Pharmacists can help manage care for both patients and caregivers.
Alzheimer’s disease (AD) is a progressive and degenerative neurologic disorder characterized by a gradual decline in cognition and behavior. It accounts for an estimated 50% to 70% of all dementia cases.1,2 Statistics from the Alzheimer’s Association report that AD affects an estimated 5.3 million individuals of all ages and is considered to be the sixth leading cause of death in the United States.3-5 One in 8 individuals 65 years and older, representing 13% of this patient population, have AD; women are more likely to develop AD than men.3-6 The prevalence increases to at least 40% in individuals older than 80 years.5,6 By the year 2030, an estimated 7.7 million Americans, 65 years and older will be diagnosed with AD—and that number could increase to as many as 11 to 16 million cases by 2050.5,6
AD is a complex disease that affects not only the patient, but loved ones and caregivers as well. A diagnosis of AD can be overwhelming and may pose various challenges for patients, their family members, and caregivers, especially as this irreversible neurologic disease progresses. Pharmacists are in a pivotal position to provide patients and their caregivers with pertinent information about the pharmacologic treatments available to manage the symptoms associated with AD. As key health care providers, they can also direct them to the various resources available to effectively manage and cope with this disease.
On average, AD progresses over a 2- to 20-year period, with individuals typically living for 8 to 10 years after receiving a diagnosis.7,8 AD generally leads to impairment of cognitive and memory functions, problems with communication, changes in one’s personality, erratic behavior, and loss of control of bodily functions.8 In general, the primary cause of death in AD patients is the result of complications from a secondary illness, such as pneumonia. 5 Patients may lose the ability to walk and swallow.5 Difficulty in swallowing may lead to aspiration pneumonia.5,9
Stages of AD Because AD is a progressive disease, it is generally characterized by the following stages: mild, moderate, and severe. During the mild stage, which can last from 2 to 4 years, patients may start to exhibit signs of minor memory loss and have difficulty learning and remembering new information. 8,10 Patients may become withdrawn or confused, get lost easily, exhibit poor judgment, and have difficulty performing routine tasks and communicating.8
As the disease progresses from the mild to the moderate stage, the signs of AD may become more noticeable to family and friends. For example, the patient may exhibit increasing difficulty in self-care and daily tasks.8,10 The moderate stage may last from 2 to 10 years; during this time the patient may exhibit behavioral changes, such as frustration, restlessness, anger, and anxiety.8,10 Usually, at this stage, the patient can still perform simple tasks, but may need caregiver assistance for more complicated tasks.8 Patients may experience speech problems, trouble communicating and sleeping, and difficulty eating, grooming, and dressing.8,10
During the severe stage of AD, which can last 1 to 3 years, AD patients are typically solely dependent on caregivers and may lose their ability to feed themselves, speak, and recognize people, even family members. Patients may also lose control of bodily functions, such as swallowing and bladder and bowel control, and they may exhibit episodes of aggression.5,8,10
Management of AD
Although there is currently no cure for AD, pharmacologic treatments can aid in the management of both cognitive and behavioral symptoms associated with AD.11,12 These agents only slow the progression of the disease and are intended to assist in enhancing the patient’s cognitive function, delay continual cognitive decline, and prevent or decrease the incidence of disruptive behavior. They also enable patients to maintain a reasonable quality of life and independence for as long as possible.12
These agents are available as tablets, orally disintegrating tablets, capsules, and liquids. One agent is also available as a topical patch formulation. During counseling, patients or caregivers should be reminded about the proper administration and potential adverse effects associated with these AD medications. Patients or caregivers should be advised to never discontinue medications without consulting their physician and to report any serious adverse reactions to their physician.
To date, the FDA has approved 2 classes of drugs—acetylcholinesterase (AChE) inhibitors and N-methyld- aspartate (NMDA) antagonists—for treating certain cognitive symptoms of AD, such as memory loss, confusion, and other mental deficits.13 AChE inhibitors used for AD treatment include donepezil hydrochloride, rivastigmine, and galantamine. In July 2010, the FDA approved an extended-release form of donepezil for once- daily dosing. The only NMDA antagonist available is memantine. Memantine HCl has been proven to manage the symptoms of moderate to severe Alzheimer’s disease when taken alone or in combination with donepezil.14-17 In June 2010, the FDA approved Namenda XR, a once-a-day formulation.18 The Table provides an overview of AD medications.
As AD progresses, patients may begin to exhibit specific behavioral symptoms, such as depression, agitation, hallucinations, or sleep disturbances. It may be necessary for physicians to prescribe other classes of pharmacologic agents, such as antianxiety drugs, antipsychotics, and antidepressants.19 These agents are prescribed at the physician’s discretion based on specific patient need. Physicians may also recommend various nonpharmacologic or behavioral strategies as well. The Table provides an overview of available pharmacologic treatments for AD.
