The Alzheimer’s Association suggests that major neurocognitive disorder (formerly known as dementia) caused by Alzheimer’s disease is a “silent epidemic” in African Americans, noting that the prevalence among African Americans ranges from 14% to 100% higher than it is among whites.
In April 2013, the National Institute on Aging highlighted a JAMA research article that noted African Americans 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 “African Americans 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 African American mental health issues. Recently, a randomized clinical trial of citalopram in agitated patients with Alzheimer’s disease found this selective serotonin reuptake inhibitor to be efficacious in reducing agitation. However, African Americans 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 watched these issues play out in real life, often delivering a harsh reality. For the past 2 years, every day, I have seen one to three elderly African American patients 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, is occurring 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 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 decided to treat this anxiety with escitalopram 10 mg, so I gave her a dose stat (and followed up with a dose every morning).
When I checked on her the next day, 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 the medical staff are amazed. 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 (agitation, blurred vision, diarrhea, insomnia, drowsiness, dry mouth, fever, frequent urination, headache, indigestion, nausea, change in appetite, sexual dysfunction, and weight change), 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 – for example, those who have treated hundreds of African Americans 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 major African American problems, we must rely on clinical experience to address these issues. I’ve been getting such positive results that I felt compelled to pass them along.
Dr. Bell is a staff psychiatrist at Jackson Park Hospital and a member of the editorial advisory board of Clinical Psychiatry News.
