Treatment Approach

I always advocate for a holistic & individualized treatment plan for each patient.  A holistic treatment plan includes trying to achieve some balance in life.  Components of this can include:  exercise, nutrition, psychotherapy, moderation or abstinence with substances, formal relaxation therapy, a good support system of friends & families, spirituality, self-help books, hobbies and meaningful activities, and judicious use of medications.  This can be very hard in elder patients, especially with dementia.  But we still try to address as many of these components as possible.  Because options can be limited for these patients, it's important to brainstorm ideas & think outside the box.  Residential care is often a major component of the treatment plan as some patients need more support & cannot always successfully live at home.  Behavior therapy is a major part of the treatment plan for patients with dementia.  This basically means family & professionals learning the best way to interact with these patients.  Some general methods include validation or their emotions & distraction (try to divert them to discussing positive topic if they are focused on something negative).  I always encourage families & caregivers to educate themselves about dementia and also consider a support group for such.  You can find a local support group through the Alzheimer's Association (www.alz.org).  They will welcome families of those with other types of dementia too, as there are many similar aspects to all types of dementia.  


Genetic Testing

I order pharmocogenomic (or genetic) testing through www.genesight.com.  It's one of the first of it's kind in psychiatry, and the only one I know of paid for by some insurances.  

It's a very easy test that involves collecting a saliva sample.  It's covered by Medicare completely (if the patient has a Medicare Advantage plan or private insurance, it's still mostly covered with a maximum one time out of pocket $330 cost...the full price of this test can be $1-6000).

This test looks at the genes responsible for liver metabolism of medications as well as at some genetic markers.  This will help me make sure the body metabolizes the medications ok, and can help narrow down medication options.  

It typically gives information about the following classes of medications:  antidepressants, anxiolytics, antipsychotics, mood stabilizers, ADHD meds, & pain meds (both opiate and non-opiate).  It also gives information about MHTFR.  This is an enzyme present in all humans that converts dietary folate (vitamin B9) into l-methylfolate.  Research shows the brain needs adequate levels of l-methylfolate for optimal brain functions.  There are prescription & over the counter versions of this supplement, and the prescription one is FDA approved for treatment of major depression. 


Psychotropic Medications & The Black Box Warning

I always try to be as conservative as possible with all psychotropic meds in my patients with dementia.    I first look at the complete medication list and see if there are any meds which we can remove rather than add (in case they are contributing to current symptoms).  The only medications FDA approved for dementia are cholinesterase inhibitors (e.g. donepezil, rivastigmine & galantamine) & memantine.  They typically help primary & cognitive symptoms of dementia.  They can sometimes (not necessarily typically) help the neuropsychiatric manifestations of dementia (e.g. insomnia, anxiety, agitation or hallucinations).  

No psychotropic meds are FDA approved specifically for the treatment of neuropsychiatric manifestations of dementia.  However, in my clinical experience, some medications certainly can help some patients with these symptoms.  There are numerous types of medicines we can used, some of which are named in the section above about pharmacogenomic testing.    

All antipsychotics carry a FDA warning to use with extreme caution in patients with dementia.  Some studies have found a 2% risk of dying sooner in patients with dementia who take these meds (usually through cardiovascular illness like heart attack, stroke, or sudden death).  There was at least one study refuting this finding.  Psychiatry & use of psychotropic medications are not exact sciences (i.e. a lot of gray area).  We should certainly heed the warning, but also look at the big picture.  Because treatment options can be limited in those with dementia, sometimes these meds are the best choice (i.e. "lesser of all evils") to treat symptoms like hallucinations or paranoia.   

I want to point out that the black boxwarning is partially a sociopolitical construct.  In other words, these warnings appear when something gets a lot of negative press.  For example, opiates got a black box warning because of severe addiction & deaths related to overdose).  There is another group of medications called benzodiazepines.  This includes lorazepam (aka Ativan) & other meds you may have heard of like diazepam (aka Valium), alprazolam (aka Xanax) & clonazepam (aka Klonopin).  This group of medicines is the #1 medication cause of falls in the elderly.  All it takes is one bad fall, and somebody dies or has a severe injury.   There is no black box warning on these meds, but I view them as just as dangerous as antipsychotics (but in a slightly different way).  They can receive anxiety quickly, but besides falls can also lead to confusion & sedation.  Nine times out of ten, if I had to pick a benzo or an antipsychotic, I would usually pick seroquel first despite the black warning. 2 large studies showed seroquel to be the least risky of this group of medications, while at least one other study has noted risperdal may be the least risk in the elderly with dementia.