From the Guidelines
Dementia is a progressive condition that inevitably worsens over time, leading to increased cognitive decline, functional impairment, and behavioral changes, and therefore, early intervention and regular monitoring are crucial to manage symptoms and improve quality of life. When dementia worsens, patients may experience increased memory loss, confusion, difficulty with language, impaired judgment, and behavioral changes. Medical evaluation is essential when symptoms worsen, as this could indicate disease progression or potentially treatable causes like infection, medication side effects, or metabolic disturbances, as noted in the ESPEN guidelines on nutrition in dementia 1.
Treatment Approaches
Treatment approaches include cholinesterase inhibitors (donepezil 5-10mg daily, rivastigmine 1.5-6mg twice daily, or galantamine 4-12mg twice daily) and memantine (5-20mg daily), which may temporarily slow cognitive decline, as recommended by the American College of Physicians and the American Academy of Family Physicians 1. Non-pharmacological interventions are equally important, including:
- Maintaining routine
- Providing a calm environment
- Ensuring proper nutrition and hydration
- Encouraging physical activity
- Supporting caregivers
Regular monitoring by healthcare providers helps adjust treatment plans as the disease progresses. The underlying mechanism involves progressive neuronal damage and death, with different dementia types (Alzheimer's, vascular, Lewy body) affecting different brain regions but all eventually causing widespread cognitive impairment, as described in the ESPEN guidelines 1.
Key Considerations
Key considerations in managing worsening dementia include:
- Early intervention when worsening is noticed can help manage symptoms more effectively and improve quality of life for both patients and caregivers
- The high burden of suffering for patients, their families, and society, as noted in the ESPEN guidelines 1
- The importance of addressing potentially reversible conditions, such as hypothyroidism or vitamin B12 deficiency, which can contribute to cognitive decline, as mentioned in the ESPEN guidelines 1.
From the FDA Drug Label
The ADCS-CGIC is a more standardized form of CIBIC-Plus and is also scored as a 7-point categorical rating, ranging from a score of 1, indicating "markedly improved," to a score of 4, indicating "no change" to a score of 7, indicating "marked worsening"
- Worsening of dementia is not directly addressed in terms of the drug causing it, but rather the drug's effect on dementia is measured by the ADAS-cog and ADCS-CGIC scores.
- The studies show that rivastigmine tartrate can improve cognitive performance and produce an overall clinical effect in patients with mild-to-moderate Alzheimer's disease and dementia associated with Parkinson's disease 2.
- However, the label does not provide information on whether rivastigmine tartrate can cause worsening of dementia. The FDA drug label does not answer the question.
From the Research
Worsening of Dementia
- Dementia is an acquired loss of cognition in multiple cognitive domains sufficiently severe to affect social or occupational function, with 47 million people living with dementia worldwide, expected to increase to 131 million by 2050 3.
- The diagnosis of dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician 3.
- Brief cognitive impairment screening questionnaires can assist in initiating and organizing the cognitive assessment, while neuropsychological testing can help determine whether dementia is present if the assessment is inconclusive 3.
- Physical examination may help identify the etiology of dementia, such as focal neurologic abnormalities suggesting stroke, and brain neuroimaging may demonstrate structural changes including focal atrophy, infarcts, and tumor 3.
Treatment of Dementia
- Patients with dementia may benefit from nonpharmacologic approaches, including cognitively engaging activities, physical exercise, and socialization 3.
- Pharmacologic approaches, such as acetylcholinesterase inhibitors, can provide modest symptomatic relief, with donepezil, rivastigmine, and galantamine being commonly used 3, 4, 5.
- The efficacy of these drugs is similar, with benefits seen on measures of cognitive function, activities of daily living, and behavior, although the effects are not large and may not be clinically significant 4, 5.
- Combination therapy with other classes of drugs, such as cholinergic precursors, N-methyl-d-aspartate receptor antagonists, and antioxidant agents, may represent a chance for renewed interest in the treatment of adult-onset dementia disorders 4.
Reversible Dementias
- Reversible dementias are rare, but dedicated efforts to screen for symptoms and signs associated with reversible causes of dementia may improve management and outcomes 6.
- A standard approach to the assessment of dementia is appropriate in most cases, but neurologists must recognize those rare patients with reversible causes of dementia and coordinate additional investigations when required 6.
- The potential to improve the outcome of patients with reversible dementias exemplifies the need to recognize these patients in clinical practice 6.
Cholinesterase Inhibitors
- Cholinesterase inhibitors, such as donepezil, rivastigmine, and galantamine, are commonly used in the treatment of Alzheimer's disease, with modest but statistically significant improvements on several measures, including cognition and global functioning 5, 7.
- The use of cholinesterase inhibitors across all stages of Alzheimer's disease is recommended, with early initiation and persistent exposure leading to delays in nursing home admission and slower rates of cognitive and functional impairment 7.
- Patients should be regularly monitored for potential serious side effects of cholinesterase inhibitor therapy, which may include syncope, bradycardia, and gastrointestinal events 7.