3 Medical Updates for Dementia

The American Geriatrics Society updated recommendations for doctors treating people with dementia. These include adjusting prescriptions of Alzheimer’s drugs if the desired effect is not achieved within 12 weeks. Learn more.

New York, N.Y. —The American Geriatrics Society (AGS) released updates to several of its recommendations for the ABIM Foundation’s Choosing Wisely® campaign. Their mission is to raise professional and public awareness about treatments and tests that may lack efficacy or cause potential harm. The AGS’s updates reflect an expert review of new research on several important conditions impacting older adults. These include agitation, delirium, dementia, insomnia, unintended weight loss, and certain other health concerns. These updates help patients, doctors and carers have deeper discussion based on new insights and information on appropriate healthcare choices.

“Providing high-quality care to older adults means recognizing and responding to the specific, evolving challenges and opportunities that we all face as we age,” said Wayne C. McCormick, MD, MPH, AGSF, President of the AGS. “Since 2012, the AGS and the ABIM Foundation have worked together through Choosing Wisely to synthesize pressing updates from the geriatrics field in a format that is easy to understand—and apply—in everyday practice.”

In this most recent update, the AGS expanded earlier guidance to reflect emerging expert opinion and the latest research insights guiding sound decision making to support elder care:

Cholinesterase Inhibitors (CIs) for Dementia

Brand Name	Generic Name
Aricept®	donepezil
Exelon®	rivastigmine
Remynil or Razadyne®	galantamine

1. The AGS expanded its rationale for recommending against the use of cholinesterase inhibitors (CIs), a class of pharmaceuticals sometimes used to manage dementia, without periodic evaluations to determine mental health benefits and gastrointestinal problems associated with treatment. Although some clinical trials suggest that CIs may improve cognitive testing results, it is now unclear whether these changes are “clinically meaningful” based on available data. Since no studies have investigated the benefits of CIs beyond a year or the risks/benefits of long-term therapy, the AGS expert panel advised that clinicians, patients, and their caregivers discuss treatment goals and the likelihood of adverse effects before beginning treatment, and that they adjust therapy if the desired effects are not achieved within 12 weeks.
2. The AGS continues to recommend  avoiding antipsychotics as the first-choice treatment for behavioral and psychological symptoms associated with dementia, and its rationale for this guidance has been expanded with new data on nonpharmacologic management of the condition. Specifically, the expert AGS panel determined that antipsychotics provide “limited and inconsistent benefits,” while also posing risks for over-sedation, a worsening of memory problems, and an increased likelihood of falls, strokes, and even mortality.
3. Although guidance for choosing alternatives to benzodiazepines and other “sedative-hypnotics” as initial treatment options for insomnia, agitation, or delirium in older adults remains unchanged, this recommendation is now supported by even more—and more recent—scholarship. Large-scale studies reviewed by AGS experts continue to point to significantly elevated risks for motor vehicle accidents, falls/fractures resulting in hospitalization, and even death for older adults taking “psychoactive” medicines like benzodiazepines. These medications may be better utilized for alcohol withdrawal or severe generalized anxiety unresponsive to other therapies.

These updates add to several other long-standing recommendations available on GeriatricsCareOnline.org and still unchanged following expert review. Additional guidance includes:

• Pursuing oral assisted feeding for patients with advanced dementia instead of a “percutaneous” feeding tube threaded through the skin into the stomach;
• Not using antibiotics to treat patients who have bacteria in their urine (a condition known as bacteriuria) unless certain urinary tract symptoms are present; and
• Conducting a treatment regimen review before prescribing medication.

“As the older adult population in the U.S. continues to grow, it’s so important that geriatrics care principles reflect the latest science, evidence, and advice supporting quality health and care,” said Paul Mulhausen, MD, MHS, FACP, AGSF, who chaired the AGS Choosing Wisely Workgroup responsible for the list. “We are grateful to the ABIM Foundation for this opportunity to share timely recommendations that will help patients avoid unnecessary tests and procedures and support overall well-being.”