What are the recommended treatments for dementia?

Recommended Treatments for Dementia

Cholinesterase inhibitors (ChEIs) and memantine are the primary pharmacological treatments for dementia, with specific indications based on dementia type and severity, while non-pharmacological approaches including cognitive stimulation, physical exercise, and caregiver support should be implemented concurrently for optimal outcomes. 1, 2

Pharmacological Treatment

First-Line Medications by Dementia Type and Severity

Mild to Moderate Alzheimer's Disease (AD), Parkinson's Disease Dementia (PDD), Lewy Body Dementia (DLB), or Vascular Dementia (VD):

• Cholinesterase inhibitors (ChEIs):
  • Donepezil: Start 5 mg once daily, target 10 mg once daily after 4-6 weeks if tolerated 2
  • Rivastigmine: Start 1.5 mg twice daily, target 3-6 mg twice daily 2, 3
  • Galantamine: Start 4 mg twice daily, target 8-12 mg twice daily 2

Moderate to Severe AD, PDD, DLB, or VD:

• Memantine: FDA-approved for moderate to severe AD 4
• Combination therapy: Memantine plus donepezil for moderate to severe AD 1, 2

Efficacy and Benefits

• ChEIs demonstrate modest but statistically significant improvements in cognition (2-4.9 points on ADAS-cog scale), global function, and activities of daily living 5, 6
• Memantine shows significant cognitive improvement in moderate to severe disease 2
• Rivastigmine may have advantages over donepezil in global function for moderately severe AD 2

Adverse Effects and Monitoring

• ChEIs commonly cause cholinergic side effects (gastrointestinal symptoms, dizziness, headache) in 7-30% of patients 2, 7
• Tacrine is no longer recommended due to hepatotoxicity (49% of patients) 2, 7
• Monitor for potential bradycardia with donepezil in patients with cardiovascular history 2

Non-Pharmacological Approaches

Individual Level Interventions

1. Exercise: Group or individual physical exercise is recommended for people living with dementia 1
2. Cognitive stimulation: Group cognitive stimulation therapy for mild to moderate dementia 1
3. Environmental modifications:
   • Provide predictable routines
   • Install safety locks on doors and gates
   • Use color-coded labels and visual cues
   • Reduce excess stimulation 2
4. Behavioral management techniques:
   • "Three R's" approach: repeat, reassure, and redirect
   • Break complex tasks into simple steps
   • Use distraction for problematic behaviors 2

Caregiver and Community Support

1. Caregiver support: Psychosocial and psychoeducational interventions for caregivers 1, 2
2. Dementia-friendly communities: Development of dementia-friendly organizations/communities 1
3. Case management: Coordination and continuity of service delivery 1

Treatment Evaluation and Deprescribing

When to Consider Discontinuation of Medications

Consider discontinuing ChEIs or memantine if:

1. Clinically meaningful worsening of dementia over past 6 months not attributable to other conditions 1
2. No clinically meaningful benefit observed during treatment 1
3. Development of severe or end-stage dementia 1
4. Intolerable side effects 1
5. Poor medication adherence 1

Important Exceptions

• Do not discontinue ChEIs in patients with clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized 1
• Continue treatment in patients who have had meaningful reduction in neuropsychiatric symptoms even with cognitive/functional decline 1
• ChEIs and memantine should be deprescribed for individuals with mild cognitive impairment 1

Deprescribing Protocol

When discontinuing medication:

• Reduce dose by 50% every 4 weeks until reaching initial starting dose 1
• After 4 weeks on starting dose, discontinue completely 1
• Monitor for worsening and reinitiate if clinically meaningful decline occurs 1

Advanced Disease Management

As dementia progresses:

• Shift focus to comfort care and quality of life 2
• Address nutrition, hydration, and infection management 2
• Intensify symptom management for pain and distress 2
• Initiate advance care planning while patient still has decision-making capacity 2

Common Pitfalls to Avoid

1. Delayed diagnosis and treatment: Early initiation of ChEI treatment may stabilize/reduce the rate of symptomatic decline 8
2. Inappropriate medication selection: Using ChEIs for frontotemporal dementia or other non-indicated conditions 1
3. Inadequate dose titration: Too rapid titration increases adverse effects; follow recommended titration schedules 7
4. Premature discontinuation: Continue treatment until there are no meaningful social interactions and quality of life has irreversibly deteriorated 8
5. Neglecting non-pharmacological approaches: Medications should be used alongside cognitive training, physical exercise, and caregiver education 2

By following this evidence-based approach to dementia treatment, clinicians can optimize outcomes for patients across different stages of the disease while minimizing adverse effects and caregiver burden.