Apathy and impaired attention are two of the most common problems that individuals with Alzheimer’s disease and dementia experience. In the second article of this three-part series, we discuss medications that can help with these problems. Speak to your doctor for more information.
Therapy for apathy
Apathy is the most common neuropsychiatric symptom in Alzheimer’s disease and other dementias, yet it is often ignored because it tends not to cause problems for caregivers. There are three main classes of medications that can be tried for apathy: levodopa formulations, dopamine agonists, and stimulants. Because stimulants will be discussed in detail in the therapy for attention section, below, we will simply note here that this class of medications can be extremely effective for treating apathy, particularly when accompanied by poor attention.
Carbidopa/levodopa (Sinemet) or one its newer formulations that are given in low dose, two to three times per day may show benefit in reducing apathy. You may have heard of this medication in association with Parkinson’s disease—that is what it is approved for. At higher d,oses its side effects are myriad, and may include (but are not limited to) confusion, hallucinations, dizziness, psychosis, nausea, and engaging in risky behavior. We generally try a low dose and move to other therapies if it is not successful.
Dopamine agonists include amantadine, memantine (Namenda), and pramipexole (Mirapex). These medications stimulate the dopamine receptor and may reduce apathy. In general, we start with memantine for patients who show apathy in the dementia stage of their disease. Memantine is FDA approved for patients with Alzheimer’s dementia in the moderate-to-severe stages. We try amantadine and/or pramipexole first for those who are apathetic but do not have dementia, such as those with mild cognitive impairment. These medications are typically used in Parkinson’s disease. We use low doses, as side effects are common at higher doses and include (but are not limited to) confusion, hallucinations, dizziness, sleepiness (sometimes coming on suddenly impairing driving), and engaging in risky behavior.
Lastly, we will note that there are some activating antidepressants that can improve apathy; we will discuss these in the next part of the series.
Therapy for impaired attention
Attention problems are common in Alzheimer’s disease and other kinds of dementia, as well as many other neurological problems such as head injuries and multiple sclerosis. Stimulants are the mainstay of therapy for attentional problems. The most common stimulants are methylphenidate (Ritalin, Concerta, Metadate, Methylin, Aptensio, Cotempla, Quillichew, Quillivant), Amphetamine (Adzenys, Dyanavel, Evekeo), and Dextroamphetamine (Dexedrine, ProCentra, Zenzedi). Stimulants boost up the monaminergic systems, often stimulating both norepinephrine and dopamine receptors. We have used a variety of short- and long-acting stimulants at various doses in various settings, and one generally needs to tailor the use of stimulants to the patient and the setting more than with most other medications.
If the individual is a student or working, it is reasonable to use during school or work hours, and give a “drug holiday” during evenings and weekends (with exceptions for difficult homework assignments). On the other hand, an individual with more marked attentional problems from CTE may need stimulants all-day, every day. Trial and error is often necessary. Common side effects include feeling nervous, jittery, anxious, anorexia, headache, palpitations, and dizziness, and serious reactions can include drug dependence and abuse, psychosis, mania, aggression, hypertension, myocardial infarction, stroke, seizures, arrhythmias, and sudden death. Consultation with a cardiologist is appropriate in the middle-aged or older individual.
Mindfulness can improve attention
One non-pharmacological therapy that can be used to improve attention is mindfulness. It turns out that one can actually practice paying active attention in the same way that one can practice playing the violin or other skills. Practicing mindfulness is not for everyone, but for some individuals it is an empowering, drug-free way for them to improve their attention. For our younger patients we generally recommend one of the many phone applications available for this purpose, and for our middle-aged and older patients, guided mindfulness meditation through audiobooks and in-person classes tend to work best.
© Andrew E. Budson, MD, 2019, all rights reserved.
