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Managing Medications for People with Dementia

Successfully managing medications, and avoiding problems, is a challenge for most older adults. It is a particular challenge for people who have Alzheimer disease or other dementias. Over one-half of seniors take at least three prescription medications daily. With the high prevalence of hypertension, heart disease, arthritis and diabetes, it is not uncommon for people to be taking six or eight daily medicines. Many of these may need to be taken more than one time a day.

The multiple medications and frequent dosage regimen complexity greatly increases the likelihood that doses will be missed (or extras taken) as well as the likelihood for side effects, adverse reactions and drug-drug or drug-disease interactions. The presence of a cognitive disorder further increases the risk for medication-related problems. This is true for several reasons. People with impaired memory and cognition may forget either to take a medication or forget that it was taken and then take a second dose. If a side effect occurs, they may not recognize it or may not remember to report it to their physician or pharmacist. They also may not know the reason for taking a medication and consequently may not take it because they don’t know why it was prescribed.

Keep a list of all medications (including non-prescription, vitamins and supplements), and bring the list, or the medications, to all appointments with healthcare providers.
There are several ways to reduce the risk for medication-related problems. Some apply to all people, while others are more important for those with a dementia. Things every older adult should know include:

Medication name and strength, including both the brand and generic names. This helps to avoid confusion if a generic medication is substituted for a brand-name medicine.

Problem or disease being treated, so that the person knows why the medicine was prescribed.

How to take the medication. This includes not only how many times a day, and when to take it, but also whether it should be taken with meals or on an empty stomach, as well as other specific instructions.

How to know the medicine is working. This may be reasonably simple for medications for diabetes or high blood pressure, when blood sugar or blood pressure may be monitored at home. For others it may not be as clear. It also is important to know how soon to expect results; some medicines may take a few days or even a few weeks to show results.

Typical or expected side effects. Some side effects can be frightening, as anyone can tell after reading the complete list for almost any medication. What is most important is to know those side effects are common, and whether they will go away over time (such as upset stomach or sleepiness) or whether they will persist as long as the person is taking the medication (such as constipation).

What to do if a problem occurs.

Problems can occur with any medication. It is important to know if the problem, such as a minor side effect, will go away, or whether it is serious and requires medical attention.

Possibility of drug interactions. Many medications have possible drug interactions. However, a large number are not sufficiently severe to cause problems. For many, they can be managed by adjusting the dose of the medications. Interactions are most likely to cause problems when a new drug is started, a dose is changed, or a drug is stopped. The best way to check is to talk with your pharmacist, physician, or other healthcare provider, and let them know all of the medications being taken (including non-prescription medicines, vitamins and supplements).

Advice that is very important for people with cognitive impairment and dementia includes:

Use as few drugs as possible. While this is good advice for everyone, it is especially important for people with dementia. The more medications that are used, the more likely it is that a problem can occur with at least one. People with dementia are less able to recognize and report problems.

Understand each drug used. Again, this is good advice for all. For people with dementia, caregivers need this information so that they can understand the reason for a medication and can report information to healthcare providers on behalf of the patient.

Avoid drugs new to the market. While not always practical or possible, it is important to recognize that new medications have not been taken by a large number of people. As a result, all of the potential side effects and other problems may not be well recognized. In addition, during testing before medications are approved by the Food and Drug Administration, few if any people with dementia were included in the clinical trials. (Medications for dementia are a notable exception, as they must be tested in people with dementia in order to prove that they are effective. Like other drugs, however, side effects are not fully recognized until after they are available.)

Change only one drug at a time. Because people with impaired cognition may not recognize side effect or adverse effects, introducing new medications requires close monitoring. When multiple medications are started together, it can be difficult to determine if a new side effect is due to one drug or another, and the person may not be able to give an accurate report. The sources of new problems are easier to identify when only one change has been made.

Avoid adding drugs during transition times (e.g., hospital discharge). Changes in location and environment, as well as changes in health status, are stressful for people with dementia. Problems such as disorientation and agitation frequently occur during these transitions. Because people with dementia may respond unpredictably to new medications, the combination of transition and new medications may complicate the picture if the person becomes agitated, disoriented, or has other behavior changes.

Avoiding medication-related problems is a challenge. In addition to the strategies listed above, others are important, as well. Use a pill box or similar aide to help ensure adherence to a medication regimen. As noted above, keep a list of all medications (including non-prescription, vitamins and supplements), and bring the list, or the medications, to all appointments with healthcare providers. Use a single pharmacy for all medications. Ask questions…and get answers that you can understand.

Bradley R. Williams, PharmD, CGP
Director of Outreach, Recruitment and Education Core, USC Alzheimer Disease Research Center
Professor, Clinical Pharmacy & Clinical Gerontology
USC School of Pharmacy