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Your Good Health: In cases of severe dementia, psychiatric meds should be reviewed

Is there still a need to continue PTSP meds if the patient no longer remembers the past trauma?
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Dr. Keith Roach

Dear Dr. Roach: My brother-in-law (age 78) recently developed dementia. Everything after the age of about 20 is gone for him, and he lives in the past, though he does still connect with my sister. For some time now, he has taken a psychopharmaceutical (Zoloft) for PTSD, stemming from earlier experiences. My question is, what is there to do in cases when past trauma(s) may have been erased from memory? Is there still a need to continue the medication? Is there any research on this matter? And, what about afflictions such as schizophrenia or bipolar and anxiety disorders that many presume to be attached to chemical problems in the brain? Do these, too, “disappear” when the memory of earlier life disappears?

U.T.

That’s an interesting question that I couldn’t find a lot of writing on. I don’t think that past trauma entirely disappears from memory, even in people with dementia. Furthermore, years of learned behaviours due to past trauma, or to mood disorders like anxiety and depression, will not change very easily. Still, in people with very severe dementia, psychiatric medications a person has used should be re-evaluated to see whether they are still needed.

Schizophrenia may be a structural brain problem: Although schizophrenia is probably not just one disease, there is evidence that schizophrenia may be caused by abnormal “pruning” of neurons during adolescence. People with schizophrenia and dementia usually do benefit from medication. Similarly, bipolar disease has clear evidence for abnormal gene expression, suggesting an underlying brain issue, which may need continued treatment even in people with dementia.

The idea that depression and anxiety are caused by a chemical imbalance — specifically with the brain neurotransmitter serotonin — may be an oversimplified explanation of a very complex issue. However, the medications we have remain moderately effective for depression.

Dear Dr. Roach: I’m a 63-year-old man with controlled blood pressure using five different meds, as well as a prescription for Synthroid due to Grave’s disease, for which I was treated with radioactive iodine. In late April, I experienced my first episode of AFib, which stopped by itself. Since then, I have had several AFib events, and like the first one, all were self-converted to a normal rhythm. Is AFib life-limiting or a condition to be controlled, like my thyroid condition?

H.C.

Well-controlled atrial fibrillation isn’t life-limiting. Everybody with atrial fibrillation should have an evaluation as to the cause behind it (abnormal thyroid levels are a very common cause), but often a cause is never found. They should also consider medication to control the heart rate and anticoagulation medication to prevent stroke. Most people with atrial fibrillation benefit from anticoagulation medication, and most of the people who do get a stroke with known atrial fibrillation should have been recommended treatment.

Your case is unusual, because you have a low risk for a stroke. (This was gathered from a clinical tool called the CHA2DS2-VASc. You have a score of 1, based on the information you have given me.) Some experts would treat you, but I think most would not treat you beyond aspirin. You should definitely have a close follow-up.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu

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