that were originally developed and are effective for the treatment of people with schizophrenia. They are the most commonly used medicine treatments for the treatment of restlessness, aggression and psychiatric problems in people with dementia. Combining the results of clinical trials suggests that this type of medicine can reduce aggression and, to a lesser extent, psychotic problems over a period of three months. However, there is no evidence that these medicines improve restlessness or other non-aggressive behavioural problems. Longer-term clinical trials show that the benefits are very limited over longer periods of time. These medicines can be safely stopped after three months, with no worsening of behavioural problems in most people. The medicine with the best evidence of effectiveness is risperidone. Until recently, antipsychotic medicine treatments have been used ‘off-licence’ to treat people with Alzheimer’s disease. Now, one of these treatments, risperidone, has been licensed specifically for the treatment of severe and persistent aggression in people with Alzheimer’s disease that have not responded to other therapies. There is no evidence of any beneficial effects of antipsychotics, in people with dementia with Lewy bodies, and there are currently no clinical trials looking at these medicines in people with vascular dementia.

Side-effects and points to remember: •

Side-effects can include excessive sedation, dizziness, unsteadiness, and problems that resemble those of Parkinson’s disease (shakiness, slowness and stiffness of the limbs), chest infections, ankle swelling and falls.

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More recently, there have been increasing concerns about the risk of serious side-effects such as stroke and premature death, leading to warnings from the regulatory authorities about the safety of these treatments for people with dementia.

• The risk of these serious side-effects is quite low over short periods of treatment (up to three months), but becomes much higher over longer treatment periods. • Antipsychotics may be particularly dangerous for people with dementia with Lewy bodies, possibly causing sudden death.

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If a person with dementia with Lewy bodies must be prescribed an antipsychotic medicine, this should be done with the utmost care, under constant supervision, and they should be reviewed regularly by the GP or consultant.

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Whichever medicine is used, treatment with antipsychotics should be regularly reviewed and the dose reduced or the medicine withdrawn if side-effects become unacceptable. Excessive sedation with antipsychotics may reduce problems such as restlessness and aggression at the expense of the person’s mobility and coherence.

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Evidence is also beginning to accumulate to suggest that antipsychotics may accelerate the rate of decline in people with dementia, so there are particular concerns about the long-term use of these medicines.

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Side-effects and the risk of premature death are even greater if antipsychotics are combined with other sedative medicines. Combinations of different sedative medicines are strongly discouraged in people with dementia.

Speak to your GP or clinician for more information and a review of your medication.

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www.southwestyorkshire.nhs.uk/prescription Treating restlessness, aggression and psychotic problems All good practice guidelines state clearly that non-pharmacological treatments should be tried before medicines for the treatment of aggression and restlessness, unless there is severe and persistent risk of harm to the person with dementia or others. Simple psychological interventions can be very beneficial, and can frequently prevent the need for medicines. These include: • social interaction • psychological therapies based on a detailed analysis of the problem • other psychological approaches such as reminiscence therapy

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Anti-dementia medicines There is increasing evidence the anti-dementia medicine memantine may be an effective treatment for aggression and other problems of agitation. Memantine has the advantage of being a very safe treatment, with other benefits for function and memory, but further work from new, specific clinical trials is still needed to confirm how effective it is for treating aggression. Cholinesterase inhibitors comprise the other class of dementia medicines, which include donepezil, rivastigmine and galantamine. They appear to be an effective treatment for psychotic problems in people with dementia with Lewy bodies and dementia related to Parkinson’s disease. In people with Alzheimer’s disease they may delay the onset of psychiatric and behavioural problems, but it is not clear whether they are a helpful treatment once these problems occur.

Anticonvulsant and antidepressant medicines Anticonvulsant medicines, such as sodium valproate and carbamazepine and antidepressants such as trazadone and citalopram are also sometimes used to reduce aggression and agitation. There is some evidence from several small clinical trials that these medicines can help these problems, but more evidence is needed, and the safety of these treatments used in this way for people with dementia has not been established in large or longer-term studies. These medicines should not usually be combined with each other or with antipsychotics.

Treating depression Problems of depression are common in dementia. In the early stages they may be a reaction to the person’s awareness of their diagnosis. Depression may also be the result of reduced chemical transmitter function in the brain. Simple non-medicine interventions, such as an activity or exercise programme or other types of psychological treatment can be very helpful - especially for mild depression. The evidence from clinical trials is not entirely clear, but the best evidence suggests that one of the newer SSRI antidepressants called sertraline is effective without any major side-effects. Antidepressants may be helpful not only in improving persistently low mood but also in controlling the irritability and rapid mood swings that often occur in dementia and following a stroke. Once started, the doctor will usually recommend prescribing antidepressant medicines for a period of at least six months. In order for them to be effective, it is important that they are taken regularly without missing any doses. Improvement in mood typically takes two-to-three weeks or more to occur. Side-effects may appear within a few days of starting treatment.

Side-effects •

Tricyclic antidepressants, such as amitriptyline, imipramine or dothiepin, which are commonly used to treat depression in younger people, are likely to increase confusion in someone with dementia. They might also cause a dry mouth, blurred vision, constipation, difficulty in urination (especially in men) and dizziness on standing, which may lead to falls and injuries.

