Use of anticholinergic medications by older adults with dementia

Use of the Agency for Health Care Policy and Research Urinary Incontinence Guideline in Nursing Homes

The objective of this study was to assess the use of the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality) Urinary Incontinence (UI) Guideline (1996) in nursing homes (NHs) using retrospective chart review and nursing assistant screening interviews. The study was conducted in a nonrandom sample of 52 NHs in upstate New York. Two hundred residents developing new UI or newly admitted with UI on the dayshift and who met criteria for evaluation and treatment/management were evaluated in the 12 weeks after onset of or admission with UI. Fifteen percent of newly admitted residents needed evaluation. Of residents already in NHs, 2.3 per 100 beds developed new UI over the 12 weeks. Aspects of UI evaluation rarely done were rectal examination (15%), digital examination of prostate (15%), and pelvic examination (2%). Sixty-eight percent had a culture/sensitivity, 56% a urinalysis, and 6% a postvoid residual. Eighty-one percent had a reversible cause at the time of onset, but only 34% had all addressed. Few (2%) needed urologist evaluation. Treatment was rare (3%), but management using toileting and absorbent products were common. Only 6% achieved resolution of UI. These results suggest that assessment and treatment of UI is manageable (a total of 4.2 new cases per 100 beds per 12 weeks) but quality is not adequate. On average, only 20% of the standards applicable were met, due primarily to lack of awareness of new UI and lack of familiarity with the guideline. Thus, improvements are needed. Recommendations for guideline revision are made.

Use of psychotropics among home-dwelling nondemented and demented elderly

OBJECTIVE

To describe the use of psychotropics in the nondemented and demented elderly.

PARTICIPANTS

The home-dwelling elderly (n=523) among the random sample of 700 subjects from the total population of individuals aged 75 years or more in 1998 and living in the city of Kuopio, Finland.

METHODS

A trained nurse interviewed the participants about their health and current use of medicines. A geriatrician performed clinical examinations and diagnosed diseases. Dementia and depression were diagnosed according to the DSM-IV criteria.

RESULTS

The demented subjects used more medicines of all kinds (p<0.01), and especially more psychotropics than the nondemented (p<0.001). One in four demented subjects, compared to one in ten nondemented ones used at least two psychotropics (p<0.01). The demented subjects used antipsychotics six times more often than the nondemented ones (p<0.001). Among the nondemented subjects, one out of two antipsychotics users was suffering from depression according to DSM-IV criteria. Three out of four persons who had dementia with Lewy bodies were using psychotropics. Persons with moderate dementia were more commonly using all kinds of psychotropic preparations especially, antipsychotics three times more commonly than persons with mild or severe dementia.

CONCLUSION

Psychotropics, especially antipsychotics, are commonly used in the treatment of both nondemented and demented elderly, even without proper indication. Physicians need more training about the appropriate use of psychotropics to minimize their adverse effects.

Drug interactions with cholinesterase inhibitors

Cholinesterase inhibitors are used for the symptomatic treatment of patients with Alzheimer's disease. This population often has numerous comorbidities and receives treatment with multiple medications. The astute clinician should remain mindful of possible drug interactions, both pharmacokinetic and pharmacodynamic, that may occur with concomitant treatment. Although pharmacokinetic interactions have been reported, pharmacodynamic interactions play a far greater role in the significance of drug interactions, with anticholinergic medications being most concerning. Commonly prescribed medications, such as antihistamines and tricyclic antidepressants, often have anticholinergic properties that alone or in combination with one another can antagonise the effects of cholinesterase inhibitors. Other medication classes such as antipsychotics and cholinergic agents may also result in pharmacodynamic interactions. However, for the most part, cholinesterase inhibitors can be used safely in combination with other medications.

Effects of toy stimulation on the cognitive, communicative, and emotional functioning of adults in the middle stages of Alzheimer's disease

Although several clinical reports describe the benefits of toy stimulation for dementia patients, there is little empirical support for this sensory stimulation approach. The purpose of this investigation was to examine the effects of toy stimulation on the language, cognition, and emotional state of patients in the middle stages of Alzheimer's disease (AD) during a formal testing situation. Eighteen patients completed a standardized test battery and picture description task twice, once with and once without a toy stimulus present. Three AD patients completed all tasks four times (twice with and twice without the toy) to examine performance consistency. Although some patients improved their performances in the presence of a toy, there were no significant group differences between the toy and no toy conditions for any experimental measure. Of the three patients who completed experimental tasks twice in the presence of a toy, two displayed some consistent improvements whereas the remaining patient's response pattern was variable. Caregiver feedback regarding toy stimulation was positive. Methodological limitations of the current study and suggestions for future research are discussed.

LEARNING OUTCOMES

As a result of reading this article, the participant will be able to: (1) summarize the previous literature regarding sensory stimulation treatment approaches for patients with Alzheimer's disease or other dementing illnesses; and (2) describe the effects of toy stimulation on the linguistic and cognitive abilities, and emotional status of patients in the middle stages of Alzheimer's disease.

Progress in clinical neurosciences: Treatment of Alzheimer's disease and other dementias--review and comparison of the cholinesterase inhibitors

BACKGROUND

Alzheimer's disease (AD) is the most common cause of dementia in older adults. Acceptance of the cholinergic hypothesis led to a search for medications which could enhance central cholinergic activity in this condition. There are now three cholinesterase inhibitors available for the treatment of AD in Canada.

OBJECTIVES

To review the currently available cholinesterase inhibitors approved for the treatment of AD in Canada and to provide guidance on who and how to treat with these agents.

RESULTS

Donepezil, rivastigmine, and galantamine are approved for the treatment of AD in Canada. In clinical trails, patients with mild to moderate AD treated with these agents experienced modest improvements in cognition, function, behaviour, and/or global clinical state. The magnitude of benefits seen with each agent appeared to be similar. While to date, there is no convincing evidence that one is more efficacious or effective, they do differ in their pharmacokinetics, additional mechanisms of action, and side effect profiles. Therefore, the selection of agent will be based on considerations such as side effect profiles, ease of administration, personal familiarity/experience, and beliefs about the importance of the noted differences in their pharmacokinetics and additional mechanisms of action.

CONCLUSION

We believe that these agents should be offered to all individuals with a mild to moderate dementia where Alzheimer's pathology is felt to be a contributing factor. We view all three available cholinesterase inhibitors as first-line drugs.