Understanding Inappropriate Medications for Alzheimer's
While several drugs are approved to treat Alzheimer's disease by managing symptoms and slowing decline, other common medications are considered inappropriate and potentially harmful for these patients,. This is because their mechanisms can exacerbate cognitive decline, increase confusion, or pose other serious health risks, including a higher risk of death. Two of the most critical classes of drugs to avoid are those with anticholinergic properties and benzodiazepines.
The Dangers of Anticholinergics
Anticholinergic drugs work by blocking acetylcholine, a neurotransmitter critical for memory, learning, and other cognitive functions. Ironically, many approved Alzheimer's drugs, such as cholinesterase inhibitors, work by increasing the availability of acetylcholine to improve communication between nerve cells. Therefore, taking an anticholinergic drug directly counteracts the intended effect of Alzheimer's medication.
Common examples of anticholinergic drugs that can cause problems include:
- Antihistamines: Such as diphenhydramine (Benadryl).
- Certain antidepressants: Particularly older tricyclics like amitriptyline (Elavil) and paroxetine (Paxil).
- Bladder control medications: Such as oxybutynin (Ditropan).
- Some antipsychotics: Older or 'typical' antipsychotics like haloperidol (Haldol).
Taking these medications can lead to increased confusion, blurred vision, dry mouth, constipation, and a higher risk of falls,.
The Risks of Benzodiazepines and Other Sedatives
Benzodiazepines are a class of anti-anxiety medications and sedatives, including drugs like diazepam (Valium) and lorazepam (Ativan). For a person with Alzheimer's, these drugs can be very dangerous, leading to,:
- Increased sedation and drowsiness.
- Exacerbated memory problems and confusion.
- Significantly higher risk of falls and fractures.
Similarly, some non-benzodiazepine hypnotics, often called 'Z-drugs' (like zolpidem/Ambien), should be used with extreme caution or avoided entirely due to similar risks,. For managing agitation or sleep issues in Alzheimer's, non-drug interventions are almost always the preferred first step.
Comparing Approved vs. Avoided Medications
| Feature | Approved Alzheimer's Drugs | Potentially Inappropriate Drugs |
|---|---|---|
| Drug Class Examples | Cholinesterase Inhibitors (e.g., Donepezil), NMDA Antagonists (e.g., Memantine), Anti-Amyloid Antibodies (e.g., Lecanemab) | Anticholinergics (e.g., Oxybutynin), Benzodiazepines (e.g., Diazepam), First-Gen Antipsychotics (e.g., Haloperidol), |
| Primary Goal | Manage cognitive symptoms, enhance nerve communication, or remove amyloid plaque | Treat other conditions like anxiety, insomnia, or incontinence |
| Mechanism in AD | Increase or regulate specific neurotransmitters (e.g., acetylcholine) critical for memory | Block acetylcholine, cause sedation, or worsen cognitive function, |
| Cognitive Impact | Aim to improve or slow the decline of cognitive function | Can worsen confusion, memory loss, and overall cognitive abilities |
| Safety Concerns | Common side effects often include nausea, dizziness, or diarrhea | High risk of falls, sedation, worsened cognition, and potentially increased mortality, |
The Complicated Use of Antipsychotics
Antipsychotic drugs are sometimes considered for severe behavioral symptoms like aggression or psychosis in late-stage Alzheimer's, but their use is highly controversial and often restricted. There is a boxed warning on these drugs for older people with dementia, as they are associated with an increased risk of death, often from cardiovascular events or infection. For this reason, physicians and caregivers are advised to exhaust all non-pharmacological interventions before considering antipsychotics, and to use them at the lowest possible dose for the shortest duration.
Prioritizing Non-Drug Strategies
For managing challenging symptoms in Alzheimer's, such as agitation, anxiety, or insomnia, non-pharmacological strategies are the safest and often most effective first-line approach. The National Institute on Aging provides valuable resources and guidance on this topic, promoting interventions like National Institute on Aging:
- Creating a calm and predictable daily routine.
- Using relaxation techniques, music therapy, or massage.
- Ensuring comfort by checking for pain, hunger, or constipation.
- Improving sleep hygiene with a regular schedule and daytime activity.
The Importance of Regular Medication Review
For caregivers and families, regular and thorough medication reviews with a healthcare professional are essential. This is particularly important when managing a complex disease like Alzheimer's. The prescribing doctor or pharmacist should be aware of all medications, supplements, and over-the-counter products being used to identify and eliminate any that could be harmful.
By understanding which drug is not used in Alzheimer's disease, families and caregivers can make more informed decisions and better advocate for the safety and well-being of their loved ones.
