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Improving Cognition in Patients With Alzheimer’s Disease

November 11, 2020

(Part 3 of 4)

In this video, geriatric psychiatrist Marc E. Agronin, MD, discusses medications that may improve cognition in patients with Alzheimer's disease. Dr. Agronin is the senior vice president for Behavioral Health and chief medical officer for MIND Institute at Miami Jewish Health in Florida.

Dr. Agronin presented "The Top Dos and Don’ts in the Psychopharmacologic Treatment of Geriatric Patients: Focus on Dementia and Late-Life Depression and Anxiety" at the virtual Psych Congress 2020 conference.

Read the transcript:

When treating Alzheimer's disease, we don't have a cure. We don't even have a medication FDA approved yet for slowing the course of the disease. This is a big challenge, because this is by definition a progressive disorder.

We do have medications we refer to as cognitive-enhancing medications, and these come in 2 categories. The first are what are known as acetylcholinesterase inhibitors. There are 3 medications in that category.

The other is what's known as NMDA or glutamate receptor antagonist. This is memantine. It has a different mechanism of action which allows us to combine an acetylcholinesterase inhibitor with memantine.

These medications can help improve symptoms. They don't have clear evidence that they slow the course of the disease. Even so, this can bring benefit.

It might be modest. It might not always be noticeable in the way we like to see it, but nonetheless, there's a tremendous body of evidence pointing to the fact that in Alzheimer's disease, and to some extent in other forms of dementia, such as vascular dementia or Lewy body disease, that we can also see symptomatic benefit from cognitive- enhancing medications.

It's important when working with these to keep in mind several basic principles. First of all, you always start with an initial dose, and you titrate it either over 4 weeks, or in some of the medications, week to week, but you want to get to the therapeutic dose.

These are not the medications that a quarter or half dose will suffice for the most part. You simply won't get the full therapeutic benefit.

Keep in mind important side effects, so you monitor the patient as you do titration over time. As an example, the acetylcholinesterase inhibitors can have important GI side effects. That's really important to be aware of to educate the patient and the caregiver about this.

Make certain your expectations are modest. These are not cures. They don't slow the course of the disease, but they do have meaningful impact.

We know from some long‑term data that individuals on combination therapy, so, a single acetylcholinesterase inhibitor—and I emphasize, a single one, we don't combine them—but in combination with memantine, will give us the best clinical outcome for individuals, at least symptomatically.

Finally, these are indicated for mild, moderate, to severe disease. Even in individuals with more advanced stage disease, when you might not imagine the medications would have as much of an impact, we know for the acetylcholinesterase inhibitors in particular, that there's good data supporting their efficacy, even in late‑stage disease.

You absolutely want to give someone the benefit of these medications. With this approach, there's no question that you'll benefit individuals with Alzheimer's disease, and possibly other forms of dementia or neurocognitive disorders.

We need better agents. There's a lot of medications being studied experimentally that hopefully will come out eventually to help modify the disease or cure it, but in the meantime, we still want to do the best we can therapeutically for these individuals.

More with Dr. Agronin:
Adjusting Psychopharmacologic Treatment for Geriatric Patients
Prescribing Psychotropic Medications for Older Adults

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