How is dementia treated?


Table of Contents


Dementia is a disease with no cure. However, some types of dementia which are caused by other physical illneses can be treated. Those are known as reversible dementias.

The first step in treating dementia is attempting to identify any underlying illnesses that may be causing memory impairment and other symptoms of the syndrome. If none is found, or if the symptoms persist after appropriate specific treatment, then several symptomatic treatments are available.

Medication may help to slow down the progress of the illness and improve the mental functions in the early stages of the illnesses. A chemical in the brain is important for cognitive functions: it is Acetyl Choline. Like may other chemical transmitters in the brain, Acetyl Choline is released between nerve cells to transfer the electrochemical impulse across the neurones. This chemical is deactiveted by an enzyme : acetylcholinesterase. Acetylcholinestarase inhibitors are often used early in the disorder; however, benefit is generally small. Treatments other than medication appear to be better for agitation and aggression. Cognitive and behavioral interventions may be appropriate. Some evidence suggests that education and support for the person with dementia, as well as caregivers and family members, improves outcomes. Exercise programs are beneficial with respect to activities of daily living, and potentially improve dementia.

Medications

How is dementia treated?

Psychopharmacotherapy

A variety of pharmacological treatments is currently available for Alzheimer's disease.

Medications Used for the Treatment of Dementia of the Alzheimer's Type

1- Cholinesterase inhibitors :

One approach to improving memory function has been to enhance cholinergic activity in the brain. Autopsies of patients with Alzheimer's disease have found reduced levels of choline acetyltransferase in the brain, a finding that is consistent with a central cholinergic deficit. Trials of cholinergic agonists have temporarily improved memory in young and old normal volunteers. Trials of several agents'including physostigmine (Antilirium), choline (Mega-B), and lecithin (PhosChol)'have yielded contradictory results (some effects versus no measurable effects on memory in demented patients) or else have not yet been replicated. The U.S. Food and Drug Administration (FDA) has approved for short-term treatment four reversible cholinesterase inhibitors, tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl), which have proven benefits for memory, other aspects of cognition, behavioral disturbances, overall functioning, and even caregiver burden. Tacrine has the disadvantage of causing reversible elevations of serum transaminase levels and is therefore rarely used.

Recent studies point to the importance of early detection and treatment with cholinesterase inhibitor drugs. In randomized, placebo-controlled trials in patients with mild to moderate Alzheimer's disease, these drugs cause significant improvement in cognitive function compared to placebo after 6 months of treatment. During the following 6-month, open-label treatment periods, the patients who were originally treated with placebo were given active drug, and, at 1 year, better cognitive performance was observed in patients who began drug treatment from the beginning of the trial compared to those who had been placebo-delayed for 6 months.

Those drugs deactivate the enzyme which break down the main neurotransmitter active in cognitive functions: acetyl choline. This group of drugs include:

  • Tacrine (Cognex)
  • Donepezil (Aricept)
  • Rivastigmine (Exelon)
  • Galantamine (Reminyl)

2- N-methyl-d-aspartate receptor antagonist

  • Memantine (Namenda)

Memantine (Namenda), a drug used for decades in Europe, was recently approved for treatment of dementia in the United States. Rather than influencing the cholinergic transmitter system, memantine works on the brain's NMDA (N-methyl-D-aspartate) receptors by blocking the brain chemical glutamate, which overstimulates these receptors, allowing too much calcium to enter cells, leading to cell destruction. When taken 20 mg daily, memantine benefits patients with moderate to severe Alzheimer's disease, but many clinicians find that it is effective in milder forms of memory loss as well. Another encouraging observation of memantine is the additional benefit it brings to many patients already taking a cholinesterase inhibitor drug, donepezil, for an average of 6 months. These patients showed additional benefit and slower memory decline when they added memantine to their treatment regimen, compared with those who remained on the donepezil without adding memantine.

3- Antioxidants

  • Vitamin E (tocopherol)

4- Hormones

  • Conjugated estrogens

5- Other potential cognitive enhancers

Ongoing studies are assessing a variety of other agents that may improve cognitive functioning, including cholesterol-lowering statins, nonsteroidal anti-inflammatory agents, and botanical agents, such as Ginkgo biloba. Unfortunately, any clinical benefit for these various treatments has been inconclusive thus far.

