Doctors are reporting some success in treating one of the most troubling symptoms of dementias such as Alzheimer's disease. A drug commonly used to treat schizophrenia and other psychotic disorders appears effective at reducing actions like screaming at or slapping caregivers – agitated behaviors that occur in as many as half of patients.
The work, led by researchers at the University of Rochester Medical Center, was presented July 22 at the 9th International Conference on Alzheimer's Disease and Related Disorders in Philadelphia, Pa. The conference is sponsored by the Alzheimer's Association.
The medication tested in the study, quetiapine, was effective at treating agitation, but with fewer side effects than other medicines that doctors turn to now.
"One of the most stressing and vexing changes in behavior in patients with dementia is agitation, which occurs in about half of patients at some point in their illness," says Pierre Tariot, M.D., professor of Psychiatry, Medicine, and Neurology, who led the study. "This behavior can be terrifying to the family and is one of the major reasons many families end up placing their loved ones in nursing homes."
Agitation is also difficult for doctors to treat. Currently there is no medication approved by the Food & Drug Administration to treat agitation in patients with dementia, though doctors and families often try to quell the symptoms with drugs that have been approved for other uses.
Doctors try anti-psychotic medications that usually reduce incidents such as slapping or yelling at caregivers or family members in about 15 to 20 percent of patients, Tariot says. But such medications can cause side effects like weight gain, high cholesterol, sleepiness, and Parkinson's-like movement difficulties, and some have recently been linked to higher incidences of cerebrovascular "adverse events" such as strokes and transient ischemic attacks.
"All the drugs used currently, including quetiapine, have drawbacks," says Tariot, who is also a researcher in the university's Center for Aging and Developmental Biology. "There is no ideal solution. For each patient you have to weigh the benefit of the drug against the potential cost in terms of side effects."
Tariot helped lead the study of quetiapine, a newer type of medication known as an "atypical antipsychotic." In a 10-week study of 333 people in nursing homes, the medication reduced such behaviors about 20 percent more often than a placebo did, comparable to the other drugs now available. In addition, the behavior of patients on the medication was more likely to be rated as "improved" or "very much improved," compared to other patients not on the medicine, by doctors and nurses who did not know which patients were on the medicine and which were not.
Significantly, in Tariot's study and in another presented at the meeting by Lon Schneider, M.D., of the University of Southern California, the medication has shown no evidence so far of causing serious side effects such as strokes, although it does cause sleepiness in some people.
"Quetiapine appears to show a similar treatment effect as other medications commonly used to treat agitation, but with a side effect profile that may be different from the other agents," says Tariot, who also serves as a paid consultant to AstraZeneca, which makes Seroquelฎ, the brand name of quetiapine. "If quetiapine remains free of the most worrisome side effects through further studies, that would represent an advantage and would offer a new therapeutic option for patients and their families."
While experienced clinicians often turn to atypical antipsychotics like quetiapine to treat agitation in dementia patients, Tariot says this is the first large, double-blind, placebo-controlled study to evaluate just how well quetiapine works. More information is expected next year, when results are announced from a large study funded by the National Institutes of Health that is the first to compare several atypical antipsychotics – such as quetiapine, risperidone, and olanzapine – for treating Alzheimer's and schizophrenia.
Before turning to medications, however, Tariot and other experts say the best way to treat dementia patients who are agitated is to try to understand if there is a reason underlying the behavior. Health care workers should make sure the person isn't in pain, for instance, and that caregiver behavior is appropriate and respectful. Check to see that there aren't features in the environment that can be easily changed, such as excessive heat or noise, which may be disturbing the patient. Sometimes, distracting a patient or changing the subject, as a parent does with a young child, is helpful. Sometimes other medications used to treat Alzheimer's disease, such as cholinesterase inhibitors or memantine, can alleviate these behaviors. When all such efforts fail – which they do often in patients with dementia, Tariot says – doctors and families should consider medication.
"It's clear that Alzheimer's will be the pandemic of the West in the next century," Tariot says. "Right now there are approximately 4.5 million Americans with dementia, and that number is expected to triple over the next few decades. Many of these patients will experience significant change in their emotions and personality. It's imperative that we find better treatments as soon as possible."
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