What is the treatment for Alzheimer's disease?

Treatment for Alzheimer's Disease

The first-line treatment for Alzheimer's disease is donepezil, starting at 5 mg once daily and targeting 10 mg once daily, along with non-pharmacological interventions including structured routines, environmental modifications, and caregiver support. 1

Non-Pharmacological Interventions

Non-pharmacological approaches form an essential foundation of Alzheimer's disease management:

• Daily Structure and Support:

  • Implement predictable routines for meals, exercise, and bedtime
  • Break complex tasks into simple steps
  • Use distraction and redirection for problematic behaviors 1

• 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:

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

Pharmacological Management

First-Line Medication

• Donepezil:
  • Starting dose: 5 mg once daily
  • Target dose: 10 mg once daily
  • For moderate to severe disease, may increase to 23 mg daily after at least 3 months on 10 mg 1, 2

Alternative Cholinesterase Inhibitors

For patients who cannot tolerate donepezil, consider:

• Rivastigmine: 1.5 mg twice daily, titrating to 3-6 mg twice daily
• Galantamine: 4 mg twice daily, titrating to 8-12 mg twice daily 1

Combination Therapy

• For moderate to severe Alzheimer's disease, consider adding memantine to donepezil therapy 1

Monitoring and Side Effects

• Monitor for cholinergic side effects (7-30% incidence):
  • Gastrointestinal symptoms (nausea, vomiting, diarrhea)
  • Dizziness and headache
  • Potential bradycardia in patients with cardiovascular history 1, 3
• Titrate medications carefully to minimize adverse effects 4
• If no benefit is seen with one cholinesterase inhibitor, switching to another medication in this class might be beneficial 4

Disease Stage-Specific Approach

Mild to Moderate Alzheimer's Disease

• Start with donepezil 5 mg daily
• After 4-6 weeks, increase to 10 mg daily if tolerated 1, 2
• Monitor cognitive and functional status every 6 months 5

Moderate to Severe Alzheimer's Disease

• Continue donepezil 10 mg daily or consider increasing to 23 mg daily
• Consider adding memantine 1, 2
• Studies show donepezil provides significant improvement in cognitive performance even in severe disease 2

End-of-Life Care

• Shift focus to comfort care and quality of life
• Consider discontinuing cholinesterase inhibitors if:
  • Clinically meaningful worsening of dementia occurs
  • No clinically meaningful benefit is observed
  • Severe or end-stage dementia develops
  • Intolerable side effects occur
  • Poor medication adherence is noted 1
• Do not discontinue if psychotic symptoms, agitation, or aggression are present until these symptoms stabilize 1
• When discontinuing, reduce dose by 50% every 4 weeks until reaching initial starting dose, then discontinue completely 1

Caregiver Support

• Provide psychosocial and psychoeducational interventions for caregivers
• Initiate advance care planning while the patient still has decision-making capacity
• Document goals of care, treatment preferences, and end-of-life wishes
• Identify a substitute decision-maker/healthcare proxy 1

Clinical Pearls

• Early diagnosis and treatment initiation may stabilize or reduce the rate of symptomatic cognitive and functional decline 5
• "No change" in status should be considered an improvement and a desirable clinical outcome for patients with Alzheimer's disease 4
• Treatment effects associated with donepezil abate within 6 weeks of discontinuation 2
• Cholinesterase inhibitors provide modest but significant therapeutic benefits despite higher rates of treatment discontinuation and side effects than placebo 6