  • Nonsteroidal anti-inflammatory drugs
  • Ginkgo biloba
  • Acetyl-carnitine

Many of these approaches diminish symptoms and increase quality of life, but none of them can halt the dementing process. Most pharmacological agents that are currently available or are in development target a specific symptom (e.g., agitation or memory loss) and are derived from the known neurobiology of the disease (e.g., a specific neurotransmitter deficit) or hypothesized antidementia approaches (e.g., antiinflammation or antioxidation).

Drugs Used for the Treatment of Behaviors Associated with Dementia

1- Antipsychotics :

  • Haloperidol (Haldol)
  • Thioridazine (Mellaril)
  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)

Antipsychotic drugs are effective in treating psychotic symptoms and agitation, with the choice of a specific agent depending on its side effect profile. A metaanalysis of controlled trials of antipsychotic treatment in dementia indicated that antipsychotics had a significantly greater effect than did a placebo, but the degree of the effects was small.

High-potency agents, such as haloperidol (Haldol), tend to cause parkinsonian symptoms, whereas low-potency drugs, such as chlorpromazine (Thorazine), cause sedation, postural hypotension, and anticholinergic effects. Less frequently, tardive dyskinesia and neuroleptic malignant syndrome may develop.

Clozapine (Clozaril) can produce anticholinergic effects, as well as agranulocytosis, and thus requires blood-count monitoring, which can be particularly problematic in frail elderly patients. Because of better side effect profiles, the newer atypical antipsychotic drugs, such as quetiapine (Seroquel), risperidone (Risperdal), olanzapine (Zyprexa), and ziprasidone (Geodon), have received greater attention in recent years. Clinical experience and data from controlled trials using these latter medications in older demented patients indicate their usefulness in this patient group.

Clinicians should be aware of the risk of tardive dyskinesia in elderly patients. One study of elderly psychiatric patients showed that the greatest risk is during the first 2 years of antipsychotic treatment. Because of such adverse effects, alternative drugs have been used to treat agitation, including beta-blocking agents and sedating antidepressant drugs, such as trazodone (Desyrel).

2- Anxiolytics :

  • Buspirone (BuSpar)
  • Lorazepam (Ativan)
  • Clonazepam (Klonopin)

Benzodiazepines have also been used to treat the agitation that accompanies dementia. However, they have undesirable adverse effects, including some particularly noxious to the demented elderly patient, such as confusion, memory impairment, disorientation, dysarthria, and agitation complicated by ataxic gait. Short-acting benzodiazepines that do not require oxidative metabolism in the liver and that have no active metabolites are safer than long-acting agents.

Long-acting benzodiazepine agents tend to accumulate in the blood and are best avoided, as are short-acting compounds, which tend to reach high peak levels rapidly. Relatively short-acting benzodiazepines may be useful for treating insomnia, although the clinician should evaluate the specific causes of the insomnia, such as restless legs syndrome, obstructive apnea, urinary frequency caused by prostatic disease, lack of daytime exercise, use of caffeine, and prolonged stays in bed. Moreover, attempts at reducing daytime sleep, avoiding nighttime stimulants, and regulating the timing of meals and activities should be made before using pharmacological agents for sleep.

3- Anti-parkinsonian drugs :

  • Selegiline (Carbex)

Many patients also use over-the-counter preparations, which should be evaluated routinely. In a trial including more than 300 patients with moderately severe Alzheimer's disease, treatment with vitamin E (alpha-tocopherol) or the selective monoamine oxidase type-B inhibitor selegiline (Carbex) (approved for Parkinson's disease treatment) was found to lower rates of functional decline. These agents, however, did not show evidence of cognitive improvement.

4- Anticonvulsants

  • Carbamazepine (Tegretol)
  • Divalproex sodium (Depakote)

Clinical experience and initial study results suggest the usefulness of anticonvulsant drugs (e.g., carbamazepine [Tegretol] and divalproex sodium [Depakote]) for agitation as well. Psychotherapies aimed at enhancing cognition are ineffective for dementia. Clinical experience also suggests the efficacy of nonpharmacological interventions in minimizing depression and agitation.

