Pharmacological Approaches

Pharmacological approaches are a mainstay of treatment for people with dementia. Yet, limited research on pharmacological approaches has taken place outside the clinical trial setting. In this section you will find papers exploring general prescribing patterns in different settings, potentially inappropriate prescribing and the use of pharmacology in specific situations such as in the management of pain for people with dementia.

Psychotropic drug prescriptions in Western European nursing homes.

Janus, S.I., van Manen, J.G., IJzerman, M.J. and Zuidema, S.U.
International Psychogeriatrics
For many years there have been warnings and guidelines in Europe related to the use of psychotropic drugs in dementia. This study by Janus et al. (2016) examined prescription of psychotropic drugs in nursing homes in Western Europe, including homes in Ireland.
High levels of anti-psychotic and anti-depressant prescription were found across Europe with Ireland being among 3 countries with the highest level of anti-psychotic drug use. The study differentiated between the general nursing home population and dementia patients only with Norway having low anti-psychotic use among both populations. The authors suggest that some differences may be explained by the way care is organised in different countries or by differing institutional prescribing cultures. They acknowledge the limitations of the review, in so far as the studies reviewed had differing inclusion and exclusion criteria, there were potential unknown differences in patient characteristics or stage of dementia and in some studies a lack of differentiation between anti-psychotic and anti-depressant use. However the study points to common usage of anti-psychotics despite clinical warnings and guidance and suggests more practice based guidelines may be required.

Exploring the prevalence of and factors associated with pain: a cross‐sectional study of community‐dwelling people with dementia.

Barry, H.E., Parsons, C., Passmore, A.P. and Hughes, C.M.
Health & social care in the community,
This study set out to determine the prevalence of pain among people with dementia, the extent of medication use and patient/caregiver variables associated with the presence of pain.
The main body of research examining pain among people with dementia has previously been limited to the care home population. Participants in this study were recruited from 2 memory clinics in Northern Ireland. All patients in the study were taking medication prescribed by their G.P. with nearly two fifths taking anti-depressants. Over three quarters were taking 5 or more medications, defined as polypharmacy. Greater numbers of patients reported experiencing pain on an average day (57.5%) than at the time of interview (36%) but caregivers reported pain more frequently than patients, with gender being a significant factor. Patients taking analgesic medication were significantly more likely to be reported as experiencing pain by their care giver.

Polypharmacy and inappropriate medication use in patients with dementia: An under researched problem.

Therapeutic advances in drug safety
In this narrative review Parsons (2017) examined the literature related to potentially inappropriate prescribing (PIP) among people with dementia.
The paper documents the increasing number of tools developed for the assessment of appropriate medication among older people but the current dearth of tools for the same assessment among people with dementia. The very limited work related to dementia has primarily focused on those with advanced dementia, but recently a number of studies have considered medication use among people with mild to moderate dementia and across the disease spectrum. The paper details research related to specific drug classes: anti cholinergic medications, psychotropics, antibiotics and analgesics. The literature evidences high levels of PIP across disease severity, setting and country of care. The authors conclude that people with dementia are at risk of sub optimal prescribing and potentially inappropriate prescribing.

Psychotropic Medications and the Transition into Care: A National Data Linkage Study

Journal of the American Geriatrics Society

Maguire et al. (2013) followed a cohort of older people living in the community in NI as they moved into long-stay residential care.

It used the Enhanced Prescribing Database (EPD), a unique centralised database of all prescriptions dispensed in community pharmacies in NI, to determine the proportion of patients who moved into care between January 2009 and January 2010 who commenced psychotropic medication before entry and the change in psychotropic medication use during the transition into care and after entry. For a small proportion of residents in care homes, use of psychotropic medication was a continuation of a medication regime that had been started before entry. However, one in six individuals with no history of psychotropic drug use in the 6 months before entry had been exposed to at least one antipsychotic prescription within six months of entering care. As well as highlighting the need to focus on reducing psychotropic drugs in care homes, the authors argue that the international concern about the level of psychotropic medication use should be extended to include all older people and not just those with dementia, focus on all types of psychotropic medication and include those living in the community. 

A population-based study of dosing and persistence with anti-dementia medications

European Journal of Clinical Pharmacology

Brewer et al. (2013) assessed the adequacy of dosing and persistence with AD medications (anti-cholinesterase inhibitors and Memantine) and predictors (age, gender and drug sub-type) of these variables in the ‘real world’, i.e. outside the clinical trial setting.

 Using prescription refill information from the HSE Primary Care Reimbursement Services pharmacy claims database in ROI, the study found a substantial increase in the rate of prescribing of AD drugs between 2007 and 2010. Donepezil and Memantine were the most frequently prescribed AD drugs with a significant proportion of patients initiated on these drugs prescribed the maximum dose. However, only two-thirds of patients maintained this dose for at least two consecutive months, suggesting that there may be room for improvement in optimising the prescribing of AD medications, and a need to investigate the reasons why these medications are stopped.