Dementia is not a single disease. Dementia is a family of diseases that cause progressive memory loss, usually in older patients. The most common cause of dementia is Alzheimer’s disease. Dementia is progressive, and while some treatments exist, their efficacy is only modest. In addition to memory loss, patients frequently suffer personality and behavior changes.
Dementia is common, affecting 3.4 million Americans as of 2002, and this number is sure to increase as our population ages.
The most difficult problem in the management of dementia is managing the agitation and hallucinations that patients frequently experience. Besides being obviously disturbing to the patients, agitation and psychotic symptoms contribute significantly to caregiver stress and burnout. It’s no surprise then that antipsychotic medication — medication developed for use in patients with schizophrenia and other psychotic disorders — has a long history of use in patients with dementia. There’s only one problem; they don’t work.
Randomized studies have shown that patients with dementia and psychotic symptoms are no more calmed by antipsychotic medication than by placebo. Worse than that, in elderly patients some antipsychotic medications increase the risk of stroke.
Despite this evidence, faced with an agitated patient with dementia, many physicians (sometimes me included) out of desperation reach for an antipsychotic medication. A New York Times article last week summarized the controversy well.
There are therapies that have been proven to help with agitation in patient with dementia, but they’re not medicines. The therapies are behavioral: calmly redirecting the patient, reorienting him to where he is, distracting him with a less stimulating activity, etc. This is more effective but requires more caregiver time, a resource that will certainly become scarcer in the future. Unless better treatments are developed, caring for dementia patients will become increasingly challenging in the next decades.
(Thanks to Michelle H. for sending me the article.)
New York Times article: Doctors Say Medication Is Overused in Dementia
Neuroepidemiology article: Prevalence of Dementia in the United States
Two years ago I wrote about the looming shortage of primary care doctors and their increasing dissatisfaction with the practice of medicine. A New York Times article last week reiterates the point that a lot of doctors no longer enjoy what they do: Eyes Bloodshot, Doctors Vent Their Discontent.