5- Beta-adrenergic receptor antagonists:

  • Propranolol (Inderal)
  • Pindolol (Visken)

6- Antidepressants

  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Trazodone (Desyrel)

Available therapies for behaviors associated with dementia (e.g., depression, agitation, psychosis, and anxiety) are often effective. Patients who have dementia with concurrent depression may improve after treatment with antidepressant medications. Antidepressants with minimal anticholinergic effects (e.g., selective serotonin reuptake inhibitors [SSRIs]) are preferred over tricyclic drugs. Lithium (Eskalith) can be an effective antidepressant for geriatric depression and bipolar I disorder. However, patients with underlying neurological diseases have been reported to do poorly with lithium treatment, so it should be used with caution in patients with dementia.

As scientists uncover the basic pathogenetic mechanisms of Alzheimer's disease, additional antidementia treatments, designed to perform functions such as inhibition of amyloid production or accumulation or alteration of apolipoprotein E physiology, will likely emerge. Additional approaches may target other neurotransmitter systems (e.g., noradrenergic) or may use drug combination strategies.

Donepezil

No medications have been shown to prevent or cure dementia. Medications may be used to treat the behavioural and cognitive symptoms, but have no effect on the underlying disease process.

Acetylcholinesterase inhibitors, such as donepezil, may be useful for Alzheimer 's disease, Parkinson's disease dementia, Dementia of Lewy Bodies, or vascular dementia. The quality of the evidence is poor and the benefit is small. No difference has been shown between the agents in this family. In a minority of people side effects include a slow heart rate and fainting. Rivastigmine is recommended for treating symptoms in Parkinson's disease dementia.

Before prescribing antipsychotic medication in the elderly, an assessment for an underlying cause of the behavior is needed. Severe and life-threatening reactions occur in almost half of people with Dementia of Lewy Bodies, and can be fatal after a single dose. People with Lewy body dementias who take neuroleptics are at risk for neuroleptic malignant syndrome, a life-threatening illness. Extreme caution is required in the use of antipsychotic medication in people with Dementia of Lewy Bodies because of their sensitivity to these agents.

Antipsychotic drugs are used to treat dementia only if non-drug therapies have not worked, and the person's actions threaten themselves or others. Aggressive behavior changes are sometimes the result of other solvable problems, that could make treatment with antipsychotics unnecessary.

Because people with dementia can be aggressive, resistant to their treatment, and otherwise disruptive, sometimes antipsychotic drugs are considered as a therapy in response. These drugs have risky adverse effects, including increasing the person's chance of stroke and death. Given these adverse events and small benefit, antipsychotics are avoided whenever possible. Generally, stopping antipsychotics for people with dementia does not cause problems, even in those who have been on them a long time.

N-methyl-D-aspartate (NMDA) receptor blockers such as memantine may be of benefit but the evidence is less conclusive than for Acetyl Choline Inhibitors. Due to their differing mechanisms of action memantine and acetylcholinesterase inhibitors can be used in combination however the benefit is slight.

An extract of Ginkgo biloba has been widely used for treating mild to moderate dementia and other neuropsychiatric disorders. Its use is approved throughout Europe. The World Federation of Biological Psychiatry guidelines lists this plant extract with the same weight of evidence given to acetylcholinesterase inhibitors, and mementine. It is the only drug that showed improvement of symptoms in both Alzheimer's disease and vascular dementia. Ginkgo biloba extract is seen as being able to play an important role either on its own or as an add-on particularly when other therapies prove ineffective. It is neuroprotective; it is a free radical scavenger, improves mitochondrial function, and modulates serotonin and dopamine levels. Many studies of its use in mild to moderate dementia have shown it to significantly improve cognitive function, activities of daily living, neuropsychiatric symptoms, and quality of life. However, its use has not been shown to prevent the progression of dementia.

While depression is frequently associated with dementia, the use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) do not appear to affect outcomes. However, the SSRIs sertraline and citalopram have been demonstrated to reduce symptoms of agitation, compared to placebo.

The use of medications to alleviate sleep disturbances that people with dementia often experience has not been well researched, even for medications that are commonly prescribed. Benzodiazepines such as diazepam, and non-benzodiazepine hypnotics, have to be avoided for people with dementia due to the risks of increased cognitive impairment and falls. Benzodiazepines are also known to promote delirium. Additionally, little evidence supports the effectiveness of benzodiazepines in this population. No clear evidence shows that melatonin or ramelteon improves sleep for people with dementia due to Alzheimer's, but it is used to treat REM sleep behavior disorder in dementia with Lewy bodies. Limited evidence suggests that a low dose of trazodone may improve sleep, however more research is needed.

