Posts tagged: Dementia

Memory Meds

It was a bit shocking. The wife remarked on the comments of her husband’s neurologist.  He was rumored to malign memory enhancing drugs used in the treatment of Alzheimer’s Disease.  He was of the opinion that this class of drugs benefited the drug companies more than the victims of a senile dementia.  The wife was understandably confused by the disparity between the opinion of the neurologist and the claims of the drug companies.  The shock was the public admission of what many physicians voice in private.

Over the last ten years, most patients I’ve evaluated with a change in mental status, due to any cause, have already been prescribed memory enhancing medications.  The drug companies caution that these drugs should be limited to the victims of a senile dementia of the Alzheimer’s type.  It is very common to observe these drugs used in the treatment of stroke and head injuries.  Is this a good thing?

Unfortunately, this clinician has never witnessed a significant increase of verbal memory performance as a consequence of these medications.  This experience applies both to the preferred use of these drugs in the treatment of Alzheimer’s, as well as off-label use of memory enhancing medications.  It is not intended as a blanket condemnation, rather it reflects the lack of statistically significant benefit displayed on well-normed tests of verbal memory.  There may be many people who have a significant increase of verbal memory with the use of these drugs, but none of these responders have been evaluated by this clinician.  Memory enhancing drugs that boost the neurotransmitter acetylcholine may display increased agitation, weight loss, and even chronic nausea with vomiting.  These reactions are fortunately not universal.  This clinician has witnessed the resolution of these symptoms many times after a reduction or discontinuation of the medication.  Personal experience of medication that affects glutamate levels in the brain is that they are neither very harmful or helpful in the treatment of moderate to severe Alzheimer’s Disease.

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The latter stages of Alzheimer’s Disease are often fraught with weight loss and agitation.  Victims of a senile dementia become too inattentive to sit through a whole meal, requiring frequent prompts and even hand feeding to keep up their body weight.  By the middle stages of Alzheimer’s, the loss of other cognitive functions largely negates a mild increase in verbal memory.  These mid-stage patients would still have trouble with planning, praxis, attention, judgment, flexibility, etceteras.  Even a significant increase in verbal memory would not return these victims to an independent lifestyle.   Memory enhancing drugs that commonly produce symptoms of weight loss and agitation should be used with obvious caution.

This clinician’s advice is to proceed with, you guessed it, caution.  Consider having a neuropsychologist perform pre and post testing to measure any significant increase in verbal memory as a consequence of these medications.  If there is not a significant increase in verbal memory after a six week trial, consider requesting the attending physician to reduce and eventually discontinue the medication.  If an acetylcholine boosting medication is utilized, and the patient develops weight loss and agitation, work with the physician to determine if the symptoms are secondary to the memory medication.  Senile dementia of the Alzheimer’s type is a horrid disease that can cripple an entire family.  Pills without a clear benefit should be considered as a risk to the patient over time; possibly creating undesired symptoms and interacting with other medications in an unpredictable fashion.  I strongly suggest to formulate conclusions based upon observation-not advertising.

Caretaker versus Doctor

It is not unusual for me to deliver a particular admonishment to family and patients.  Sometimes people need a simple reminder; others need a figurative beating about the head and shoulders.  This warning is critical to the care of the people we love.  The essence of the advice is this-function as a caretaker rather than as a doctor when treating a loved one.

The definition of a human being invariably dwells on our fragile and temporary existence.  The most primitive of tribal cultures always includes a medicine man to counter this fragility.  Whether the setting is composed of desert nomads or slick urbanites, people consult specialists that smooth and extend their existence.  Once the specialist is consulted, patients arrive at their own decisions regarding treatment.  The specialist consulted may be termed an internist or shaman, yet both are healers that direct our behavior in pursuit of health.  The mission of all health specialists is to provide specific directions for others to follow.  Whether the treatment is eagle feathers or a new drug, the aim is to cure sickness and extend human life.  Neither the shaman or internist provide day-to-day physical or emotional care.

Most family members of ailing patients want to be as helpful as possible, and this is where the trouble begins.  Caregivers may cajole or force a loved one to comply with the directions of the health specialist, and find themselves ostracized by the one they are seeking to help.  There is no guarantee that the behaviors proscribed by the health specialist may cure or even be helpful.  Most long-term follow-up studies of actual patient compliance hover around five percent after one year.  Stated another way, ninety-five percent of people do not follow doctor’s orders.  Most people take more or less drugs than proscribed, and rarely comply with non-drug behaviors suggested by the physician.  The caretaker who is frustrated with their loved one’s lack of compliance are very likely to be poorly compliant themselves.  It’s good advice for the other guy.
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All doctors can be replaced, though all caretakers are not replaceable.  Parents often comment that “I’m just a mother or father” when confronting disease in their children.  This often gives voice to the parent’s sense of helplessness and feelings of inferiority to the specialist.  The response I frequently employ is, “There are many doctors, but you are the only mother there will ever be.”  The emotional support of a mother, father, husband and wife are indispensable and irreplaceable.  Strangers may provide excellent physical care, but their actions do not have the emotional importance of close relations.  Occasionally I will turn the phrase around, stating to the parent, “I’m just the doctor, you’re the parent.”  It is an effort to reinforce the importance of the caregiver’s emotional support.

Even if you are a health care provider, do not fulfill that role with your loved ones.  There is no shortage of opinions regarding our health, but there is always a shortage of love and support when the chips are down.  Nagging a loved one into compliance with the doctor is more likely to result in bitter feelings than better health.  Such nagging may be taken as a need to control, rather than the need to see the patient regain their health.  As a parent, best friend or spouse, remember that the relations built over a lifetime cannot be replaced by a stranger-no matter how educated and skilled.  The non-specific factor in all forms of recovery is love and support.  Leave the specifics to the specialists.