Benzodiazepines such as Klonopin (generic = clonazepam), Xanax (generic = alprazolam), Ativan (generic = lorazepam) have a long and controversial history of use to treat behavioral challenges in those with Alzheimer’s disease. These disturbances range from agitation, anxiety, delusions, and hallucinations to sleep disturbances. The controversy deepened with the recent finding of a correlation between benzodiazepine use and risk of dementia. This risk appears to develop with chronic (i.e., daily) use of these medications for three or more months. At this time there is no agreement on use benzodiazepines as an alternative to antipsychotics, which have potentially serious side effects in the elderly. Current guidelines recommend use of benzodiazepines be limited to a few weeks despite the fact that they are often used for years. Long-term daily use of benzodiazepines is associated with increased risk of falls, dependence, and withdrawal […]
Medication
The cholinesterase inhibitors like Aricept (i.e., donepezil) have been available for treatment of dementias such as Alzheimer’s disease for two decades. It is clear that long-term use of these medications slows the progression of Alzheimer’s disease (in those who tolerate them) and that discontinuing these medications after extended use produces a risk of more rapid decline even in those who are in middle and late stage dementia. The standard of care for use of medications to treat Alzheimer’s related dementias recommends use of a cholinesterase inhibitor (donepezil, Exelon, and galantamine) starting in Mild Cognitive Impairment and early stage dementia. Namenda (i.e., memantine) has been available to treat middle and late stage (but not early stage) dementia for over a decade. A recent study (Cumulative, additive benefits of memantine and donepezil combination over component monotherapies in moderate to severe dementia: a […]
The cholinesterase inhibitors like Aricept (i.e., donepezil, rivastigmine, and galantamine) have been available for treatment of dementias such as Alzheimer’s disease since the mid 1990s. These medications slow the progression of Alzheimer’s disease (in those who tolerate them) and discontinuing them after extended use may induce a rapid decline even in those so impaired that they are in skilled nursing facilities. Despite these facts, the cholinesterase inhibitors are often maligned, not used, or discontinued too soon because they do not produce dramatic effects and do not arrest or reverse decline. Although Alzheimer’s and similar dementias are classified as memory disorders, they actually have an impact on many brains skills or domains. In addition to memory, Alzheimer’s disease may produce impairments in attention, language such as word finding, visuospatial skills like drawing/handiwork, personality, mood, and/or executive functions. All of these skills […]
The cholinesterase inhibitors like Aricept (i.e., donepezil) have been available for treatment of dementias such as Alzheimer’s disease since the mid 1990s. It is clear that long term use of these medications slows the progression of Alzheimer’s disease (in those who tolerate them) and that discontinuing the medication after extended use produces a more rapid decline even in those so impaired that they are in skilled nursing facilities. Despite these findings, the cholinesterase inhibitors are often maligned, not used, or discontinued too soon because they do not produce dramatic effects and do not stop or reverse decline. One way to determine the efficacy of these medications is to determine if treatment reduces the burden that caregivers express (“Effects on caregiver burden of donepezil hydrochloride dosage increase to 10 mg in patients with Alzheimer’s disease,” Nakamura et al. Patient Preference and […]
Benzodiazepines are widely used to treat anxiety and/or insomnia. They include medications like Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), and Klonopin (clonazepam) that are used for anxiety and Restoril (temazepam) and Halcion (triazolam) that are used to help induce sleep. Benzodiazepines may also be separated into those that are long acting (e.g., Valium and Klonopin) and those that are short acting (e.g., Xanax and Halcion). Long acting medications tend to remain in the body for extended periods of time (e.g., days) whereas short acting medications remain in the body for hours – hence you need to take the medication more than once a day to maintain effects. Benzodiazepines are probably most effectively used as short-term management of anxiety and insomnia. As with any medication, there are trade offs that must be considered by both prescribers and consumers. First, there are […]
Caffeine appears to enhance memory consolidation according to a study published in Nature Neuroscience (“Post-study caffeine administration enhances memory consolidation in humans,” 2014, 17, 201-203). But before you down an extra cup of coffee or an extra diet Coke, consider the details of the study. The subjects were 160 young adults who reported they consume little caffeine each week – < 500 mg, which is less than the equivalent 2-3 cups of coffee per week. Furthermore, they consumed caffeine pills not coffee. Participants studied 200 pictures, swallowed the caffeine pill, and returned the next day for a surprise memory test. Those who had the caffeine were better able to discriminate items similar to those actually seen from different items – familiarity not memory as most of us think of it. Let’s break down this result. First, there were three doses […]
Does taking a multivitamin/mineral supplement help prevent or delay cognitive decline? In 2012, Mayo Clinic Health Letter (March 2012) reviewed well-conducted research concluding that many vitamins and minerals that we used to think prevented diseases may not help after all. Furthermore, there are consistent findings that under some circumstances vitamins and supplements may cause harm – even use of a multivitamin in those who are well nourished may slightly increase the risk of premature death. A recent editorial, “Enough is enough: stop wasting money on vitamin and mineral supplements,” in the Annals of Internal Medicine (2013, 59: 851) pushed the issue even further. The journal published three articles presenting data that indicate no benefits from a multivitamin/mineral supplement in well-nourished adults. A review of primary prevention studies focused on community dwelling adults with no nutritional deficiencies. There was no clear […]
In 2004 the best available research indicated that supplementation with vitamin E slowed Alzheimer’s disease. A major clinical trial at the time indicated that taking 2000 IU of vitamin E per day delayed placement in care facilities by several months compared to placebo. By the way, treatment with selegiline (a type of antidepressant) produced the same effect. Another study at the time demonstrated that eating a diet high in vitamin E was correlated with higher mental function in men and women aged 65 – 100. Hence, many were taking high doses of vitamin E and supplementation was the standard of care for Alzheimer’s disease. However, there were concerns regarding such a high dose of vitamin E as it produced side effects such as potentiating the effects of anticoagulants such as aspirin and Coumadin and increasing bruising and risk of bleeding. […]
Initially, I was excited to see a review article titled, “Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis” (Canadian Medical Association Journal, 2013, September 16). However, I was disappointed after carefully reading the paper. I had hoped to gain insight into whether cognitive enhancing medications (Aricept/donepezil, Exelon/rivastigmine, and Razadyne/galantamine – there were no cognitive data for Namenda) help those with Mild Cognitive Impairment but there are too few studies with too many limitations to get a clear answer to the question of benefits. Mild Cognitive Impairment is usually characterized by mild memory/cognitive deficits in those without functional decline in everyday skills. These are persons who do not meet the criteria for Alzheimer’s disease but are clearly at greater risk of obtaining the diagnosis in the future. The question is whether treating […]
One of the most important yet difficult issues we all face with the proliferation of medications available and in development of new drugs, especially those affecting the central nervous system, is how to determine what is a meaningful drug effect. How does one know which drugs are effective and which are not? What is a meaningful treatment effect? How do professionals decide which drugs to recommend? Are newly available drugs better than older medications? We rely on large studies called randomized clinical trials (RTCs) to answer these questions. RTCs are scientifically rigorous studies designed to evaluate the safety and efficacy of medications (often compared to a placebo). The problem comes when we try to interpret the findings from these studies. What constitutes a meaningful result depends upon whom you ask (Defining a clinically meaningful effect for the design and implementation […]
