New research presented at the Alzheimer's Association International Conference (AAIC) 2018 in Chicago focuses on the recent successes and ongoing challenges of drug and non-drug treatments for the non-cognitive symptoms experienced by people living with Alzheimer's dementia

At this time, the U.S. Food and Drug Administration (FDA) has not approved any drug treatments for these symptoms in people with Alzheimer's dementia. All drug treatments currently used are approved for other indications and prescribed for people with Alzheimer's "off-label."

"These underrecognized and undertreated symptoms in people with Alzheimer's and other dementias are often very difficult to live with and challenging to treat," said Maria Carrillo, Ph.D., Alzheimer's Association Chief Science Officer. "One of the 'untold stories' of Alzheimer's is the regular occurrence and overwhelming impact of these symptoms on the lives of people with Alzheimer's, their family members and caregivers."

"It is very important that as we continue to make advances in treating and preventing the memory and thinking symptoms of Alzheimer's and other dementias, we also focus on therapeutic strategies for the behavioral and other non-cognitive symptoms," Carrillo added.

Psychotropic medications may need to be considered when the dementia-related behavior has not responded to non-pharmacologic approaches, especially if it is causing physical or emotional harm to the person with dementia or caregiver(s), however, they must be used with extreme care, and must be regularly evaluated to determine the appropriate time of cessation.

Synthetic Cannabinoid Treatment Shows Improvement in Agitation in People with Alzheimer's

Results of a randomized, double-blind clinical trial suggest that nabilone—a synthetic cannabinoid—may be effective in treating agitation in people with Alzheimer's disease. "Agitation, including verbal or physical outbursts, general emotional distress, restlessness, pacing, is one of the most common behavioral changes associated with Alzheimer's as it progresses, and can be a significant cause of caregiver stress," said Krista L. Lanctôt, Ph.D.

Lanctôt and colleagues investigated the potential benefits of nabilone for adults with moderate to severe Alzheimer's dementia with clinically significant agitation. Over the 14-week trial duration, 39 participants received nabilone in capsule form for six weeks, followed by six weeks of placebo, with one week between each treatment period.

The researchers also observed small benefits in cognition and nutrition during the study. More people in the study experienced sedation on nabilone (45 percent) compared to placebo (16 percent).

"Currently prescribed treatments for agitation in Alzheimer's do not work in everybody, and when they do work the effect is small, and they increase the risk of harmful side effects, including increased risk of death. As a result, there is an urgent need for safer medication options," said Lanctôt.

"These findings suggest that nabilone may be an effective treatment for agitation; however, the risk of sedation must be carefully monitored. A larger clinical trial would allow us to confirm our findings regarding how effective and safe nabilone is in the treatment of agitation for Alzheimer's."

Beyond Anti-Psychotics: Exploring Efficacy and Harms of Z-Drugs for Sleep Disturbance

Many people with dementia have problems sleeping. This affects their quality of life and that of the people who care for them. Non-benzodiazepine hypnotic "Z-drugs," such as zolpidem, zopiclone, and zaleplon, are often prescribed to help treat insomnia in older adults, but it is thought that they may cause problems such as falls, fractures, and increase confusion. 

They compared data for up to two years for 2,952 people with dementia who were newly prescribed Z-drugs with data for 1,651 who were not, in order to evaluate the benefits and harms of these medicines.

They found that the use of Z-drugs is associated with a 40% increased risk of any type of fracture, with risk increasing for those on higher doses. Z-drug use was also associated with a greater risk specifically of hip fracture. The study did not identify a higher risk of other effects, such as falls, infections or stroke.

"We desperately need better alternatives to the drugs currently being prescribed for sleep problems and other non-cognitive symptoms of dementia. Wherever possible, suitable non-pharmacological alternatives should be considered, and where Z-drugs are prescribed, patients should receive care that reduces or prevents the occurrence of falls."