Dementia Drugs: Mainstream and Alternative Medicines

1. Dementia Drugs:Mainstream and Alternative Medicines Susan Kurrle

2. 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

3. The role of medications in the management of dementia 1. Cure disease 2. Prevent disease or delay onset 3. Slow progression of disease 4. Treat primary symptoms eg memory 5. Treat secondary symptoms eg depression, hallucinations

4. Jean’s medication • Vitamin E • Donepezil • Ginkgo biloba • Lemon balm • Memantine • Sertraline • Risperidone

5. The role of medications in the management of dementia 1. Cure 2. Prevent disease or delay onset 3. Slow progression 4. Treat primary symptoms eg memory 5. Treat secondary symptoms eg depression, hallucinations

6. 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

7. The role of medications in the management of dementia 1. Cure 2. Prevent disease or delay onset 3. Slow progression 4. Treat primary symptoms eg memory 5. Treat secondary symptoms eg depression, hallucinations

8. Medications to treat primary symptoms • cholinesterase inhibitors: • donepezil • rivastigmine • galantamine • memantine • ginkgo biloba

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. The role of medications in the management of dementia 1. Cure 2. Prevent disease or delay onset 3. Slow progression 4. Treat primary symptoms eg memory 5. Treat secondary symptoms eg depression, hallucinations

18. 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)

19. Medications to treat secondary symptoms • antipsychotics: • typical antipsychotics (haloperidol) • atypical antipsychotics (risperidone) • modest effect on symptoms • watch for side-effects • mood stabilisers: • anticonvulsants (carbemazepine)

20. 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

21. “Alternative” medicines in the management of dementia • 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

22. “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

23. 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

26. “I am living with dementia, not dying with dementia.”