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Persons with Alzheimer’s disease use prescription opioids as frequently as persons without the disease. This was indicated in the doctoral thesis of Aleksi Hamina, MSc (Pharm). In general, use of painkillers, or analgesics, was as frequent between these two groups, but the medicines used were different. Use of paracetamol was more frequent among those with the disease, whereas use of anti-inflammatory analgesics was less frequent, when compared to those without the disease. The thesis also indicated that among persons with Alzheimer’s disease, opioid initiation was associated with a decreasing trend of psychotropic drug use, but also with an increased risk of pneumonia.

These results are based on the Finnish nationwide study MEDALZ, which comprises data from national health care registers. Broad population-based studies on the use of analgesics among persons with Alzheimer’s disease are scarce and this thesis is the first to describe the impact of opioid initiation on psychotropic drug use and on the risk of pneumonia.

Approximately one third used an analgesic within six months of Alzheimer’s diagnosis

Paracetamol was the most common analgesic used by both persons with and without Alzheimer’s disease. There were also changes within the study period: analgesic use in general and opioid use in particular became more frequent from 2005 to 2011, whereas use of anti-inflammatory analgesics decreased.

Among persons with Alzheimer’s disease, long-term use of opioids was strongly associated with transdermal patches. Approximately one third of those who initiated opioid use continued to use for at least six months. “Long-term use of opioids is potentially problematic due to arising adverse effects. These findings indicate that medications should be regularly assessed both among persons with and without cognitive disorders,” says Hamina.

Initiating an opioid analgesic was linked to decreasing use of antipsychotic and benzodiazepine drugs

Persons with Alzheimer’s disease may sometimes express their pain through behavioural and psychiatric symptoms that are frequently treated with psychotropic drugs. The thesis indicated that initiating an opioid was associated with a downward trend of using antipsychotic drugs and benzodiazepines and related drugs, whereas there was an increase in the use of these drugs among those who did not initiate an opioid. Opioid initiation did not however change the use of antidepressants. It is possible that these changes were due to more efficient treatment of pain, but the results should be confirmed in later studies.

Opioid analgesics were associated with an increased risk of pneumonia

Opioid analgesic use was associated with an approximately 30% increase in the risk of pneumonia among persons with Alzheimer’s disease. Opioids weaken the cough reflex and increase sedation, which may explain an increased susceptibility to a lung infection. “Pneumonia is a severe infection and it is relatively common among persons with Alzheimer’s disease, but there is little research assessing drug use as a risk factor,” says Hamina.

Pain and pain medication should be assessed regularly

According to previous research, pain is a common symptom among older persons with and without Alzheimer’s disease. Due to frequent problems in communication related to Alzheimer’s disease, pain may manifest as uncommon symptoms and therefore remain unrecognized and untreated. The results of this thesis highlight the importance of regular pain assessment in this population. Similarly, the pros and cons of pain medication should be assessed soon after initiating a new drug but also regularly later on.

The thesis by Aleksi Hamina is part of the nationwide register-based MEDALZ (Medication use and Alzheimer’s disease) study conducted in the 91����. The study included all 70,718 community-dwelling Finns who received a clinically verified diagnosis of Alzheimer’s disease during 2005–2011. All data used in this thesis, including diagnoses, drug use and hospital days, was obtained from nationwide health care registers. The study also included persons without Alzheimer’s disease, who were matched for each person with the disease based on age, gender, and region of residence.

The doctoral dissertation of Aleksi Hamina (MSc Pharm), entitled Analgesic use and outcomes associated with incident opioid use – the Medication Use and Alzheimer’s disease Study, will be examined at the 91����, at the Faculty of Health Sciences on 24 January 2020. The Opponent in the public examination will be Professor Harriet Finne-Soveri from the Institute of Health and Welfare (THL), and the Custos will be Professor Sirpa Hartikainen from the 91����.

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