What are the treatment options for dementia, specifically Alzheimer's disease?

Treatment Options for Alzheimer's Disease Dementia

For Alzheimer's disease, a combination of pharmacological and non-pharmacological interventions is recommended, with donepezil being the first-line medication for mild to severe Alzheimer's dementia. 1, 2

Pharmacological Treatment

First-Line Medication

• Donepezil:
  • Indicated for mild, moderate, and severe Alzheimer's disease 2
  • Dosing protocol: Start at 5 mg once daily, target dose 10 mg once daily 1
  • For moderate to severe disease, may increase to 23 mg daily after at least 3 months on 10 mg 1

Alternative Cholinesterase Inhibitors

• Rivastigmine:

  • Indicated for mild to moderate Alzheimer's disease 3
  • Dosing: Start at 1.5 mg twice daily, titrate to 3-6 mg twice daily 1, 3
  • Titration should occur after minimum 2 weeks if well tolerated 3

• Galantamine:

  • For mild to moderate Alzheimer's disease
  • Dosing: Start at 4 mg twice daily, titrate to 8-12 mg twice daily 1

Additional Medication for Moderate to Severe Disease

• Memantine:
  • Indicated for moderate to severe Alzheimer's dementia 4
  • Can be considered as add-on therapy with donepezil for moderate to severe disease 1

Monitoring and Side Effects

• Monitor for cholinergic side effects (7-30% incidence):
  • Gastrointestinal symptoms (nausea, vomiting, diarrhea)
  • Dizziness and headache 1
• Watch for potential bradycardia with donepezil in patients with cardiovascular history 1
• Higher doses of medications are associated with more adverse events 5, 6

Non-Pharmacological Interventions

Daily Routine and Environment

• Establish predictable routines for meals, exercise, and bedtime 1
• Break complex tasks into simple steps 1
• Implement environmental modifications:
  • Install safety locks on doors and gates
  • Use color-coded or graphic labels as orientation cues
  • Install grab bars in bathrooms
  • Reduce excess stimulation and clutter
  • Ensure adequate lighting, especially at night 1

Cognitive and Physical Activities

• Group or individual physical exercise to improve physical and cognitive function 1
• Group cognitive stimulation therapy for mild to moderate dementia 1

Caregiver Support and End-of-Life Care

• Provide psychosocial and psychoeducational interventions for caregivers 1
• As disease progresses, shift focus to comfort care and quality of life:
  • Address nutrition, hydration, and infection management
  • Discuss appropriateness of life-sustaining measures
  • Intensify symptom management for pain and distress 1
• Initiate advance care planning while patient still has decision-making capacity 1

Medication Discontinuation Considerations

• Consider discontinuing cholinesterase inhibitors or memantine if:
  • Clinically meaningful worsening of dementia occurs
  • No clinically meaningful benefit is observed
  • Development of severe or end-stage dementia
  • Intolerable side effects
  • Poor medication adherence 1
• Do not discontinue cholinesterase inhibitors in patients with clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized 1
• When discontinuing medication, reduce dose by 50% every 4 weeks until reaching initial starting dose, then discontinue completely 1

Treatment Selection Based on Evidence

The evidence from systematic reviews shows that donepezil, galantamine, and rivastigmine all provide modest improvements in cognitive function for patients with Alzheimer's disease, though the clinical significance of these improvements may be limited 5, 6, 7. Donepezil 10 mg appears to have the greatest effect on cognition but is associated with more adverse events than lower doses 5, 8.