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What treatment and management options are available for Alzheimer's disease patients?

The management of Alzheimer's disease consists of medication based and non-medication based treatments. Two different classes of pharmaceuticals are approved by the FDA for treating Alzheimer's disease: cholinesterase inhibitors and partial glutamate antagonists. Neither class of drugs has been proven to slow the rate of progression of Alzheimer's disease. Nonetheless, many clinical trials suggest that these medications are superior to placebos (sugar pills) in relieving some symptoms.

 

Alzheimer's disease medications

 

Cholinesterase inhibitors (ChEIs)

In patients with Alzheimer's disease there is a relative lack of a brain chemical neurotransmitter called acetylcholine. (Neurotransmitters are chemical messengers produced by nerves that the nerves use to communicate with each other in order to carry out their functions.) Substantial research has demonstrated that acetylcholine is important in the ability to form new memories. The cholinesterase inhibitors (ChEIs) block the breakdown of acetylcholine. As a result, more acetylcholine is available in the brain, and it may become easier to form new memories.

Four ChEIs have been approved by the FDA, but only donepezil hydrochloride (Aricept), rivastigmine(Exelon), and galantamine (Razadyne - previously called Reminyl) are used by most physicians because the fourth drug, tacrine (Cognex) has more undesirable side effects than the other three. Most experts in Alzheimer's disease do not believe there is an important difference in the effectiveness of these three drugs. Several studies suggest that the progression of symptoms of patients on these drugs seems to plateau for six to 12 months, but inevitably progression then begins again.

Of the three widely used ChEIs, rivastigmine and galantamine are only approved by the FDA for mild to moderate Alzheimer's disease, whereas donepezil is approved for mild, moderate, and severe Alzheimer's disease. It is not known whether rivastigmine and galantamine are also effective in severe Alzheimer's disease, although there does not appear to be any good reason why they shouldn't.

The principal side effects of ChEIs involve the gastrointestinal system and include nauseavomiting, cramping, and diarrhea. Usually these side effects can be controlled with change in size or timing of the dose or administering the medications with a small amount of food. A majority of patients will tolerate therapeutic doses of ChEIs.

 

 

Partial glutamate antagonists

Glutamate is the major excitatory neurotransmitter in the brain. One theory suggests that too much glutamate may be bad for the brain and cause deterioration of nerve cells. Memantine (Namenda) works by partially decreasing the effect of glutamate to activate nerve cells. Studies have demonstrated that some patients on memantine can care for themselves better than patients on sugar pills (placebos). Memantine is approved for treatment of moderate and severe dementia, and studies did not show it was helpful in mild dementia. It is also possible to treat patients with both AchEs and memantine without loss of effectiveness of either medication or an increase in side effects.

 

Other medications for Alzheimer's disease

In 2014, Namzaric was FDA approved for use as a fixed-dose combination of memantine hydrochloride extended-release (an NMDA receptor antagonist) and donepezil hydrochloride (an acetylcholinesterase inhibitor) for treatment of moderate to severe Alzheimer's.

Memantine ER (extended release) is currently marketed under the name Namenda XR, and it is used to treat moderate to severe Alzheimer's.

 
 

Non-drug based treatments for Alzheimer's disease 

Non-medication based treatments include maximizing patients' opportunities for social interaction and participating in activities such as walking, singing, dancing that they can still enjoy. Cognitive rehabilitation, (whereby a patient practices on a computer program for training memory), may or may not be of benefit. Further studies of this method are needed.

 

 

 

Treatment of psychiatric symptoms in Alzheimer's disease

Symptoms of Alzheimer's disease include agitation, depressionhallucinations, anxiety, and sleep disorders. Standard psychiatric drugs are widely used to treat these symptoms although none of these drugs have been specifically approved by the FDA for treating these symptoms in patients with Alzheimer's disease. If these behaviors are infrequent or mild, they often do not require treatment with medication. Non-pharmacologic measures can be very useful.

