Is codeine (opioid analgesic) recommended for managing symptoms in dementia?

Codeine is Not Recommended for Managing Symptoms in Dementia

Codeine should not be used for managing symptoms in dementia due to its significant risks of cognitive impairment, sedation, anticholinergic effects, and fall risk in this vulnerable population.

Risks of Opioids in Dementia Patients

• Opioids including codeine have significant risks in older adults with dementia, including sedation, cognitive impairment, anticholinergic properties, addiction potential, withdrawal syndrome, and increased fall risk 1
• Codeine specifically appears in guidelines as a medication to avoid in older adults with dementia due to shared sedation, anticholinergic properties, and cognitive impairment 1
• The use of codeine can worsen cognitive function in patients with dementia, potentially exacerbating neuropsychiatric symptoms rather than alleviating them 1

Recommended Approach to Managing Dementia Symptoms

First-Line: Non-Pharmacological Interventions

• Non-pharmacological approaches should be the first-line treatment for neuropsychiatric symptoms of dementia (NPS) 1
• The DICE approach (Describe, Investigate, Create, Evaluate) offers a structured method for addressing behavioral symptoms without immediately resorting to medications 1
• Key non-pharmacological strategies include:
  • Caregiver education about dementia and communication techniques 1
  • Creating meaningful activities and establishing structured routines 1
  • Environmental modifications to enhance safety and reduce triggers 1
  • Addressing underlying medical conditions (pain, infection, etc.) 1

Pain Management in Dementia

• For pain management in dementia patients, acetaminophen on a scheduled basis is recommended as first-line for moderate musculoskeletal pain 1
• If pain is suspected as contributing to behavioral symptoms, appropriate pain assessment and management should be implemented before considering psychotropics 1
• There is currently insufficient evidence to support the safety of opioid analgesics like codeine in people with dementia 2
• When analgesics are necessary, they should be carefully selected with consideration of the risk-benefit profile in this vulnerable population 3

Pharmacological Options for Neuropsychiatric Symptoms

• Psychotropic medications should only be used after significant efforts with behavioral and environmental modifications, with three exceptions 1:

  1. Major depression with or without suicidal ideation
  2. Psychosis causing harm or with great potential of harm
  3. Aggression causing risk to self or others

• FDA-approved medications for dementia treatment include:

  • Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate Alzheimer's dementia 1
  • Memantine for moderate to severe dementia 1

• For depression in dementia, SSRIs with minimal anticholinergic effects may be appropriate 4, 5

Monitoring and Limitations

• If any psychotropic medication is used, close follow-up is essential to monitor for adverse effects, and use should be time-limited 1
• Many behavioral symptoms in dementia will resolve spontaneously within six months, making trials of deprescribing recommended 6
• Psychotropics are unlikely to impact certain symptoms including poor self-care, memory problems, repetitive verbalizations, rejection of care, and wandering 1

Special Considerations

• There is no FDA approval for the use of opioids like codeine in the treatment of neuropsychiatric symptoms of dementia 1
• The risk-benefit ratio of medication use must be carefully evaluated, especially with medications like codeine that can worsen cognitive function 1
• Behavioral symptoms should be seen as having underlying causes that need to be addressed rather than simply medicated 6