In the struggle with Alzheimer's disease, pharmacists can provide pertinent information about the associated myths, realities, and symptomatic treatments.
In the struggle with Alzheimer’s disease, pharmacists can provide pertinent information about the associated myths, realities, and symptomatic treatments.
For most Americans, the words “Alzheimer’s disease” (AD)— often mispronounced purposefully or by accident as “old timers’ disease”—mean devastating end-of-life memory loss and stigma.1 The information about AD—often learned solely through the media—may lead individuals to believe that AD is inevitable (it isn’t),2,3 and they may think that all AD patients receive poor care (there are many remarkably good AD units).4,5
Many individuals may see a future burdened with more dementia patients and fewer societal resources to care for them (a real possibility).5
In general, pharmacists are well aware of what AD is and isn’t (see “Refreshing Your Memory: What Is Alzheimer’s Disease?”). Complex and relentlessly progressive, AD affects patients, loved ones, and caregivers adversely. Pharmacists can provide pertinent information about AD’s myths, realities, and available symptomatic treatments.
AD’s harbinger is language difficulties, including aphasia (language disturbance), apraxia (inability to carry out motor functions), and agnosia (failure to recognize or identify objects). Patients often create new words for items. They may call a pencil a “list writer,” or a key a “door turner.”14 Clinicians stage AD as mild, moderate, or severe on the patient’s cognitive and memory impairment, communication problems, personality changes, behavior, and loss of control of bodily functions (Figure).13 People often dismiss mild AD as normal cognitive decline or senility—in other words, “normal” aging. For this reason, most people don’t seek treatment and are diagnosed in the late mild to early moderate stage.
In the severe stage, difficulty swallowing elevates risk of aspiration pneumonia, which often starts the downward spiral to death.10,15
AD has no cure. A handful of pharmacologic treatments—acetylcholinesterase inhibitors and N-methyl-D-aspartate antagonists—alter the decline trajectory. These treatments slow disease progression, enhance cognitive function, delay cognitive decline, and decrease disruptive behaviors. Not all patients respond to these medications, but experts generally believe that those who do will show mild to modest improvements for 6 months to a year.16,17 Although the drugs’ effects are short-lived, they improve patients’ quality of life and briefly allow independence.17,18
All approved drugs are most effective at their target dose, and all require slow titration to the target dose (Online Table).19-21
(Scroll down to continue reading.)
Table: Medications Approved for Treating Alzheimer’s Disease
Common Adverse Effects
Donepezil (Aricept and various generics)
• Take in the evening without regard to food, with a full glass of water
• Do not break or crush immediate-release tablet
• Orally disintegrating tablet: allow tablet to dissolve in mouth followed by a glass of water
• Available as an ER form for once- daily dosing
• Appetite loss
• Increased frequency of bowel movements and diarrhea
• Muscle cramps
• Nausea, vomiting
• Weight loss
Galantamine (Razadyne, Razadyne ER and various generics)
Mild to moderate
• Take the ER capsule in the morning with food and water
• Take other tablet formulations and oral solution twice a day with morning and evening meal
• Liquid form can be mixed in 4 oz of juice if needed
• Maintain adequate hydration
Rivastigmine (Exelon and various generics)
• Take oral formulation with food; liquid form may be mixed in small glass of water or cold fruit juice
• Consider the patch for patients who have difficulty eating or swallowing or who have severe nausea
• Apply topical patch to clean, dry intact skin on upper or lower back once a day, alternating on the upper arm or chest
N-methyl-D-aspartate Receptor Antagonist
Moderate to severe
• Take at the same time daily without regard to food
• Available as immediate release, ER, or liquid
• Administer the liquid form using the calibrated dosing device
• Prescribed alone or in combination with donepezil
• Renally eliminated drug; dose adjustments needed for creatinine clearance <30
• Educate patients about significant reactions (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin; seizures; swelling of face, lips, tongue, or throat)
ER = extended release.
Adapted from references 19-21 and the following: Aricept [prescribing information]. Eisai Inc and Pfizer Inc; 2014. www.aricept.com. Accessed January 16, 2014. Razadyne [prescribing information]. Janssen Pharmaceuticals; 2014. www.razadyneer.com. Accessed January 16, 2014. Exelon [prescribing information]. Novartis; 2014. www.exelonpatch.com. Accessed January 16, 2014. Namenda [prescribing information]. Forest Laboratories, Inc; 2014. www.namendaxr.com. Accessed January 16, 2014.
Determining when medications stop providing a therapeutic benefit and should be discontinued is challenging. Clinicians use various methods to monitor decline, including mental status tools, patient self-report, and loved ones’ observations. Most clinicians continue the drugs if the patient seems to tolerate the medication well and can afford it, and if there seems to be a benefit.16
With disease progression, specific behavioral symptoms including depression, agitation, hallucinations, and sleep disturbances become concerns. Antianxiety drugs, antipsychotics, and antidepressants are sometimes used to alleviate symptoms, but behavioral strategies are much preferred if they work.22
The FDA hasn’t approved a new drug for AD since 2003.16 Experts are cautiously hopeful and actively pursuing treatments to stop or significantly delay its progression. Some researchers have identified a link between AD and diabetes mellitus, obesity, and cardiovascular disease, suggesting that this condition be called type 3 diabetes mellitus.23,24 Some coumarin and flavonoid derivatives seem to offer promise.19 Two monoclonal antibodies—bapineuzumab and solanezumab—navigated phase 3 trials, but with disappointing results. Regardless, other monoclonal antibodies are in the pipeline.25
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy. She has extensive experience with the geriatric population.