Interventions for Alzheimer’s Disease in Older Adults

The DSM-5 diagnosis of major or mild neurocognitive disorder due to Alzheimer’s disease is commonly seen in older adults. Alzheimer’s disease can cause many different psychological, behavioral, or cognitive symptoms in older adults that can affect their quality of life along with their caregivers. Pharmacological and nonpharmacological treatments are used to manage neurocognitive disorders due to Alzheimer’s disease.

FDA Approved Drug

Donepezil is FDA approved for mild, moderate, and severe Alzheimer’s disease and can take up to six weeks to show improvement in a client’s memory or behaviors (Stahl, 2017). Dyer et al. (2018) analyzed systematic reviews of different pharmacological interventions used in treating dementia and found that donepezil has high-quality evidence for reducing behavioral and psychological symptoms. Before prescribing donepezil to a client, the risks of medication interactions, adverse effects, and benefits must be assessed. Donepezil is metabolized by CYP450 2D6 and 3A4, making it essential to check for any drug interactions before prescribing this drug (Stahl, 2017). Donepezil has also been associated with bradycardia, syncope, gastrointestinal effects, and sleep disturbances, which need to be considered and closely monitored when initiating this medication (Stahl, 2017). Donepezil has been shown to improve cognition, which has positively affected the function of individuals with Alzheimer’s disease (Adlimoghaddam et al., 2018). The risks and benefits should be monitored when initiating therapy with donepezil, and if after an adequate trial there is no cognitive or behavioral improvement, discontinuation should be discussed. 

Off Label Drug

Risperidone has been used off-label in Alzheimer’s disease, and it has been found to be one of the most effective antipsychotics in treating psychosis, agitation, and behavioral and psychological symptoms associated with dementia (Bessey & Walaszek, 2019). The risks and benefits need to be very carefully assessed if prescribing risperidone, and its use should only be considered if a client with Alzheimer’s disease has symptoms that would cause harm to themselves or others. There is only modest evidence for the use of antipsychotics in dementia, and the FDA has a black box warning advising against the use of atypical antipsychotics in older adults with dementia (Bessey & Walaszek, 2019). Risperidone is metabolized by CYP 450 2D6 and has other drug interactions, so this would need to be assessed before initiating the drug (Stahl, 2017). Risperidone has many adverse side effects, including metabolic effects, tardive dyskinesia, orthostatic hypotension, and increased risk of cerebrovascular effects that need to be assessed before using this medication (Stahl, 2017). 

Non-pharmacological Intervention

Non-pharmacological interventions are recommended as a first-line intervention when working with neurocognitive disorder due to Alzheimer’s disease. Tailored activity programs can help reduce behavioral and psychological symptoms of dementia and work by identifying the client’s interests and capabilities and working to develop an appropriate activity program for them (Bessey & Walaszek, 2019). This intervention can be taught to the caregivers and implemented to help to decrease their stress and burden.

Clinical Practice Guidelines

            The American Psychiatric Association (APA) (2016) has clinical guidelines for the use of antipsychotics in dementia and recommends that non-pharmacological intervention be used before using nonemergency antipsychotic medications. The APA (2016) also recommends that antipsychotics only be used with agitation or psychosis when a client’s symptoms are dangerous or causing severe distress. The APA (2006) has guidelines for treating Alzheimer’s disease and found that donepezil showed benefit over the placebo in studies regarding improvement in both cognitive and functional areas and is recommended for use in patients with mild to moderate Alzheimer’s disease. These clinical practice guidelines support the initiation of donepezil and risperidone in certain circumstances with clients with Alzheimer’s disease.

References

Adlimoghaddam, A., Neuendorff, M., Roy, B., & Albensi, B. C. (2018). A review of clinical treatment considerations of donepezil in severe Alzheimer’s disease. CNS neuroscience & therapeutics, 24(10), 876–888. https://doi.org/10.1111/cns.13035

American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. https://doi.org/10.1176/appi.books.9780890426807

American Psychiatric Association. (2006). The American Psychiatric Association Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimers.pdf

Bessey, L. J., & Walaszek, A. (2019). Management of behavioral and psychological symptoms of dementia. Current psychiatry reports21(8), 66. https://doi.org/10.1007/s11920-019-1049-5

Dyer, S. M., Harrison, S. L., Laver, K., Whitehead, C., & Crotty, M. (2018). An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia. International psychogeriatrics30(3), 295–309. https://doi.org/10.1017/S1041610217002344

Stahl, S. M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide. (6th ed.). Cambridge University Press.

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