Nevertheless, frequently these symptoms are so severe that it becomes impossible for caregivers to take care of the patient, and treatment with medication to control these symptoms becomes necessary. Agitation is common, particularly in middle and later stages of Alzheimer's disease. Many different classes of agents have been tried to treat agitation including:

  • antipsychotics,
  • mood-stabilizing anticonvulsants,
  • trazodone (Desyrel),
  • anxiolytics, and
  • beta-blockers.

Studies are conflicting about the usefulness of these different drug classes. It was thought that newer, atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal), olanzapine (ZyprexaZydis), quetiapine (Seroquel), and ziprasidone (Geodon) might have advantages over the older antipsychotic agents because of their fewer and less severe side effects and the patients' ability to tolerate them. However, more recent studies have not demonstrated superiority of the newer antipsychotics. Some research shows that these newer antipsychotics may be associated with increased risk of stroke or sudden death than the older antipsychotics, but many physicians believe this question is still not resolved.

Apathy and difficulty concentrating occur in most Alzheimer's disease patients and should not be treated with antidepressant medications. However, many Alzheimer's disease patients have other symptoms of depression including sustained feelings of unhappiness and/or inability to enjoy their usual activities. Such patients may benefit from a trial of antidepressant medication. Most physicians will try selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), citalopram (Celexa), or fluoxetine (Prozac), as first-line agents for treating depression in Alzheimer's disease.

Anxiety is another symptom in Alzheimer's disease that occasionally requires treatment. Benzodiazepinessuch as diazepam (Valium) or lorazepam (Ativan) may be associated with increased confusion and memory impairment. Non-benzodiazepine anxiolytics, such as buspirone (Buspar) or SSRIs, are probably preferable.

Difficulty sleeping (insomnia) occurs in many patients with Alzheimer's disease at some point in the course of their disease. Many Alzheimer's disease specialists prefer the use of sedating atypical antidepressants such as trazodone (Desyrel). However, other specialists may recommend other classes of medications. Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids to prevent the need for urination, should also be implemented.

 

What is the prognosis for a person with Alzheimer's disease? 

Alzheimer's disease is invariably progressive. Different studies have stated that Alzheimer's disease progresses over two to 25 years with most patients in the eight to 15 year range. Nonetheless, defining when Alzheimer's disease starts, particularly in retrospect, can be very difficult. Patients usually don't die directly from Alzheimer's disease. They die because they have difficulty swallowing or walking and these changes make overwhelming infections, such as pneumonia, much more likely.

Most persons with Alzheimer's disease can remain at home as long as some assistance is provided by others as the disease progresses. Moreover, throughout much of the course of the illness, individuals maintain the capacity for giving and receiving love, sharing warm interpersonal relationships, and participating in a variety of meaningful activities with family and friends.

A person with Alzheimer's disease may no longer be able to do math but still may be able to read a magazine with pleasure. Playing the piano might become too stressful in the face of increasing mistakes, but singing along with others may still be satisfying. The chessboard may have to be put away, but playing tennis may still be enjoyable. Thus, despite the many exasperating moments in the lives of patients with Alzheimer's disease and their families, many opportunities remain for positive interactions. Challenge, frustration, closeness, anger, warmth, sadness, and satisfaction may all be experienced by those who work to help the person with Alzheimer's disease.

The reaction of a patient with Alzheimer's disease to the illness and his or her capacity to cope with it also vary, and may depend on such factors as lifelong personality patterns and the nature and severity of stressin the immediate environment. Depression, severe uneasiness, paranoia, or delusions may accompany or result from the disease, but these conditions can often be improved by appropriate treatments. Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.

 

Caring for the caregiver and Alzheimer's disease resources

Caring for the caregiver is an essential element of managing the patient with Alzheimer's disease. Caregiving is a distressing experience. On the other hand, caregiver education delays nursing home placement of Alzheimer's disease patients. The 3Rs -

Repeat,

Reassure, and

Redirect

can help caregivers reduce troublesome behaviors and limit the use of medications. The short-term educational programs are well liked by family caregivers and can lead to a modest increase in disease knowledge and greater confidence among caregivers. Educational training for staffs of long-term care facilities can decrease the use of antipsychotics in Alzheimer's disease patients.

 

 

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Source: medicinenet.com

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