Alzheimer's Disease Causes, Stages, and Symptoms (cont.)
Howard Crystal, MD
William C. Shiel Jr., MD, FACP, FACR
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
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Partial glutamate antagonists
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Glutamate is the major excitatory neurotransmitter in the brain. One theory suggests that too much glutamate may be bad for the brain and cause deterioration of nerve cells. Memantine (Namenda) works by partially decreasing the effect of glutamate to activate nerve cells. It has not been proven that memantine slows down the rate of progression of Alzheimer's disease. Studies have demonstrated that some patients on memantine can care for themselves better than patients on sugar pills (placebos). Memantine is approved for treatment of moderate and severe dementia, and studies did not show it was helpful in mild dementia. It is also possible to treat patients with both AchEs and memantine without loss of effectiveness of either medication or an increase in side effects.
Non-medication based treatments
Non-medication based treatments include maximizing patients' opportunities for social interaction and participating in activities such as walking, singing, dancing that they can still enjoy. Cognitive rehabilitation, (whereby a patient practices on a computer program for training memory), may or may not be of benefit. Further studies of this method are needed.
Treatment of psychiatric symptoms
Symptoms of Alzheimer's disease include agitation, depression, hallucinations, anxiety, and sleep disorders. Standard psychiatric drugs are widely used to treat these symptoms although none of these drugs have been specifically approved by the FDA for treating these symptoms in patients with Alzheimer's disease. If these behaviors are infrequent or mild, they often do not require treatment with medication. Non-pharmacologic measures can be very useful.
Nevertheless, frequently these symptoms are so severe that it becomes impossible for caregivers to take care of the patient, and treatment with medication to control these symptoms becomes necessary. Agitation is common, particularly in middle and later stages of Alzheimer's disease. Many different classes of agents have been tried to treat agitation including:
Studies are conflicting about the usefulness of these different drug classes. It was thought that newer, atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa, Zydis), quetiapine (Seroquel), and ziprasidone (Geodon) might have advantages over the older antipsychotic agents because of their fewer and less severe side effects and the patients' ability to tolerate them. However, more recent studies have not demonstrated superiority of the newer antipsychotics. Some research shows that these newer antipsychotics may be associated with increased risk of stroke or sudden death than the older antipsychotics, but many physicians believe this question is still not resolved.
Apathy and difficulty concentrating occur in most Alzheimer's disease patients and should not be treated with antidepressant medications. However, many Alzheimer's disease patients have other symptoms of depression including sustained feelings of unhappiness and/or inability to enjoy their usual activities. Such patients may benefit from a trial of antidepressant medication. Most physicians will try selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), citalopram (Celexa), or fluoxetine (Prozac), as first-line agents for treating depression in Alzheimer's disease.
Anxiety is another symptom in Alzheimer's disease that occasionally requires treatment. Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) may be associated with increased confusion and memory impairment. Non-benzodiazepine anxiolytics, such as buspirone (Buspar) or SSRIs, are probably preferable.
Difficulty sleeping (insomnia) occurs in many patients with Alzheimer's disease at some point in the course of their disease. Many Alzheimer's disease specialists prefer the use of sedating atypical antidepressants such as trazodone (Desyrel). However, other specialists may recommend other classes of medications. Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids to prevent the need for urination, should also be implemented.
Reviewed by William C. Shiel Jr., MD, FACP, FACR on 12/5/2013
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