Out of 173 countries, Malta has the 23rd highest rate of death from dementia. Maltese with dementia are dying earlier. We need to look at both emerging new research and historical research to understand why this might be happening. Unfortunately, we do not have data from Malta, so we have to look elsewhere for some indication to what is happening.
In 2015 in a French study, Clément Pimouguet and his colleagues reported that people with dementia who had consulted a specialist at the start of their disease died earlier than those who only saw their general practitioner.
They also found that there was no difference between participants who visited their GP and those who did nothing. We know that there are no drugs to cure dementia. We also know that some drugs are dangerous. It seems we do not have any medication for dementia that is both effective and safe. In fact, all evidence points to dementia medication as being ineffective and, in most cases, dangerous – a conclusion that was arrived at in a 2014 study by two Dartmouth University professors, Steven Woloshin and Lisa Schwartz, reporting for Consumer Reports.
In addition to the costs of dementia medication – ranging on average from €177 to €400 a month – there was not one drug they could recommend. Not one. From this information, we can see how a specialist might prescribe drugs that become progressively dangerous as the disease progresses. And this is exactly what we find.
A lack of follow-up by the specialist was one of the reasons given for the higher rate of death. Could it be that after the initial consultation with the specialist, who prescribes some strong medication, there is no follow-up and the medication becomes inappropriate with time?
In 2017, Paula Rochon and Jeremy Matlow and colleagues in Toronto, Ontario, reported that half of 2,998 nursing home residents with dementia were still getting questionable medication in their last year of life. These medications might have had some benefit at the early stages of the disease but they were definitely having a negative effect on the well-being of these confused patients. Regular review of medications taken by patients with dementia will help to ensure that they are appropriate and not dangerous. It is likely, therefore, that too much, and inappropriate, medication is a culprit.
A specialist might prescribe drugs tht become progressively dangerous as the disease progresses
In France only the specialist can prescribe drugs for dementia and when the diagnosis is vascular dementia these drugs are not to be prescribed. So, if the argument is that it is these anti-dementia drugs that are killing off patients, then we should find that vascular dementia patients benefit from seeing a specialist.
Amelie Bruandet, with the University of Lille, France and her colleagues, found that with vascular dementia, the shorter the delay between first symptoms and first visit, the longer patients survived. It seems that these patients do better because specialists are not prescribing dangerous medications that are killing dementia patients earlier.
The logical assessment would be that since physicians have no medication to provide for patients with dementia, then, following the Hippocratic Oath and ‘first, do no harm’, no medication should be prescribed.
But a 2015 study of elderly patients showed that drugs being prescribed show evidence of increasing dementia. Sometimes this medication is given for non-life-threatening disease, such as an overactive bladder.
Christian Meyer from the University Medical Centre Hamburg–Eppendorf in Germany and his colleagues reported that more than one in three older Americans with an overactive bladder are prescribed with oxybutynin. Despite the established link between this drug and dementia, we seem to be over-prescribing medication for older patients. And we have seen this in our medical history.
In 2016, psychiatrists Patrick Lemoine and Boris Cyrulnik, with the University of Toulon, wrote a chapter in a French book entitled The Crazy History of Crazy Ideas in Psychiatry. From hundreds of examples, one of the weirdest is the practice of infecting patients with malaria to cure dementia. And it worked.
However, this type of dementia was brought about by syphilis, a sexually transmitted disease. In its late stages of the disease the bacteria eat away at your brain, causing dementia-like symptoms, called neurosyphilis. Before Penicillin was invented neurosyphillis was very common in hospitals. So much so that most cases in psychiatric wards at the time were due to late-stage syphilis. Alois Alzheimer’s specialty was in syphilis before defining Alzheimer’s disease.
After being infected with malaria, patients develop an extremely high fever that would kill the syphilis bacteria. Unfortunately, the malaria itself would eventually kill off the patient.
There is a need to address the cure for dementia now, as much as we did a hundred years ago. Careful periodic assessment of the prescriptions would ensure that we are not adding to the patient’s problems. Early death might be paved with good intentions, but it remains bad medicine.
Mario Garrett was born in Malta and is currently a professor of gerontology at San Diego State University in California, US.
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