In the JournalsPerspective

Information on treatment of dementia may be lacking in primary care

J. William Kerns
J. William Kerns

Dementia is becoming an increasingly important health problem in the United States, but primary care providers may be lacking understanding of guidelines and pharmacologic treatment options based on results of a survey published in a recent issue of the Journal of the American Board of Family Medicine.

“Stakeholders in dementia care have been purposeful in efforts to reduce the use of risky medications to treat challenging dementia symptoms because of poor evidence for safety and efficacy,” J. William Kerns MD, Shenandoah Family Practice Residency at Virginia Commonwealth University, told Healio Family Medicine. “Contrary to these various guidelines and initiatives, primary care doctors continue to prescribe potentially dangerous medications for dementia symptoms to hundreds of thousands of U.S. seniors. Our study sought to begin to explain and detail why this is so.”

He added that dementia is currently the sixth leading cause of death in the U.S., and the number of U.S. residents with the disease will rise by 35% by 2025.

Kerns and colleagues conducted interviews with 26 PCPs in northwestern Virginia with at least 3 years’ experience. Questions focused on the providers’ demographics; whether their patients lived at home, nursing homes or assisted living; medications prescribed; and how dementia was diagnosed.

The themes researchers identified based on participant answers were:

  • “PCPs need practical evidence-based guidelines for all aspects of behavioral and psychological symptoms of dementia management.”
  • “Pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications.”
  • “Nonpharmacologic methods have substantial barriers.”
  • “Medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate.”

The themes suggest there may be a disconnect in the perceptions and the reality of medications that are used to treat dementia, Kerns said.

“Physicians and caregivers need to understand that using medications in dementia may not be as safe or effective as they believe them to be. There needs to be a thorough discussion about the risks and benefits of any medication used in patients with dementia before trying them. Guidelines and policies regarding management of dementia symptoms, which currently often endorse medication use only for threat to life, should be more flexible to these palliative considerations,” he said.

“Current guidelines are not helpful. PCPs should also be included in any guideline development for such symptoms,” Kerns added. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

J. William Kerns
J. William Kerns

Dementia is becoming an increasingly important health problem in the United States, but primary care providers may be lacking understanding of guidelines and pharmacologic treatment options based on results of a survey published in a recent issue of the Journal of the American Board of Family Medicine.

“Stakeholders in dementia care have been purposeful in efforts to reduce the use of risky medications to treat challenging dementia symptoms because of poor evidence for safety and efficacy,” J. William Kerns MD, Shenandoah Family Practice Residency at Virginia Commonwealth University, told Healio Family Medicine. “Contrary to these various guidelines and initiatives, primary care doctors continue to prescribe potentially dangerous medications for dementia symptoms to hundreds of thousands of U.S. seniors. Our study sought to begin to explain and detail why this is so.”

He added that dementia is currently the sixth leading cause of death in the U.S., and the number of U.S. residents with the disease will rise by 35% by 2025.

Kerns and colleagues conducted interviews with 26 PCPs in northwestern Virginia with at least 3 years’ experience. Questions focused on the providers’ demographics; whether their patients lived at home, nursing homes or assisted living; medications prescribed; and how dementia was diagnosed.

The themes researchers identified based on participant answers were:

  • “PCPs need practical evidence-based guidelines for all aspects of behavioral and psychological symptoms of dementia management.”
  • “Pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications.”
  • “Nonpharmacologic methods have substantial barriers.”
  • “Medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate.”

The themes suggest there may be a disconnect in the perceptions and the reality of medications that are used to treat dementia, Kerns said.

“Physicians and caregivers need to understand that using medications in dementia may not be as safe or effective as they believe them to be. There needs to be a thorough discussion about the risks and benefits of any medication used in patients with dementia before trying them. Guidelines and policies regarding management of dementia symptoms, which currently often endorse medication use only for threat to life, should be more flexible to these palliative considerations,” he said.

“Current guidelines are not helpful. PCPs should also be included in any guideline development for such symptoms,” Kerns added. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

    Perspective
     Judith L. Beizer

    Judith L. Beizer

    This study was very limited in its focus in that it was conducted in a rural area and most of the physicians were older white males with little experience treating patients with dementia. While this group may be indicative of the medical community that treats older adults, I think Kerns and colleagues took a very simple approach to a complex topic.

    I was disturbed at the cavalier nature of some of the doctors’ responses, such as “I know there is black box warning on this medication, but I haven’t seen any problems so I’m going to use it anyway.” If you look at the previous studies on patients with Alzheimer’s disease taking antipsychotics, one showed only 18% of patients had good response from using them for their behavioral and psychological symptoms of dementia. Other studies have also found a similarly very low effective rate, and the discontinuation rate often mirrors that of placebo.

    In the geriatric population as a whole, we only use antipsychotics in patients with dementia if the patient is a danger to themselves or others, or if their functional status is severely impaired after all nonpharmaceutical options have been considered. Primary care physicians can advise family members and caregivers of patients with dementia who are acting out or acting distressed or fidgety to think about their experiences with a fussy baby. You don’t give the baby an antipsychotic, you determine if he or she is hungry. You determine if they need their diaper changed, if they are in pain, or do they just need companionship? The same questions can be asked of patients with dementia. You need to figure out what is going on before you ask for an antipsychotic medication to be prescribed or given. Sometimes finding answers to these questions can be much more effective. In addition, there are a lot of low-tech, easy things to do, like play the patient’s favorite music or movies that can sometimes be just as effective as the antipsychotic medications to manage the symptoms the patient is having.  

    • Judith L. Beizer, PharmD, BCGP, FASCP, AGSF
    • Clinical Professor, College of Pharmacy and Health Sciences St. John's University

    Disclosures: Beizer reports being a member of the 2018 American Geriatrics Society’s Beers Criteria Expert Panel.