bs_bs_banner
Geriatr Gerontol Int 2014; 14: 515–517
EDITORIAL
Anti-dementia drugs in a psychiatric hospital for dementia patients
It has been reported that anti-dementia drugs are useful for improving cognitive functions and activities of daily livinge, and for delaying being under the care of nursing homes.1 Behavioral and psychological symptoms of dementia (BPSD) are other difficult problems of dementia, as well as cognitive impairments.2 Patients with severe BPSD cannot even be cared for by institutions, such as nursing homes or group homes, and finally become inpatients of psychiatric hospitals for dementia patients.3 Recently, some anti-dementia drugs have been reported to show adverse effects, such as worsening BPSD.4 It is wondered whether or not BPSD of some patients with dementia might be worsened by antidementia drugs, resulting in being admitted as inpatients of psychiatric hospitals for dementia patients. In the present study, we report how anti-dementia drugs have been prescribed before and after admission as inpatients to Sendai Tomizawa Hospital, a psychiatric hospital for dementia patients. A total of 81 dementia patients were admitted to the second floor of Sendai Tomizawa Hospital from April 2012 to March 2013, and BPSD related to antidementia drugs were compared before and after admission. Of the 81 dementia patients, 65 had Alzheimer’s disease, three were dementia patients with Lewy bodies, six patients had vascular type dementia and seven were dementia patients with psychosis (4 schizophrenia, 1 manic depression and 2 mental deterioration). Before being hospitalized, anti-dementia drugs were prescribed as follows: donepezil for 23 Alzheimer’s disease and three dementia patients with Lewy bodies, rivastigmine for one Alzheimer’s disease patient, galantamine for one Alzheimer’s disease patient and memantine for three Alzheimer’s disease patients, and a combination of both denepezil and memantine for five Alzheimer’s disease patients. Anti-dementia drugs were not prescribed for the other 32 Alzheimer’s disease patients, six vascular type dementia patients and seven dementia patients with psychosis. As both rivastigmine and galantamine offer similar effects on acetylcholine as donepezil,1 the three different drugs – rivastigmine, galantamine and donepezil – were summarized as donepezil analogy, and were given to the donepezil group of 30 Alzheimer’s patients (23 donepezil, 1 rivastigmine, 1 galantamine and 5 combination of both donepezil and memantine). Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth © 2014 Japan Geriatrics Society
Edition criteria.5 At baseline, we carried out a physical/ neurological examination, Mini-Mental State Examination (MMSE) for cognitive function,6 Barthel Index for activities of daily living (higher scores indicate better performance)7 and a brain computed tomography scan. BPSD was assessed using the Neuropsychiatric Inventory (lower scores indicate better performance).8 After being admitted as inpatients at Sendai Tomizawa Hospital, memantine was continuously prescribed for three Alzheimer’s patients who had been prescribed memantine before becoming inpatients. Donepezil was continuously prescribed for three dementia patients with Lewy bodies who had been prescribed donepezil before becoming inpatients. Antidementia drugs were not prescribed for six patients with vascular type dementia and seven dementia patients with psychosis, except some psychotropics if necessary. After becoming inpatients, anti-dementia drugs were not prescribed for 32 Alzheimer’s disease patients who had not been prescribed anti-dementia drugs before becoming inpatients (group A). Among the 30 Alzheimer’s disease patients who had been prescribed donepezil analogy before becoming inpatients, 14 patients had been continuously prescribed the donepezil analogy, including three patients who had been prescribed both donepezil and memantine before becoming inpatients (group B), but as the other 16 patients showed extremely intolerable BPSD, such as asking