No solid evidence indicates that folate or vitamin B12 improves outcomes in those with cognitive problems. Statins have no benefit in dementia. Medications for other health conditions may need to be managed differently for a person who has a dementia diagnosis. It is unclear whether blood pressure medication and dementia are linked. People may experience an increase in cardiovascular-related events if these medications are withdrawn.

Psychological and psychosocial therapies

Psychological therapies for dementia include some limited evidence for reminiscence therapy (namely, some positive effects in the areas of quality of life, cognition, communication and mood the first three particularly in care home settings), some benefit for cognitive reframing for caretakers, unclear evidence for validation therapy and tentative evidence for mental exercises, such as cognitive stimulation programs for people with mild to moderate dementia. A 2020 Cochrane review found that offering personally tailored activities could help reduce challenging behavior and may improve quality of life. The reviewed studies (5 RCTs with 262 participants) were unable to draw any conclusions about impact on individual affect or on improvements for the quality of life for the caregiver.

Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers. In addition, home care can provide one-to-one support and care in the home allowing for more individualized attention that is needed as the disorder progresses. Psychiatric nurses can make a distinctive contribution to people's mental health.

Since dementia impairs normal communication due to changes in receptive and expressive language, as well as the ability to plan and problem solve, agitated behaviour is often a form of communication for the person with dementia. Actively searching for a potential cause, such as pain, physical illness, or overstimulation can be helpful in reducing agitation. Additionally, using an "ABC analysis of behaviour" can be a useful tool for understanding behavior in people with dementia. It involves looking at the antecedents (A), behavior (B), and consequences (C) associated with an event to help define the problem and prevent further incidents that may arise if the person's needs are misunderstood. The strongest evidence for non-pharmacological therapies for the management of changed behaviours in dementia is for using such approaches. Low quality evidence suggests that regular (at least five sessions of) music therapy may help institutionalized residents. It may reduce depressive symptoms and improve overall behaviour. It may also supply a beneficial effect on emotional well-being and quality of life, as well as reduce anxiety. In 2003, The Alzheimer's Society established 'Singing for the Brain' (SftB) a project based on pilot studies which suggested that the activity encouraged participation and facilitated the learning of new songs. The sessions combine aspects of reminiscence therapy and music. Musical and interpersonal connectedness can underscore the value of the person and improve quality of life.

Some London hospitals found that using color, designs, pictures and lights helped people with dementia adjust to being at the hospital. These adjustments to the layout of the dementia wings at these hospitals helped patients by preventing confusion.

Life story work as part of reminiscence therapy, and video biographies have been found to address the needs of clients and their caregivers in various ways, offering the client the opportunity to leave a legacy and enhance their personhood and also benefitting youth who participate in such work. Such interventions be more beneficial when undertaken at a relatively early stage of dementia. They may also be problematic in those who have difficulties in processing past experiences.

Animal-assisted therapy has been found to be helpful. Drawbacks may be that pets are not always welcomed in a communal space in the care setting. An animal may pose a risk to residents, or may be perceived to be dangerous. Certain animals may also be regarded as unclean or dangerous by some cultural groups.

Pain

As people age, they experience more health problems, and most health problems associated with aging carry a substantial burden of pain; therefore, between 25% and 50% of older adults experience persistent pain. Seniors with dementia experience the same prevalence of conditions likely to cause pain as seniors without dementia. Pain is often overlooked in older adults and, when screened for, is often poorly assessed, especially among those with dementia, since they become incapable of informing others of their pain. Beyond the issue of humane care, unrelieved pain has functional implications. Persistent pain can lead to decreased ambulation, depressed mood, sleep disturbances, impaired appetite, and exacerbation of cognitive impairment and pain-related interference with activity is a factor contributing to falls in the elderly.

Although persistent pain in people with dementia is difficult to communicate, diagnose, and treat, failure to address persistent pain has profound functional, psychosocial and quality of life implications for this vulnerable population. Health professionals often lack the skills and usually lack the time needed to recognize, accurately assess and adequately monitor pain in people with dementia. Family members and friends can make a valuable contribution to the care of a person with dementia by learning to recognize and assess their pain. Educational resources and observational assessment tools are available.

