Ask the Pharmacist

Q: My dad lives with us and has been diagnosed with Alzheimer Disease. We have been learning to deal with the periodic memory and confusion issues, but recently, he has become extremely emotional at times without reason. Is this normal?

A: This sounds an awful lot like a condition known as Pseudobulbar Affect (PBA) and while we would not characterize it as being likely to occur in patients with Alzheimer Disease or other neurological disorders, it is, unfortunately, not rare either.

PBA is a condition that causes the affected person to laugh or cry uncontrollably in a frequent and very spontaneous manner. The outward actions often do not, in any way, reflect what is actually going on within the mind of the person. In other words, people affected by this may have an intense crying period even when they are not the least bit sad and the same applies to the laughing spells.

The classic diagnostic sign is a person laughing hysterically during what should be a very sad event, such as a funeral. This can, obviously, cause a great deal of confusion, embarrassment and stress for the caregivers and the affected individuals, themselves.

PBA occurs in people whose brains have already been damaged by a pre-existing neurological disease, including Alzheimer’s, ALS, multiple sclerosis, Parkinson’s, stroke, or an injury to the brain from trauma such as a car crash or repetitive head injuries from sports. While scientists are unsure as to what exactly is going on within the brain to result in this condition, the current speculation centres on some kind of disruption in the flow of nerve impulses from the cerebellum to the limbic and paralimbic systems.

While the exact incidence is unknown, with some estimating that it ranges from five per cent to well over 50 per cent of people already diagnosed with a neurological condition, there is little dispute that it is generally under-recognized due to the many other symptoms people with these diagnoses are already trying to cope with.

Estimates in the United States put the number at almost two-million, with another five-million people who show symptoms that suggest they may have PBA (e.g. they cry when they are in fact sad but the exaggeration in the crying response seems extreme).

Diagnosis is made by questioning the patient (or caregiver) and looking for the hallmark symptoms of emotional responses that are: inappropriate to a situation; not reflective of the person’s actual state of mind at times; unable to be controlled by the person with respect to his/her duration or intensity; do not provide any feeling of relief to the person when the emotional responses eventually subside (i.e. they do not feel better after a “good cry”).

Treatment is focused on reducing the severity and frequency of these episodes. The main group of drugs that has traditionally been tried, despite a lack of good evidence as to whether they are helpful or not, are the same ones we use to treat depression, namely the SSRIs (selective serotonin reuptake inhibitors, such as citalopram and fluoxetine) and the TCAs (tri-cyclic antidepressants, such as amitriptyline).

Both classes of drugs are aimed at increasing the serotonin levels within the brain and in small trials and case studies, they seem to help at least some of the affected within a few days to two weeks. Given the proven safety of these classes (the SSRIs usually have way fewer side effect issues than the TCAs), they seem like a no-brainer to try for those families living through this condition.

There is also a drug called Nuedexta that is the first one approved specifically for the treatment of PBA. It contains a combination of dextromethorphan (the same ingredient found in all of the over-the-counter cough suppressants that use DM) and quinidine. This drug affects a different neurotransmitter known as glutamate and in doing so, has shown to reduce the PBA-episode daily rate to 49 per cent lower than it was before.

Nuedexta has the potential for a large number of interactions with other drugs (and foods) and has some potential for side effects. There are also some people who should not be prescribed it due to other medical conditions they may have (such as those with heart rhythm abnormalities). Currently, Nuedexta is not available in Canada but has been approved for use in the U.S. for a number of years.

Still, the SSRIs seem like a safer initial choice for most, and can provide much-needed relief for a group of patients and their families who are currently dealing with a lot on their collective plates already.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts