Be Careful With Central Nervous System Medications

Like the population at large, it’s not unusual for people with dementia
to also experience and be treated for mental health issues such as depression, anxiety, and sleep disturbances. “Cognitive behavioral therapy and medications are both effective in treating depression and anxiety,” says Grace Cheng, PharmD, UCLA Medical Center. “However, in dementia patients, it may be more difficult for them to participate in cognitive
behavioral therapy; therefore, caregivers, family members and health-care providers may be more reliant on giving them medications.”

Medications that affect the central nervous system, such as those
for anxiety, depression, and sleep, can be problematic in older people
in general. These medications can increase fall risk, the leading cause of
injuries in people over age 65. Taking these medications in combination with other drugs also might cause impaired cognition, irregular heartbeats (arrhythmias), respiratory suppression, and possibly death.

It isn’t that medications for mental health issues should never, ever
be prescribed to people with dementia. But rather they should be done so very judiciously.

Overprescribed? New Study Insights

Researchers from the University of Michigan analyzed Medicare claims data on prescriptions for antidepressants, antipsychotics, antiepileptics, benzodiazepines, certain sleep aids, and opioids for more than a million older adults with dementia. The analysis, funded by the National Institute on Aging, was published in the March 19, 2021, issue of JAMA. About 14% of the study participants were prescribed three or more of the drugs that affect the central nervous system. Antidepressants were prescribed most frequently, followed by antiepileptics (which can be used to treat anxiety or pain) and antipsychotic drugs.

The most common combination included at least one antidepressant, an antiepileptic, and an antipsychotic.

“All three of these medication classes may cause changes in cognition, behavior, and other psychological symptoms. In dementia patients, it would be especially difficult to differentiate whether the changes
are resulting from medication adverse events or any underlying disease progression,” explains Cheng. “Specifically, there is a black-box warning for the use of antipsychotics in elderly adults with dementia, given the increased risk of mortality and morbidity.”

In the study, patients with prescriptions for drugs that affected the central nervous system had a median age of 79.4 years, and 71.2% were female. The most commonly prescribed medications included gabapentin (an antiepileptic), trazodone (an antidepressant), and quetiapine (an antipsychotic).

The study authors suggest that the problem is likely to get worse as more Americans are diagnosed with cognitive issues. They write, “Although memory impairment is the cardinal feature of dementia, behavioral and psychological symptoms (e.g., apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress. Despite limited high-quality evidence of efficacy for pharmacological treatment, clinicians regularly prescribe psychotropic medications to community dwelling persons with dementia in rates that far exceed use in the general older adult population.”

Unintended Consequences

Cheng points out that one of the most commonly prescribed dementia medication classes is acetylcholinesterase inhibitors, which includes drugs such as donepezil (Aricept) and rivastigmine (Exelon). “These agents inhibit neurotransmitter breakdown to maintain cognition and delay the progression of the disease,” she explains. “However, many medications, prescribed and over-the-counter, are considered as anticholinergic, which directly decrease the neurotransmitter’s action, which may worsen cognition and cause altered mental status.”

Some anticholinergic medications are available without a prescription and include those for allergy and sleep, such as diphenhydramine (Benadryl, Nytol) and doxylamine (Wal-Som, Unisom, Sleep Aid).

Cheng stresses that it’s crucial to have an open discussion with patients, caregivers, and family members regarding the reason for a medication, any potential side effects and management strategies, as well as expectation of therapy and the goals of care. Because any new complaints or changes in patient status may be medication related, caregivers should be aware of possible medication side effects and bring them to the attention of health-care providers.

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