• Newer antidepressants are preferable as first-line treatments for depression in dementia. • Medicines such as fluoxetine, sertraline and citalopram (known as the selective serotonin re-uptake inhibitors, SSRI), or the selective noradrenaline re-uptake inhibitor (SNRI) venlafaxine, do not have the side-effects of tricyclics, and are well-tolerated by older people. • SSRIs can produce headaches and nausea - especially in the first week or two of treatment. The best evidence of effectiveness in people with dementia is for the SSRI sertraline. Venlafaxine, however, has many of the side-effects of tricyclic anti depressants, but can be very helpful in people who have not responded to other treatments.

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Treating anxiety Anxiety states, accompanied by panic attacks and fearfulness, may lead to demands for constant company. There is no research evidence about the treatment of anxiety in people with dementia, so recommendations made here are based on clinical experience. Mild problems are usually helped by reassurance, adjustments to the environment or an improved structure to everyday life. For more persistent mild anxiety, psychological treatments can be helpful. More severe and persistent anxiety is often related to underlying depression, and will probably improve with antidepressant treatments. Benzodiazepines and antipsychotics are sometimes used to treat anxiety, but both of these types of medicine should usually be avoided as treatments for anxiety in people with dementia.

Side-effects •

There are many different benzodiazepines - some with a short duration of action (such as lorazepam and oxazepam) and some with longer action (such as chlordiazepoxide and diazepam). All of these medicines may cause excessive sedation, unsteadiness and a tendency to fall, and may accentuate any confusion and memory deficits that are already present. These medicines can also cause dependency, and may lead to withdrawal problems when they are stopped.

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Antipsychotics (see above) are sometimes used for severe or persistent anxiety, but should be avoided for this purpose in people with dementia. If taken for long periods, these medicines can produce a side-effect called tardive dyskinesia, which is recognised by persistent involuntary chewing movements and facial grimacing, in addition to the side-effects described above.

Treating sleep disturbance Sleep disturbance - in particular, persistent wakefulness and night-time restlessness - can be distressing for the person with dementia and difficult for the people around them. Many of the medicines commonly prescribed for people with dementia can cause excessive sedation during the day, leading to an inability to sleep at night. Increased stimulation during the day and avoiding caffeinated drinks late at night will reduce sleep problems. Aromatherapy with lavender can also help. It is important to have realistic expectations about what duration of sleep should be expected. Older people rarely sleep for more than five-to-six hours at night, and in people with dementia this will often be spread out over a full 24 hours. In care homes and nursing homes, the person’s care plan must meet these 24-hour needs. In most circumstances, this should be achieved without the need for medication. When people are at home, pressure upon carers, or risks related to people getting up at night, can sometimes necessitate the use of medication - although there is no research evidence assessing the value of this approach. If hypnotics (sleeping tablets) are used, the preference would be for one of the newer agents such as zopiclone or zolpidem, which have fewer side-effects, fewer hangover effects in the morning, and are less addictive than others. Another good option is a sedative antidepressant, such as trazadone. It is usually better to avoid benzodiazepines in people with dementia. Hypnotics are generally more helpful in getting people off to sleep at bedtime than they are at keeping people asleep throughout the whole of the night. They are usually taken 30 minutes to one hour before going to bed.

Side-effects • If excessive sedation is given at bedtime, the person may be unable to wake to go to the toilet and incontinence may occur - sometimes for the first time. • If the person does wake up during the night despite sedation, increased confusion and unsteadiness may occur. • Hypnotics are often best used intermittently, rather than regularly, when the carer and person with dementia feel that a good night’s sleep is necessary for either or both of them. The use of such medicines should be regularly reviewed by the doctor.

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Commonly prescribed medicines This list includes the names of many (but not all) of the different medications available. New medicines are appearing all the time and you may need to ask your doctor what type of medication is being prescribed. The generic name is given first, followed by some of the common proprietary (trade) names.

Antipsychotics

Anticonvulsant medicines

Amisulpride (Solian)

Sodium valproate (Epilim)

Aripiprazole (Abilify)

Carbamazepine (Tegretol)

Chlorpromazine (Largactil) Fluphenazine (Modecate)

Antidepressants

Haloperidol (Haldol, Serenace)

Amitriptyline (Lentizol)

Olanzapine (Zyprexa)

Amoxapine (Asendis)

Promazine (Promazine)

Citalopram (Cipramil)

Quetiapine (Seroquel)

Dothiepin (Prothiaden)

Risperidone (Risperdal)

Doxepin (Sinequan)

Sulpiride (Dolmatil, Sulparex, Sulpitil)

Fluoxetine (Prozac)

Trifluoperazine (Stelazine)

Fluvoxamine (Faverin)

Zotepine (Zoleptil)

Imipramine (Tofranil)

Zuclopenthixol (Clopixol)

Lofepramine (Gamanil)

Anxiety-relieving medicines

Mirtazipine (Zispin) Nefazodone (Dutonin)

Alprazolam (Xanax)

Nortriptyline (Allegron)

Diazepam (Valium)

Paroxetine (Seroxat)

Lorazepam (Ativan)

Reboxetine (Edronax)

Oxazepam (Oxazepam

Sertraline (Lustral) Trazodone (Molipaxin)

Hypnotics Flurazepam (Dalmane)

Venlafaxine (Efexor)

Nitrazepam (Mogadon)

Antidementia medicines

Temazepam (Temazepam)

Donepezil (Aricept)

Zopiclone (Zimovane)

Rivastigmine (Exelon)

Zolpidem (Stilnoct)

Galantamine (Reminyl) Memantine (Ebixa)

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Job no. 4627 January 2012

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