Transcript Dementia Drugs: Mainstream and Alternative Medicines

Dementia Drugs:
Mainstream and Alternative
Medicines
Susan Kurrle
Causes of dementia
• Alzheimers Disease
• Vascular Dementia
• “Mixed” Dementia (Alzheimers Disease
and Vascular Dementia)
• Dementia with Lewy Bodies
• Frontotemporal Dementia
• Parkinsons Disease with Dementia
• Others
The role of medications in the
management of dementia
1.
2.
3.
4.
5.
Cure disease
Prevent disease or delay onset
Slow progression of disease
Treat primary symptoms eg memory
Treat secondary symptoms eg
depression, hallucinations
Jean’s medication
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Vitamin E
Donepezil
Ginkgo biloba
Lemon balm
Memantine
• Sertraline
• Risperidone
The role of medications in the
management of dementia
1.
2.
3.
4.
5.
Cure
Prevent disease or delay onset
Slow progression
Treat primary symptoms eg memory
Treat secondary symptoms eg
depression, hallucinations
Medications to slow progression
• Vitamin E
– 2 year study of Vitamin E in Alzheimers
Disease showing a significant delay in
functional decline, and nursing home
placement, compared to selegiline and placebo
– appears to work through its antioxidant effect
– need to watch its use with blood thinning
medications
The role of medications in the
management of dementia
1.
2.
3.
4.
5.
Cure
Prevent disease or delay onset
Slow progression
Treat primary symptoms eg memory
Treat secondary symptoms eg
depression, hallucinations
Medications to treat primary
symptoms
• cholinesterase inhibitors:
– donepezil
– rivastigmine
– galantamine
• memantine
• ginkgo biloba
Cholinesterase inhibitors
• these drugs stop the breakdown of
acetylcholine which is an important
neurotransmitter in memory and cognition
• all show modest improvement in cognition
and function, and behavioural symptoms
• response: 1/3 improve, 1/3 stabilise, 1/3
have no response
• do not prevent progression of underlying
disease
Cholinesterase inhibitors
• donepezil (Aricept)
– given once daily, dosage of 5mg to 10mg
• rivastigmine (Exelon)
– given twice daily, dosages of 3mg to 12mg
• galantamine (Reminyl)
– given once daily, dosages of 8mg to 24mg (can
also be given twice daily)
Use of cholinesterase inhibitors
• need specialist diagnosis of Alzheimers
Disease, and a MMSE score of 10 to 24.
• need to show an improvement on MMSE of
2 points to continue medication on PBS
• side effects - nausea, vomiting, diarrhoea,
dizziness, headache, muscle cramps
• use carefully if gastric ulcer, heart disease,
chronic lung disease present
Use of cholinesterase inhibitors
• warn against unrealistic expectations
• watch for return of insight leading to
depression or anxiety
• stopping of medication:
– unacceptable side effects
– lack of response to medication
– late stages of the disease
Memantine (Ebixa)
• glutamate is a transmitter in the brain that is
affected by Alzheimers Disease
• memantine blocks the pathological effects
of abnormal glutamate release, and allows
better function of the impaired brain
• indicated for moderate to severe AD
• trials show slowing in cognitive and
functional decline and decrease in agitation
in treated group compared to placebo
Memantine
• can use with other AD medications
• side effects - headaches, dizziness
• do not use in kidney disease or seizure
disorders
• dosage: start with 5mg daily and increase
to10mg twice daily
• private script - not on the PBS
• costs approx $160/month
Ginkgo biloba
• extract from the ginkgo tree (EGb761) taken
in doses of 120mg to 240 mg daily
• anti-inflammatory, anti-oxidant properties
• trials show modest improvements in some
measures of function and memory
• reasonably safe and well tolerated, but
watch for bleeding
• current trial for prevention of Alzheimers
Disease underway with 3000 participants
Medications under late stage
research to treat primary symptoms
• Huperzine A (Chinese herbal medicine)
– cholinesterase inhibitor, antioxidant, possible
neuroprotection properties
– nutraceutical - 200 to 800 mcg daily
• Alzhemed
– prevents formation and deposition of amyloid
in the brain
• Phenserine (recent poor trial results)
– cholinesterase inhibitor and regulates formation
of amyloid in the brain
The role of medications in the
management of dementia
1.
2.
3.
4.
5.
Cure
Prevent disease or delay onset
Slow progression
Treat primary symptoms eg memory
Treat secondary symptoms eg
depression, hallucinations
Medications to treat secondary
symptoms
• many people with dementia develop
symptoms such as agitation, aggression,
depression, delusions, hallucinations, sleep
disturbance and wandering
• antidepressants:
– specific serotonin reuptake inhibitors
(citalopram, sertraline)
Medications to treat secondary
symptoms
• antipsychotics:
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typical antipsychotics (haloperidol)
atypical antipsychotics (risperidone)
modest effect on symptoms
watch for side-effects
• mood stabilisers:
– anticonvulsants (carbemazepine)
Medications to treat secondary
symptoms
• aromatherapy with essential oils:
– melissa officinalis (lemon balm)
– lavendula officinalis (lavender)
– trials showed significant beneficial effect on
agitation and improved quality of life
– good compliance and no side-effects
“Alternative” medicines in the
management of dementia
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ginkgo biloba
lemon balm - melissa officinalis
lavender - lavendula officinalis
sage - salvia officinalis
– memory improving through cholinergic activity
– one small trial showed improvement in
Alzheimers Disease
“Alternative” medicines in the
management of dementia
• curcumin
– yellow pigment in turmeric (curry)
– anti-oxidant, anti-inflammatory, cholesterol
lowering
– reduces accumulation of amyloid in mice brains
– in Phase II trials in US
Management of Alzheimers
Disease
• as we cannot currently prevent or cure
Alzheimers Disease, the main aim of
treatment is to reduce symptoms and to
improve quality of life
• can use multiple medications with different
modes of action together or separately
across the various stages of the disease
• medication is just one of many strategies in
the management of this disease
“I am living with dementia,
not dying with dementia.”