There is currently no single treatment for the complex chronic disease that is “Alzheimer’s Disease”. In fact, most chronic diseases are multi-factorial and benefit from multiple therapies.
It is up to your doctor to present and discuss the pros and cons of the various treatment. We believe it is important to not only try to treat the cognitive impairment but also evaluate and treat the other physical, emotional, social & financial issues that also impact the quality of life of the individual and the family. For example, if one’s cognitive impairment limits their mobility, finding ways to help increase ambulation with behavioral therapy or medication can improve one’s physical and emotional health and improve interactions with social system. Unfortunately, many primary care providers do not address these co existing conditions and miss out on opportunities to improve overall function and quality of life.
We all use adaptive techniques and devices every day to improve our performance and quality of life and treating any chronic disease is no different. What is different is you need to have an open mind to try various medical and non – medical interventions to see if they improve the quality of life for the individual or the caregiving system that supports them.
Treating Co-Morbid Illnesses
The most important element for treating ANY chronic disease including Alzheimer’s disease is to look beyond a single medical label. Human beings are so much more complicated than any one label. You miss many opportunities to improve function, social interactions and quality of life if you only focus on single label.
Medical care is different from medical research where the focus is on data, defining & documenting a set of criteria and observations. Medical care is different in that it requires the doctor or “provider” to assess & balance not only the medical data but also emotional, social & financial elements which are often not included in research studies. In order to ensure the highest quality medical are the doctor & patient should both have the expectation of delivering and receiving continuity of care.
As previously discussed under Alzheimer’s diagnosis, Alzheimer’s Disease is a difficult diagnosis to make and requires ruling out many common, co morbid illnesses and circumstances. Some common examples include Parkinson’s, Vascular Disease, COPD, Dementia, Clinical Depression, Anxiety Disorder, Mobility Issues, Infection, Incontinence, Constipation and many more.
Below, we discuss Behavioral & Medication Therapies that are commonly used in treating Alzheimer’s Disease. As stated earlier it is important for the primary care provider or doctor to evaluate the entire picture. Too often patients get pushed away from primary care to sub specialists who have a narrower focus and often miss opportunities to improve overall function & quality of life by not addressing & treating underlying co morbid illnesses. Geriatric medicine is based in primary care and includes advanced training on many sub specialty fields including Alzheimer’s and Dementia which helps improve continuity and quality of care.
Behavioral Therapy combined with the right structured and supportive care setting can help a person with Dementia or Alzheimer’s live as full a life as possible given their illness.
There are a wide variety of Behavioral Therapies which may be used to treat the early signs of Dementia and Alzheimer’s Disease, these include: reducing noise levels in the environment, changing the environment from inside to outside, playing soothing music, pet therapy, speaking in calm manner, using verbal cuing & reminding, or providing “busy activities” like folding towels.
While people praise the positive effects of Behavioral Therapy, they often fail to mention the enormous amount of time & patience required to deliver it. Most facilities and institutions do not have the manpower required to provide effective Behavioral Therapy. It requires a significant amount of time and energy in educating and training the staff on identifying triggers and appropriate interventions to use when dealing with the behaviors associated with Alzheimer’s like repetition of words or thoughts, lack of insight and judgment, agitation, aggression, paranoia, fear, anxiety and depression. Individuals will present with varied symptoms or behaviors. In all Alzheimer’s stages, it is very important to have an experienced team who knows how to identify triggers and implement the appropriate behavioral intervention. Unfortunately, this is hard to find in many health and senior care settings.
Having a Geriatrician, who is trained and knowledgeable on the many overlapping medical, emotional, social and financial issues associated with chronic illness and Alzheimer’s is important to ensure the most effective treatments and best outcomes. It is not only important to seek guidance from a Geriatric Medical doctor, but that doctor needs to have frequent interactions & communication with the patient, staff and family to ensure continuity, effectively monitor, adjust and coordinate the appropriate treatment plan. The goal of any Alzheimer’s treatment should look for ways improve the overall physical, emotional health which help improve quality of life for BOTH patient and the family.
All medications should be considered a second line of therapy to behavioral therapy, continuity & coordination of care by a geriatrician. Sadly, in today’s acute care health care system it can be a long time between visits. For the best Dementia therapy, you need daily communication between the caregivers and doctor. The caregiving team needs to feel supported and have easy access to the medical Provider overseeing the care.
Before starting any medication it’s important for the “provider” to not only consider the Dementia diagnosis but multiple potential co existing issues as well, like depression, anxiety, chronic pain, physical limitations & mobility issues.