to be discharged from hospital, resistive attitude to care workers, abusing families, crying and restless attitudes, the denepezil analogy was omitted after they became inpatients (group C). Among these 16 patients who had the donepezil analogy (group C), memantine was prescribed in 10 patients, including two patients who had been prescribed both donepezil and memantine before becoming inpatients, and another six patients had not been prescribed memantine. Some psychotropics, but not antipsychotics, have been used for reducing BPSD, if necessary, in all Alzheimer’s disease patients.9 Two weeks after becoming inpatients, BPSD of groups A, B and C changed from 31 ± 18 to 25 ± 14 (n = 32, no significance), from 21 ± 12 to 19 ± 11 (n = 13, no significance) and from 38 ± 18 to 22 ± 14 (n = 16, P < 0.01), respectively (Table 1). There was no significant difference of MMSE or Barthel Index before and after becoming inpatients in groups A, B, and C. Durations of suffering Alzheimer’s disease were not doi: 10.1111/ggi.12175
| 515
Editorial
Table 1 Physical characteristics of Alzheimer’s disease Groups
Donepezil analogy Before After inpatients inpatients
Duration of sickness (years)
A (n = 32)
(−)
(−)
6±3
B (n = 14)
(+)
(+)
6±4
C (n = 16)
(+)
(−)
5±3
NPI MMSE Barthel Index NPI MMSE Barthel Index NPI MMSE Barthel Index
Before inpatients
2 weeks after inpatients
31 ± 18 12 ± 7 39 ± 18 21 ± 12 9±7 35 ± 13 38 ± 18## 8±7 32 ± 16
25 ± 14 11 ± 7 33 ± 11 17 ± 11 9±6 31 ± 9 22 ± 14** 7±6 27 ± 13
**Significance (P < 0.01) between Neuropsychiatric Inventory (NPI) before and after being admitted as inpatients of group C. ##Significance (P < 0.01) between NPI of groups B and C before being admitted as inpatients. Values are mean ± SD. MMSE, Mini-Mental State Examination.
different among groups A, B and C. There was a significant difference of the Neuropsychiatric Inventory between groups B and C before becoming inpatients (P < 0.01). We observed a significant decrease of BPSD after ceasing the donepezil analogy in group C. The criteria for ceasing the donepezil analogy was the doctor’s judgment for reducing high BPSD, such as restless behavior including screaming, crying, anger and/or asking to go home, which were thought to be caused by the donepezil analogy. In five patients in group C, BPSD dramatically subsided within a few days after ceasing the donepezil analogy. It is speculated that the donepezil analogy might stimulate extra emotions, which might enhance BPSD in some patients. However, once the donepezil analogy was stopped, impairments of not only emotions and cognitive functions, but also of activities of daily living, might occur as a result of withdrawal syndrome in some patients.10 Memantine was prescribed for some patients in group C in order to prevent withdrawal syndrome, although we could not prove the effect of memantine in the present study.11 Several limitations of the present study were as follows: (i) the observation period was 2 weeks; (ii) the study was open-label and had no control group, and therefore the present results might be partially explained by the severity of dementia, although there were no significant differences of Barthel Index or MMSE among groups A, B and C before being admitted as inpatients; and (iii) the sample size was not large enough to lead to conclusions. Although anti-dementia drugs have been widely prescribed, not enough information on the effects of anti-dementia drugs on BPSD has been reported, especially in patients with increased BPSD, which can cause patients to be admitted to psychiatric hospitals for dementia patients. The prognosis of 516 |
patients taking anti-dementia drugs has not been reported. When anti-dementia drugs are suddenly stopped because of anorexia, dysphagia or to save medical costs, withdrawal syndrome might occur. Overprescription of anti-dementia drugs might cause complications in the care of dementia patients.12,13 We should take care to keep the use of anti-dementia drugs to a minimum and only use them when necessary.
