Special care urged in prescribing medications for patients with dementia

June 28, 2000
Web posted at: 1:10 p.m. EDT (1710 GMT)

From staff reports

CHICAGO (CNN) -- Using the prestige of the Journal of the American Medical Association, three Chicago physicians are urging their colleagues to be especially careful in prescribing medications for patients with dementia.

"When therapy involves a patient with dementia, the established equations balancing the benefits of treatment no longer add up," said Dr. Daniel Brauner, associate professor of clinical medicine at the University of Chicago and lead writer of the article.

"Besides the usual risk-benefit analysis, physicians need to consider a patient’s ability to comprehend, remember and follow directions, and to recognize and report problems," he said. "Treatment choices should also take into account the capacity of each patient’s caregivers to listen, understand and act."

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Mental health

Often associated with elderly people, dementia is a general loss of intellectual ability -- memory, judgment, abstract thinking. Changes in personality are noted. A common cause is Alzheimer’s disease, but dementia can occur with brain tumors or trauma in patients of any age.

Brauner and his colleagues also argue that people with slowed mental functions and other signs of dementia should be included in tests of new drugs involving patients with osteoporosis, arthritis and other age-related diseases.

"Far too little attention has been paid to how the presence of dementia should influence the treatment of non-dementia illnesses," Brauner said, "despite the fact that Alzheimer's can have a profound effect on the risks and benefits of treatment."

In Wednesday’s edition of JAMA, Brauner described several cases to illustrate his point.

In one, a woman in her 80s with mild dementia visited her physician complaining of back pain from a vertebral fracture. Her doctor prescribed an osteoporosis medication.

Since the drug can irritate the esophagus, the woman was instructed to take the medicine with water and to stay upright afterward. The woman's family, with whom she lived, also received this instruction, but "it is unknown how well these instructions were followed," Brauner wrote.

Four weeks after starting the medication,the patient was brought to an emergency room, suffering from shortness of breath. An examination showed severe damage to her esophagus, presumably caused by the medication. Her esophagus had ulcerated. Then further tissue eroded, leading to her death.

Brauner and his colleagues argue that "the presence of dementia put this woman at greater risk for developing serious complications from this drug."

She may not have understood how to take the drug properly, despite instruction, and may not have fully understood the consequences of taking it incorrectly, they wrote. Moreover, she did not report any symptoms before her esophagus perforated; the researchers suggest she may have had trouble communicating her problems because of the dementia.

To help prevent such incidents, the researchers suggest doctors write out all medication instructions and be sure caregivers are thoroughly informed about how to administer the medicine. Caregivers should also be coached "to look for behavioral changes such as decreased appetite, increased restlessness, or decreased activity, which may provide clues that something is wrong."

Doctors also need to carefully assess their goals when treating patients for dementia, the researchers wrote, and tailor the treatments to the level of decreased mental ability.

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The American Geriatrics Society
The AGS Foundation for Health in Aging
National Institute on Aging - NIA
Alzheimer's Disease Education and Referral (ADEAR) Center
Mayo Health Clinic Alzheimer's Center

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