Table. Medications for Alzheimer’s Disease
|Generic (Brand name)||Approved Indication||Patient Information||Common Adverse Effects|
|donepezil (Aricept)||All stages||Can be taken without regard to food. Take with full glass of water. Usually given at bedtime. If taking the orally disintegrating tablet, allow tablet to dissolve in mouth followed by a glass of water.||Nausea, vomiting, loss of appetite, and increased frequency of bowel movements.|
|galantamine (Razadyne)||Mild to moderate||Take at the same time every day. The ER form should be preferably taken in the morning with food and water. Other tablet formulation and oral solution are taken twice a day with morning and evening meal. Patients should maintain adequate hydration unless otherwise directed. Liquid form can be mixed in 4 oz of juice if needed||Nausea, vomiting, loss of appetite, and increased frequency of bowel movements.|
|rivastigimine (Exelon)||Mild to moderate||Take oral formulation with food to decrease nausea and vomiting. Liquid form may be mixed in small glass of water or cold fruit juice. If using topical patch, apply once a day to upper or lower back, alternating on the upper arm or chest. Must be applied to clean, dry intact skin.||Nausea, vomiting, loss of appetite, and increased frequency of bowel movements.|
|memantine (Namenda)||Moderate to severe||Take at the same time each day. Can be taken without regard to food. If taking liquid form, administer dose with calibrated dosing device.||Headache, constipation, confusion, and dizziness.|
ER = extended release.
Adapted from references 14-17, 21, 22.
The Role of the Caregiver
According to the Alzheimer’s Foundation, it is estimated that 1 to 4 family members act as caregivers for each individual with Alzheimer’s disease.19 Once diagnosed with AD, the patient’s family members and caregivers may feel stressed or overwhelmed and have a host of questions. They must learn to cope with the progressive physical and mental changes in their loved one and learn to handle both the emotional and physical demands of caring for an AD patient.
It is important for patients and their family and friends to learn means of managing and coping with this disease. Encourage those affected by AD to educate themselves. The Alzheimer’s Foundation of America offers strategies to help caregivers, including20:
1. Develop caregiving techniques, including communication skills, an understanding of safety concerns, and skills to help manage both day-to-day activities and behavioral changes.
2. Be understanding of the patient’s needs and practice empathy and patience.
3. Be reminded to also take care of yourself and get adequate rest, practice relaxation techniques, and eat a balanced diet. It may also be beneficial to join an AD support group.
4. Modify both the patient’s environment and schedule as symptoms change to ensure patient safety.
5. Because support systems are crucial to handling and coping with AD, discuss the needs of the patient with other family members.
6. Keep lines of communication open with all primary health care providers regarding patient progress. Maintain routine checkups.
7. Make plans for long-term care that address medical, financial, and legal issues.
8. Seek help when warranted, especially if feeling overwhelmed.
An excellent resource for caregivers, “Caring for a Person with Alzheimer’s Disease: Your Easy-to-Use Guide,” can be found on the National Institute on Aging Web site at www.nia.nih.gov/Alzheimers/Publications/CaringAD.
Pharmacists can be a vital resource for both patients and their caregivers, so having an understanding of the disease and the pharmacologic therapies available is imperative to providing effective care. Pharmacists can assist patients with AD by monitoring drug regimens for potential drug–drug interactions and possible contraindications, as well as by making recommendations to increase patient adherence, such as suggesting the use of once-a-day dosing formulations.
More importantly, pharmacists should always try to demonstrate empathy toward patients with AD and their caregivers. When possible, pharmacists should keep patients and caregivers informed about new developments in AD research and suggest resources that may be beneficial. Caring for a patient with AD can be difficult and caregivers may experience high levels of stress and depression. Pharmacists can provide both patients and their caregivers with hope and encouragement by informing them about the variety of resources available as they deal with this progressive disease.
Alzheimer’s Disease Resources
Alzheimer’s Association Web site: http://www.alz.org
Alzheimer’s Disease Education and Referral Center Web site: http://www.alzheimers.org"
National Institute on Aging: Alzheimer’s Disease Education and Referral Center Web site: http://www.nia.nih.gov"
Alzheimer’s Foundation of America Web site: http://www.alzfdn.org"
Fisher Center for Alzheimer’s Research Foundation Web site: http://www.ALZinfo.org"
National Institutes of Mental Health Web site: http://www.nimh.nih.gov"
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
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/> Accessed February 12, 2011.
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15. Exelon prescribing information. www.exelon.com. Accessed February 10, 2011.
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17. Namenda prescribing information. www.frx.com/pi/namenda_pi.pdf. Accessed February 12, 2011.
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22. Alzheimer’s disease medications fact sheet. National Institute on Aging Web site. www.nia.nih.gov/NR/rdonlyres/5178456B-4E16-4A71-A704-46637C6FE61B/16133/ADMedsFS.pdf. Accessed February 13, 2011.