Disclosure statement The authors declare no conflict of interest. Masahiko Fujii and Hidetada Sasaki Sendai Tomizawa Hospital, Sendai, Japan
References 1 Lockhart IA, Mitchell SA, Kelly S. Safety and tolerability of donepezil, rivastigmine and galantamine for patients with Alzheimer’s disease; Systematic review of the “real-world” evidence. Dement Geriatr Cogn Disord 2009; 28: 389–403. 2 Satoh S, Kajiwara M, Kiyokawa E, Toukairin Y, Fujii M, Sasaki H. Rivastigmine patch and massage for Alzheimer’s disease patients. Geriatr Gerontol Int 2013; 13: 515–516. 3 Fujii M, Sasaki H. Stimulation but not neuroleptics. Geriatr Gerontol Int 2009; 9: 217–219. 4 Kimura T, Takamatsu J. Pilot study of pharmacological treatment for frontotemporal dementia; Risk of donepezil treatment for behavioral and psychological symptoms. Geriatr Gerontol Int 2013; 13: 506–507. 5 American Psychiatric association. Diagnosis and Statistical Manual of Mental Disorder, 4th edn. Washington, DC: American Psychiatric association, 1994. 6 Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practetical method for grading the cognitive state of patients for clinician. J Psychiatr Res 1975; 12: 189–198. 7 Mahoney FL, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1969; 14: 61–65. © 2014 Japan Geriatrics Society
Editorial 8 Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Garusi DA, Gormbein J. The neuropsychiatric inventory comprehensive assessment of psychopathology in dementia. Neurology 1994; 44: 2308–2314. 9 Asanuma K, Sumi S, Fujii M, Sasaki H. Psychotropics for patients with dementia. Geriatr Gerontol Int 2013; 13: 1–2. 10 Holmers C, Wilkinson D, Dean C et al. The efficacy of donepezil in the treatment of neuropsychiatric symptoms in Alzheimer disease. Neurology 2004; 63: 214–219.
© 2014 Japan Geriatrics Society
11 Wilkinson D. A review of the effects of memantine on clinical progression in Alzheimer’s disease. Int J Geriatr Psychiatry 2012; 27: 769–776. 12 Butler JP. Fujii m, Sasaki H. New Lessons of nurturing life for geriatric patients. Tohoku J Exp Med 2012; 227: 203–210. 13 Azumi M, Ishizuka S, Fujii M, Sasaki H. Antipsychotics and cognitive function. Psychogeriatrics 2011; 11: 79–82.
| 517
Geriatr Gerontol Int 2014; 14: 515–517
EDITORIAL
Anti-dementia drugs in a psychiatric hospital for dementia patients
It has been reported that anti-dementia drugs are useful for improving cognitive functions and activities of daily livinge, and for delaying being under the care of nursing homes.1 Behavioral and psychological symptoms of dementia (BPSD) are other difficult problems of dementia, as well as cognitive impairments.2 Patients with severe BPSD cannot even be cared for by institutions, such as nursing homes or group homes, and finally become inpatients of psychiatric hospitals for dementia patients.3 Recently, some anti-dementia drugs have been reported to show adverse effects, such as worsening BPSD.4 It is wondered whether or not BPSD of some patients with dementia might be worsened by antidementia drugs, resulting in being admitted as inpatients of psychiatric hospitals for dementia patients. In the present study, we report how anti-dementia drugs have been prescribed before and after admission as inpatients to Sendai Tomizawa Hospital, a psychiatric hospital for dementia patients. A total of 81 dementia patients were admitted to the second floor of Sendai Tomizawa Hospital from April 2012 to March 2013, and BPSD related to antidementia drugs were compared before and after admission. Of the 81 dementia patients, 65 had Alzheimer’s disease, three were dementia patients with Lewy bodies, six patients had vascular type dementia and seven were dementia patients with psychosis (4 schizophrenia, 1 manic depression and 2 mental deterioration). Before being hospitalized, anti-dementia drugs were prescribed as follows: donepezil for 23 Alzheimer’s disease and three dementia patients with Lewy bodies, rivastigmine for one Alzheimer’s disease patient, galantamine for one