Medication Side Effects
- at higher risk of side effects than cognitively-intact people
- often unable to recognise side effects from their medications
- often unable to report side effects from their medications
Principles of medication use
- provide a current medication list that includes indications, administration instructions, and planned dates for review
- regularly monitor for actual benefit of each medication
- regularly monitor for actual side effects
- start new medications at the lowest therapeutic dose
- review doses frequently to see if a lower dose would be adequate
- change only one medication at a time
- assess impact of dementia on activities of daily living
Medication reviews
- underpinned by a current, valid indication
- effective for that individual
- consistent with individual’s care goals
- documented with a time frame to review
A medication review should be triggered by:
- a significant event (e.g. cardiovascular event, fall, fracture, hospital admission, residential care facility admission)
- increasing frailty
- resistance to taking medications
- belief taking medications is a burden
- writing a new prescription for the medication
- decline in cognitive function
- decline in ability to manage activities of daily living
- regular use of five or more medications
Treatment Goals
An important treatment goal for people living with dementia is to simplify the medication regimen.
Health professionals and the carer or family of the person living with dementia should discuss and document:
- treatment goals
- likely prognosis
- document wishes for treatment in specific future scenarios
Health professionals and the person living with dementia should discuss and document:
ALL STAGES
- writing an advance care directive to indicate their wishes for treatment in specific future scenarios
EARLY STAGE and MID STAGE
- using a dose administration aid to support medication use
Preventative medication
When prescribing medications intended to modify the risk of a future event for a person living with dementia, health professionals should consider:
ALL STAGES
- functionality as the most important factor
- the potential benefits weighed against the actual harm
- potential for side effects
- actual side effects
- the risks of polypharmacy
- the administration burden
- maximise quality of life rather than prolong survival
- continue annual influenza vaccines indefinitely
- continue annual influenza vaccines indefinitely
- use less stringent targets for blood pressure
- use less stringent targets for blood glucose
- cease lipid-lowering medications
- cease medications that have a longer potential time to benefit than the person’s likely prognosis
- use less stringent targets for blood glucose
- only use diuretics for symptomatic management of heart failure
- cease antihypertensive agents
- cease lipid-lowering medications
- cease medications to manage osteoporosis
- cease anti-platelet, anti-coagulants and anti-thrombotic agents
- cease all medications that do not also provide tangible symptom relief
- cease medications that have a longer potential time to benefit than the person’s likely prognosis
Symptom management
- trialled for withdrawal every three to six months if the symptoms are stable
- reviewed regularly for efficacy
- reviewed regularly for side effects
- review doses frequently to see if symptoms can be adequately maintained on a lower dose
- maximised to alleviate distress
Psycho-active medications
- use non-pharmacological strategies in preference to medications
- benzodiazepines should not generally be used, but
- short acting benzodiazepines can be useful for managing acute agitation provided use is monitored
- antipsychotics can be useful when prescribed at a low dose for a limited period to alleviate distressing neuropsychiatric symptoms
- antipsychotics should be considered if distressing behavioural
- symptoms are not responsive to other management strategies
- tricyclic antidepressants have a limited role, but
- tricyclic antidepressants may be useful in managing refractory neuropathic pain
Medications to modify dementia progression
EARLY STAGE and MID STAGE
- consider a trial of an anticholinesterase inhibitor
- consider a trial of memantine
- review dementia treatments with respect to desired benefits and actual side effects (i.e. memantine, anticholinesterases)
- maximise cognitive function by reducing exposure to medications with sedative and anticholinergic properties
- stop dementia treatments in late stage dementia (i.e. memantine, anticholinesterases)
- maximise cognitive function by reducing exposure to medications with sedative and anticholinergic properties
Expert consensus is that these practices are NOT recommended in the care of people with dementia
Treatment Goals
These treatment goals are important for people living with dementia:
EARLY STAGE and MID STAGE
- the wishes and needs of family and carers should take priority over those of the person living with dementia
- it is acceptable to conceal medications in food or drink if the person with dementia refuses them
Preventative Medications
When prescribing medications intended to modify the risk of a future event for a person living with dementia, health professionals should consider:
- cease all medications that do not also provide tangible symptom relief
- cease anti-platelet, anti-coagulants and anti-thrombotic agents
- cease medications to manage osteoporosis
- cease antihypertensive agents
- cease medications to manage osteoporosis
- cease antihypertensive agents
Symptom Management
for people living with dementia, regular medications intended only to provide symptom relief should be continued indefinitely in people who are unable to reliably report symptom recurrence
Psycho-active medications
- for managing behavioural and psychological symptoms of dementia, antipsychotics are never appropriate for behavioural management
- for people living with dementia, long acting benzodiazepines can be useful, provided the risks are weighed against the benefits