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Many Alzheimer’s Patients Prescribed Drugs with Opposing Effects

Many patients taking common Alzheimer’s disease medications are also given medications that are counterproductive, a new study shows.

This particular study looks at cholinesterase inhibitors, one of the most common medications for Alzheimer’s patients, and medications with anticholinergic properties, which oppose their effects.

Drugs with anticholinergic properties are often used to treat allergies, gastrointestinal disorders, urinary incontinence, Parkinson’s disease and depression,. These medications can also have negative effects on function and cognition in the elderly.

“There’s concern that if someone is taking both types of drugs — cholinesterase inhibitors and anticholinergic medications — they will antagonize each other, and neither will work,” said Dr. Denise Boudreau, study leader and an associate scientific investigator at Group Health Research Institute.

In recent clinical trials, the cholinesterase inhibitors have shown modest effects against the functional and cognitive decline of people with Alzheimer’s disease. These medications, such as donepezil work by inhibiting the breakdown of acetylcholine, which is used to send signals in the nervous system. By contrast, anticholinergics — such as Benadryl and Ditopan — block the action of acetylcholine.

Since the two types of drugs have opposite effects, it’s advisable not to give both kinds of drugs to an individual patient. But until this most recent study, very few researchers had explored how often patients are prescribed both types of medications and which harms this might cause.

Researchers conducted a retrospective cohort study of 5,625 patients, 50 or older, who had been given a new prescription for cholinesterase inhibitors between 2000 and 2007.

The research team found patients who also had a prescription for anticholinergics from the year before their cholinesterase prescription until the analysis ended on Dec. 31, 2008, or the patient left the health care system or died.

The study was the first to use state death records and insurance claims for nursing home care to examine effects of taking both drug types.

The researchers discovered:

• Of those who used cholinesterase inhibitors, 37 percent were also taking at least one anticholinergic drug, and more than 11 percent had two or more prescriptions.
• For those using both of these types of medications, dual use generally lasted three to four months, but a fourth of these patients used both classes of drugs for more than a year.
• Anticholinergics were already being used in 23 percent of people receiving a new cholinesterase inhibitor prescription, and 77 percent continued, even after starting the cholinesterase inhibitor.
• Subjects using both medication types were not more likely to enter a nursing home or to die than those taking only cholinesterase inhibitors.

Researchers did not discover a link between simultaneous use of the two drugs and an increased risk of death or nursing home placement, which was reassuing, said Dr. Boudreau. But use of both of these drugs at the same time not optimal clinic practice.

Preventing such concurrent use of opposing drugs could also be an opportunity to reduce waste in health care spending, since a month of donepezil treatment costs about $180.

Researchers say one of the reasons health care providers might prescribe conflicting medications is that patients suffering from dementia often have multiple medical conditions. Also, anticholinergics are often given to counteract the side effects of cholinesterase inhibitors, which are one of the few available treatments for people with Alzheimer’s.

Researchers say this study should raise awareness about the potential inappropriateness of prescribing both types of drugs — and stimulate new discussions about the best way to make therapeutic decisions for Alzheimer’s patients.

According to Dr. Boudreau, health professionals, families and patients should carefully weigh the benefits and negative effects of these drugs to see if they justify long-term use for individual patients.

For more on medical safety issues, see the library of articles by medical malpractice attorney.

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