Alzheimer’s medications like Aricept (donepezil), Namenda, (memantine) and Exelon (rivastigmine) are designed to slow the progression of Alzheimer’s Disease. They typically are started when early signs of Alzheimer’s are observed. It is unclear if these drugs truly slow the progression of disease. The effectiveness varies greatly from individual to individual. My experience with my patients has shown little benefit from taking these types of medications. In fact, it is more commonly noted that these medications can increase symptoms of anxiety, agitation, paranoia or make symptoms worse. Typically, psychosis and paranoia occur in later stages of Dementia, but they can progress more quickly with these medications, unnecessarily putting an individual in the early stages of Alzheimer’s into a higher level of care more rapidly. Alzheimer’s treatment of any kind requires a high level of monitoring & continuity of care by the doctor to assess for effectiveness or need to stop any medication or treatment.
The use of antipsychotic medications in those with Dementia is controversial. Common antipsychotics are Seroquel & Risperdal. As stated earlier the use of any medication should not be considered unless it is truly needed and expected to improve one’s health, function or quality of life.
In general, antipsychotic medications are a group of drugs used to treat those with psychosis. Psychosis is a term to describe people who lose their sense of reality. For example, they may have hallucinations (seeing hearing or smelling things that are not there, delusions (beliefs that are unfounded like people are out to get them). These medications help to improve insight and judgment and calm people enough to break the hallucination or delusion and give them the opportunity to have positive interactions with people and their environment.
It is important to remember that the use of antipsychotic medications is not intended to treat the dementia. Rather they treat the negative symptoms and behaviors that are present with various co-morbid diseases that significantly decrease quality of life for the person with Alzheimer’s and their family. Some assert that these medication cloud one’s judgement or that they increase complications or death in those with Dementia. It’s hard to truly know if someone with dementia dies because the medication or because of Alzheimer’s, advanced age or a variety co morbid illnesses. While behavioral therapy is the first line of action, people with Dementia often display symptoms of agitation, aggression, combativeness, paranoia that limit the effectiveness of the Behavioral Therapy. If an individual with Alzheimer’s resists and fights when receiving assistance with bathing, grooming or incontinent care it makes it almost impossible for a caregiver to safely provide care without putting themselves at risk of injury. Family caregivers often have more difficulty than third-party caregivers and are more susceptible to out bursts and anger because the individual with Alzheimer’s is paranoid that the family caregiver is trying to take over. The agitation & paranoia associated with Alzheimer’s can be reduced with appropriate use of anti-psychotics helping them remain positively connected to their family and loved ones, improving the individual’s quality of life.
The appropriate use of an anti-psychotic can dramatically improve the independence of the patient with Alzheimer’s with in their own supported care setting. If the individual is paranoid, that they are being poisoned, it may impede their ability to take other important medications or eat and drink consistently, which can cause other problems like dehydration, or other issues. In many cases, the use of medications improves the patient’s ability to interact with caregivers and family thereby improving quality of life. Other medications which may be useful are antidepressants or anti-anxiety drugs, but these mediations get much less attention.
Unfortunately, in today’s health system the focus is on Acute Care rather than Chronic Care or Long-Term Care. Continuity of care & personal communication is hard to come by. Information is largely obtained from a patient’s chart or notes on a computer, which is a much less effective way to get a clear picture of a patient’s actual physical, functional and emotional status. Reading from a chart or Electronic Heath Record (EHR) does not provide enough information and can’t describe, question and/or clarify what is actually happening, nor can it quantify how much agitation, paranoia a patient may be displaying. Only through ongoing verbal communication with the entire team and through physical exam can an accurate assessment be made, and appropriate treatment plan developed.
The effective use of medications requires the doctor, preferably a Geriatric Medical doctor who has frequent involvement & interaction with the patient, as well as, frequent communication with the staff and family to get up to date reports about how behaviors have improved, worsened or stayed the same on or off any medication and monitor for any unintended side effects. Continuity of Care requires consistent discussions between the doctor, caregivers and family, who interact with the patient on a daily basis are key to effectively adjusting the medication and achieving the best balance of Behavioral Therapy and Medication Therapy.
The right balance of geriatric leadership & coordination of care in a small, personal, community-based setting can help deliver a well-balanced behavioral & medication plan for the patient and help relieve the stress and caregiver burn out families often endure while caring for a loved one with Alzheimer’s.