Alzheimer’s disease patient and memantine for three Alzheimer’s disease patients, and a combination of both denepezil and memantine for five Alzheimer’s disease patients. Anti-dementia drugs were not prescribed for the other 32 Alzheimer’s disease patients, six vascular type dementia patients and seven dementia patients with psychosis. As both rivastigmine and galantamine offer similar effects on acetylcholine as donepezil,1 the three different drugs – rivastigmine, galantamine and donepezil – were summarized as donepezil analogy, and were given to the donepezil group of 30 Alzheimer’s patients (23 donepezil, 1 rivastigmine, 1 galantamine and 5 combination of both donepezil and memantine). Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth © 2014 Japan Geriatrics Society
Edition criteria.5 At baseline, we carried out a physical/ neurological examination, Mini-Mental State Examination (MMSE) for cognitive function,6 Barthel Index for activities of daily living (higher scores indicate better performance)7 and a brain computed tomography scan. BPSD was assessed using the Neuropsychiatric Inventory (lower scores indicate better performance).8 After being admitted as inpatients at Sendai Tomizawa Hospital, memantine was continuously prescribed for three Alzheimer’s patients who had been prescribed memantine before becoming inpatients. Donepezil was continuously prescribed for three dementia patients with Lewy bodies who had been prescribed donepezil before becoming inpatients. Antidementia drugs were not prescribed for six patients with vascular type dementia and seven dementia patients with psychosis, except some psychotropics if necessary. After becoming inpatients, anti-dementia drugs were not prescribed for 32 Alzheimer’s disease patients who had not been prescribed anti-dementia drugs before becoming inpatients (group A). Among the 30 Alzheimer’s disease patients who had been prescribed donepezil analogy before becoming inpatients, 14 patients had been continuously prescribed the donepezil analogy, including three patients who had been prescribed both donepezil and memantine before becoming inpatients (group B), but as the other 16 patients showed extremely intolerable BPSD, such as asking to be discharged from hospital, resistive attitude to care workers, abusing families, crying and restless attitudes, the denepezil analogy was omitted after they became inpatients (group C). Among these 16 patients who had the donepezil analogy (group C), memantine was prescribed in 10 patients, including two patients who had been prescribed both donepezil and memantine before becoming inpatients, and another six patients had not been prescribed memantine. Some psychotropics, but not antipsychotics, have been used for reducing BPSD, if necessary, in all Alzheimer’s disease patients.9 Two weeks after becoming inpatients, BPSD of groups A, B and C changed from 31 ± 18 to 25 ± 14 (n = 32, no significance), from 21 ± 12 to 19 ± 11 (n = 13, no significance) and from 38 ± 18 to 22 ± 14 (n = 16, P < 0.01), respectively (Table 1). There was no significant difference of MMSE or Barthel Index before and after becoming inpatients in groups A, B, and C. Durations of suffering Alzheimer’s disease were not doi: 10.1111/ggi.12175
| 515
Editorial
Table 1 Physical characteristics of Alzheimer’s disease Groups
Donepezil analogy Before After inpatients inpatients
Duration of sickness (years)
A (n = 32)
(−)
(−)
6±3
B (n = 14)
(+)
(+)
6±4
C (n = 16)
(+)
(−)
5±3
NPI MMSE Barthel Index NPI MMSE Barthel Index NPI MMSE Barthel Index
Before inpatients
2 weeks after inpatients
31 ± 18 12 ± 7 39 ± 18 21 ± 12 9±7 35 ± 13 38 ± 18## 8±7 32 ± 16
25 ± 14 11 ± 7 33 ± 11 17 ± 11 9±6 31 ± 9 22 ± 14** 7±6 27 ± 13
**Significance (P < 0.01) between Neuropsychiatric Inventory (NPI) before and after being admitted as inpatients of group C. ##Significance (P < 0.01) between NPI of groups B and C before being admitted as inpatients. Values are mean ± SD. MMSE, Mini-Mental State Examination.
