Managing Major Neurocognitive Disorder in Blacks

Abstract

The Alzheimer’s Association suggests that major neurocognitive disorder (formerly known as dementia) caused by Alzheimer’s disease is a “silent epidemic” in blacks, noting that the prevalence among blacks ranges from 14% to 100% higher than it is among whites. In April 2013, the National Institute on Aging highlighted a Journal of the American Medical Association research article that noted blacks were more likely to have a variant of the ABCA7 gene and that this gene variant led to almost double the risk of developing Alzheimer’s disease (JAMA 2013;309:1483-92). In addition, the Alzheimer’s Association suggests that blacks are “seriously underrepresented in current clinical trials of potential treatment of Alzheimer’s disease, particularly in trials conducted by drug companies.” This observation echoes former U.S. Surgeon General David Satcher’s 2001 Culture, Race, and Ethnicity report, which underscored a historic dearth of research on mental health issues. Recently, a randomized clinical trial of citalopram in agitated patients with Alzheimer’s disease found this selective serotonin reuptake inhibitor (SSRI) to be efficacious in reducing agitation. However, blacks were grossly underrepresented, comprising 15 of 94 patients in the experimental arm of this study (JAMA 2014;311:682-91). While working on the medical/psychiatric floor at Jackson Park Hospital on Chicago’s South Side, I have seen one to three elderly black patients every day, who had been transferred from local nursing homes with complaints of restlessness, wandering, aggression, depression, and psychosis characterized by hallucinations and delusions, which resulted in disruptive behaviors. Clinical lore suggests that such behaviors are responsible for about 50% of admissions to nursing homes and 95% of hospital admissions from such nursing homes. Despite the known risks, too often, I see patients being prescribed first- and second-generation antipsychotics. I suppose this is because of the agitation, aggression, and psychotic symptoms. But according to the Food and Drug Administration, such prescribing is associated with premature mortality in Alzheimer’s disease. I also see a lot of benzodiazepine regimens, and this, too, occurs despite the recent findings that benzodiazepines are associated with the etiology of Alzheimer’s disease. These practices just do not make any sense. Recently, I saw an elderly black woman with suspected Alzheimer’s disease. When I asked her the year, I saw fear and panic spread over her face as she realized that she did not remember. I gave her 10 mg of escitalpram for anxiety, and followed up with a dose every morning. When I checked on her the day after the first dose, after confirming that she did not remember me from the previous day (quite unusual as I wear a garish cowboy hat that my daughter gave me), I again asked what year it was. She replied with a pleasant smile: “I don’t know, and I don’t care.” She was calm and agreeable, not the frightened, panic-stricken, irritable woman I had seen the day before. Since then, I have been repeatedly impressed with this particular SSRI in managing major neurocognitive disorder caused by Alzheimer’s disease. It brings about a night and day difference in terms of agitation and irritability. And no, I do not own stock in pharmaceutical companies; escitalopram (not citalopram) is the one that the hospital formulary offers and, in my experience, seems to have minimal side effects, including hepatotoxicity and hyponatremia. The other SSRIs (citalopram, duloxetine, fluoxetine, fluvoxamine, paroxetine, or sertraline) might work just as well. I would be interested to hear from other clinicians with extensive experience with treating hundreds of blacks or other patients with Alzheimer’s disease — as it might take years for the research to be published and even longer before we see related data on underserved populations. In the absence of research focused on Alzheimer’s disease in blacks, we must rely on clinical experience to address these issues. Dr. Bell is a staff psychiatrist at Jackson Park Hospital. DISCLAIMER: The opinions expressed here do not represent the opinion of AMDA or Caring for the Ages.