The Value of Pharmacists in Treating Alzheimer Disease

The month of November is National Alzheimer’s Disease (AD) Awareness Month, a time dedicated to the life-altering disease that affects over 6 million Americans. AD is the most common cause of dementia.¹

AD is a neurodegenerative disorder that is mostly seen in older adults, with the risk doubling every 5 years beyond 65 years of age.² Patients with AD initially experience cognitive decline, with physical and neuropsychiatric disturbances being characteristic of later-stage disease.³

The mainstay of pharmacotherapy for AD has been limited to temporarily alleviating symptoms and improving quality of life; no current drug offers a cure. Alongside the inability to cure, traditional therapy options have been unable to target the underlying pathophysiology of AD itself.

However, in June 2021, aducanumab (Aduhelm) became the first FDA-approved drug for AD that is marketed as disease-altering. Aducanumab is reported to halt AD decline by removing the characteristic amyloid-beta deposits found in the brain of AD patients.^4,5

Although aducanumab is an exciting advancement, extensive controversy has surrounded its approval and clinical efficacy. New drug approvals, such as with aducanumab, create the perfect opportunity for the expanding-role of a pharmacist to be demonstrated.

A pharmacist can offer up to date knowledge on the clinical evidence behind new drugs, serving as a source of guidance for patients amongst the controversy with aducanumab and other new medications.

The value that a pharmacist can add to the care of a patient with AD is vital to recognize. As the average life expectancy in the United States continues to increase, the prevalence of AD is also projected to rise.^1,2

Moreover, older-aged adults commonly comprise the largest consumers of prescription drugs, likely due to multiple comorbid conditions.⁶ Together, all of these areas represent the clear role that a pharmacist can play in the management of patients with AD—a multifaceted process that requires a high level of patient-specificity.

Due to the high frequency of interactions that a pharmacist has with their patients, they might be one of the first providers to recognize signs of cognitive decline, especially for cases in which the pharmacist-patient relationship is longstanding. In such instances, a pharmacist can first review medication lists and identify drugs that may be inducing dementia-like symptoms.

While a host of medications exist that can induce memory loss and confusion, examples of less commonly associated agents include statins, beta-blockers, diuretics, digoxin, and non-steroidal anti-inflammatory drugs.^7,8 Often, discontinuation of the drug or switching to an appropriate alternative will reverse these concerning symptoms, relieving both the patient and their loved ones.

The AD population can face many challenges that impede their medication compliance. To assist with this, pharmacists can make medication packaging more user-friendly by using easy-open caps, blister packs, and pill organizers. Additionally, as AD progresses, dysphagia is common, which leads to issues with not only swallowing, but also medication adherence.

A pharmacist can tailor a patient’s drug regimen to one that would best fit their needs. Such steps include identifying medications that come in alternative forms or by consulting assistance from a compounding pharmacy.

For example, donepezil comes as an oral disintegrating tablet, and rivastigmine is available as a transdermal patch and an oral solution. Other medications taken by the patient may also be inducing esophageal irritation.

Agents to take note of include aspirin, alendronate, and tetracycline antibiotics.^9,10 Proper education should be provided to patients with AD and their caregivers, with counseling on medication-specific instructions that may help avoid swallowing dysfunction, including certain oral medications that require administration with a full glass of water, or agents that advise against lying down after being taken.

Collectively, all these services offered by a pharmacist have the ability to improve medication adherence and thus, improve the level of safety in the management of AD.

In the mid to later stages of AD, patients may lose the ability to manage their medications and partake in personal care activities, becoming reliant on their caregivers. The health of the caregiver should not be overlooked in such instances, as these individuals can be at an increased risk for adverse health events, including hypertension, depression, and anxiety.^11,12

A pharmacist serves as an easily accessible health care provider for a caregiver, both in terms of how to optimally manage their loved ones and how to personally cope with their newfound responsibilities. A pharmacist can be a key source in providing information on support services and referrals to appropriate providers, alleviating the hardship on the caregiver.

While November is National Alzheimer’s Disease Awareness month, attention to AD should not be limited to the course of a single month. AD is an irreversible condition that affects millions. It not only takes a toll on patient’s themselves, but also their caregivers and our health care system.

As the population is aging quickly, the demand for providers knowledgeable in AD and other dementias is vital. The role of a pharmacist is essential in providing patient-centered, easily accessible care to patients with AD and their families.

References

1. (2021), 2021 Alzheimer's disease facts and figures. Alzheimer's Dement., 17: 327-406. https://doi.org/10.1002/alz.12328
2. Trevisan K, Cristina-Pereira R, Silva-Amaral D, Aversi-Ferreira TA. Theories of Aging and the Prevalence of Alzheimer’s Disease. BioMed Research International. 2019;2019:9171424. doi: 10.1155/2019/9171424.
3. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Alzheimer's disease: Overview. 2013 Jul 3 [Updated 2017 Jun 29]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279360/
4. Aducanumab [Internet]. Memory and Aging Center. University of California San Francisco Weill Institute for Neurosciences; [cited 2021 Oct 7]. Available from: https://memory.ucsf.edu/aducanumab
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7. Ellison JM, Swank Center for Memory Care and Geriatric Consultation. "Is It Something I'm Taking?" Medications That Can Mimic Dementia [Internet]. BrightFocus Foundation. 2020 [cited 2021 Oct 7]. Available from: https://www.brightfocus.org/alzheimers/article/is-it-something-im-taking-medications-that-can-mimic-dementia
8. Feinberg MV, Michocki RJ. Clinical and regulatory concerns in Alzheimer's disease management: role of the pharmacist. Am J Health Syst Pharm. 1998 Nov 1;55 Suppl 2:S26-31. doi: 10.1093/ajhp/55.suppl_2.S26. PMID: 9809109.
9. Milliken, L. The Role of Polypharmacy in Swallowing — Its Implications for Clinicians. Today’s Geriatric Medicine. 2018;11(4):14. https://www.todaysgeriatricmedicine.com/archive/JA18p14.shtml
10. Aslam M, Vaezi MF. Dysphagia in the elderly. Gastroenterol Hepatol (N Y). 2013 Dec;9(12):784-95. PMID: 24772045; PMCID: PMC3999993.
11. Cheng ST. Dementia Caregiver Burden: a Research Update and Critical Analysis. Curr Psychiatry Rep. 2017 Aug 10;19(9):64. doi: 10.1007/s11920-017-0818-2. PMID: 28795386; PMCID: PMC5550537.
12. Novais T, Chomel M, Dauphinot V, Mouchoux C. Caregiver in Alzheimer's disease, pharmacist, and pharmacy technician attitudes and knowledge about caregiver burden screening in community pharmacies. Ann Pharm Fr. 2020 May;78(3):199-205. doi: 10.1016/j.pharma.2019.12.002. Epub 2019 Dec 16. PMID: 32037030