different among groups A, B and C. There was a significant difference of the Neuropsychiatric Inventory between groups B and C before becoming inpatients (P < 0.01). We observed a significant decrease of BPSD after ceasing the donepezil analogy in group C. The criteria for ceasing the donepezil analogy was the doctor’s judgment for reducing high BPSD, such as restless behavior including screaming, crying, anger and/or asking to go home, which were thought to be caused by the donepezil analogy. In five patients in group C, BPSD dramatically subsided within a few days after ceasing the donepezil analogy. It is speculated that the donepezil analogy might stimulate extra emotions, which might enhance BPSD in some patients. However, once the donepezil analogy was stopped, impairments of not only emotions and cognitive functions, but also of activities of daily living, might occur as a result of withdrawal syndrome in some patients.10 Memantine was prescribed for some patients in group C in order to prevent withdrawal syndrome, although we could not prove the effect of memantine in the present study.11 Several limitations of the present study were as follows: (i) the observation period was 2 weeks; (ii) the study was open-label and had no control group, and therefore the present results might be partially explained by the severity of dementia, although there were no significant differences of Barthel Index or MMSE among groups A, B and C before being admitted as inpatients; and (iii) the sample size was not large enough to lead to conclusions. Although anti-dementia drugs have been widely prescribed, not enough information on the effects of anti-dementia drugs on BPSD has been reported, especially in patients with increased BPSD, which can cause patients to be admitted to psychiatric hospitals for dementia patients. The prognosis of 516 |
patients taking anti-dementia drugs has not been reported. When anti-dementia drugs are suddenly stopped because of anorexia, dysphagia or to save medical costs, withdrawal syndrome might occur. Overprescription of anti-dementia drugs might cause complications in the care of dementia patients.12,13 We should take care to keep the use of anti-dementia drugs to a minimum and only use them when necessary.
Disclosure statement The authors declare no conflict of interest. Masahiko Fujii and Hidetada Sasaki Sendai Tomizawa Hospital, Sendai, Japan
References 1 Lockhart IA, Mitchell SA, Kelly S. Safety and tolerability of donepezil, rivastigmine and galantamine for patients with Alzheimer’s disease; Systematic review of the “real-world” evidence. Dement Geriatr Cogn Disord 2009; 28: 389–403. 2 Satoh S, Kajiwara M, Kiyokawa E, Toukairin Y, Fujii M, Sasaki H. Rivastigmine patch and massage for Alzheimer’s disease patients. Geriatr Gerontol Int 2013; 13: 515–516. 3 Fujii M, Sasaki H. Stimulation but not neuroleptics. Geriatr Gerontol Int 2009; 9: 217–219. 4 Kimura T, Takamatsu J. Pilot study of pharmacological treatment for frontotemporal dementia; Risk of donepezil treatment for behavioral and psychological symptoms. Geriatr Gerontol Int 2013; 13: 506–507. 5 American Psychiatric association. Diagnosis and Statistical Manual of Mental Disorder, 4th edn. Washington, DC: American Psychiatric association, 1994. 6 Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practetical method for grading the cognitive state of patients for clinician. J Psychiatr Res 1975; 12: 189–198. 7 Mahoney FL, Barthel DW. Functional evaluation: the Barthel Index. Md State Med J 1969; 14: 61–65. © 2014 Japan Geriatrics Society
Editorial 8 Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Garusi DA, Gormbein J. The neuropsychiatric inventory comprehensive assessment of psychopathology in dementia. Neurology 1994; 44: 2308–2314. 9 Asanuma K, Sumi S, Fujii M, Sasaki H. Psychotropics for patients with dementia. Geriatr Gerontol Int 2013; 13: 1–2. 10 Holmers C, Wilkinson D, Dean C et al. The efficacy of donepezil in the treatment of neuropsychiatric symptoms in Alzheimer disease. Neurology 2004; 63: 214–219.
© 2014 Japan Geriatrics Society
11 Wilkinson D. A review of the effects of memantine on clinical progression in Alzheimer’s disease. Int J Geriatr Psychiatry 2012; 27: 769–776. 12 Butler JP. Fujii m, Sasaki H. New Lessons of nurturing life for geriatric patients. Tohoku J Exp Med 2012; 227: 203–210. 13 Azumi M, Ishizuka S, Fujii M, Sasaki H. Antipsychotics and cognitive function. Psychogeriatrics 2011; 11: 79–82.
| 517