Eating difficulties

Persons with dementia may have difficulty eating. Whenever it is available as an option, the recommended response to eating problems is having a caretaker assist them. A secondary option for people who cannot swallow effectively is to consider gastrostomy feeding tube placement as a way to give nutrition. However, in bringing comfort and maintaining functional status while lowering risk of aspiration pneumonia and death, assistance with oral feeding is at least as good as tube feeding. Tube-feeding is associated with agitation, increased use of physical and chemical restraints and worsening pressure ulcers. Tube feedings may cause fluid overload, diarrhea, abdominal pain, local complications, less human interaction and may increase the risk of aspiration.

Benefits in those with advanced dementia has not been shown. The risks of using tube feeding include agitation, rejection by the person (pulling out the tube, or otherwise physical or chemical immobilization to prevent them from doing this), or developing pressure ulcers. The procedure is directly related to a 1% fatality rate with a 3% major complication rate. The percentage of people at end of life with dementia using feeding tubes in the US has dropped from 12% in 2000 to 6% as of 2014.

Exercise

Exercise programs may improve the ability of people with dementia to perform daily activities, but the best type of exercise is still unclear. Getting more exercise can slow the development of cognitive problems such as dementia, proving to reduce the risk of Alzheimer's disease by about 50%. A balance of strength exercise to help muscles pump blood to the brain, and balance exercises are recommended for aging people, a suggested amount of about 2 and a half hours per week can reduce risks of cognitive decay as well as other health risks like falling.

Alternative medicine

Aromatherapy and massage have unclear evidence. Studies support the efficacy and safety of cannabinoids in relieving behavioral and psychological symptoms of dementia.

Palliative care

Given the progressive and terminal nature of dementia, palliative care can be helpful to patients and their caregivers by helping people with the disorder and their caregivers understand what to expect, deal with loss of physical and mental abilities, support the person's wishes and goals including surrogate decision making, and discuss wishes for or against CPR and life support. Because the decline can be rapid, and because most people prefer to allow the person with dementia to make their own decisions, palliative care involvement before the late stages of dementia is recommended. Further research is required to determine the appropriate palliative care interventions and how well they help people with advanced dementia.

Person-centered care helps maintain the dignity of people with dementia.

Attention to the Environment

Patients with cognitive losses are sensitive to their surroundings and seem to do best with optimal stimulation. Understimulation may cause withdrawal; overstimulation may cause confusion and agitation. Familiar and constant surroundings maximize the patient's existing cognitive functions. Daily routines often increase a patient's sense of security; memory and orientation can be facilitated by prominent displays of clocks and calendars, a night light, checklists, and diaries. Medication schedules should be simplified, if possible. If moves cannot be avoided, it helps to place familiar objects (e.g., photographs and furniture) in the new environment and to create a home-like atmosphere. The availability of newspapers, radio, and television can be useful in maintaining a patient's contact with and awareness of the outside world.

Family Intervention

Psychotherapeutic intervention with family members is a critical aspect of treatment. Education and counseling about the nature of the patient's illness help relatives cope with the anger and puzzlement that they often experience when the demented patient behaves in peculiar, disturbing, and uncharacteristic ways. Relatives may need reassurance that their emotional reactions are common and that talking about them can bring relief. Many relatives also need help in grieving the loss of the patient who now behaves like a stranger rather than the person whom they once knew. The Alzheimer's Association, a national organization of family members with local chapters throughout the United States, has been at the forefront of providing educational and emotional support for family members.

Dementia of the Alzheimer's type has captured the attention of the mass media. Consequently, the public's concern and anxiety have led to a heightened awareness of memory changes and a tendency to overinterpret normal age-related memory impairment as dementia of the Alzheimer's type. Family members of Alzheimer's victims are generally the most anxious about any memory changes that they observe in themselves, given the likelihood of genetic components in the disease.

Sometimes, education and a full physical and neuropsychological evaluation allay, at least temporarily, unfounded anxiety about the disease. At other times, such an evaluation will uncover the early signs of progressive dementia.

In many situations, the elderly person with dementia is the identified patient. However, interpersonal conflicts among the family members require resolution to help the geriatric patient. Moreover, the adult child often makes the initial contact with the geriatric psychiatrist, and considerable skill and sensitivity are necessary to maintain an alliance with the adult child while respecting the elderly parent's autonomy, dignity, and privacy.


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