What are the initial treatment options for dementia?

Initial Treatment Options for Dementia

For patients with dementia, donepezil is recommended as the first-line pharmacological treatment, starting at 5 mg once daily with a target dose of 10 mg once daily, alongside essential non-pharmacological interventions. 1

Non-Pharmacological Interventions

Non-pharmacological approaches should be implemented for all patients with dementia, regardless of severity:

• Environmental modifications:

  • Install safety locks on doors and gates
  • Use color-coded or graphic labels as orientation cues
  • Install grab bars in bathrooms
  • Ensure adequate lighting, especially at night
  • Reduce excess stimulation and clutter 1

• Behavioral strategies:

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

• Cognitive and physical interventions:

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

• Caregiver support:

  • Psychosocial and psychoeducational interventions to reduce caregiver burden 1

Pharmacological Treatment

First-line Medication:

• Donepezil:
  • Starting dose: 5 mg once daily
  • Target dose: 10 mg once daily after minimum 2 weeks 1, 2
  • Benefits include modest improvements in cognition, global function, and activities of daily living 3

Alternative Options for Mild to Moderate Alzheimer's Disease:

• Rivastigmine:

  • Starting dose: 1.5 mg twice daily
  • Target dose: 3-6 mg twice daily 1, 4
  • Take with meals in divided doses (morning and evening) 4

• Galantamine:

  • Starting dose: 4 mg twice daily
  • Target dose: 8-12 mg twice daily 1

For Moderate to Severe Alzheimer's Disease:

• Donepezil: 5-10 mg daily, with option to increase to 23 mg daily after at least 3 months on 10 mg 1
• Consider adding memantine for combination therapy in moderate to severe disease 1

Monitoring and Side Effect Management

Common Side Effects:

• Cholinergic side effects (incidence 7-30%):
  • Gastrointestinal symptoms (nausea, vomiting, diarrhea)
  • Dizziness
  • Headache 1

Important Monitoring:

• Cardiovascular: Monitor for potential bradycardia with donepezil in patients with cardiovascular history 1
• Gastrointestinal: Watch for significant nausea, vomiting, diarrhea, anorexia/decreased appetite, and weight loss 4
• Hydration status: Prolonged vomiting or diarrhea can lead to dehydration with serious outcomes 4

Treatment Discontinuation Considerations

Consider discontinuing cholinesterase inhibitors if:

• Clinically meaningful worsening of dementia
• No clinically meaningful benefit
• 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

Treatment Efficacy Expectations

Clinical trials show that cholinesterase inhibitors provide modest benefits:

• Donepezil improves cognition by approximately 2.67 points on the ADAS-Cog scale 3
• Benefits are maintained for approximately 21 to 81 weeks with donepezil 10 mg/day 5
• Effects on quality of life are less clear, with some studies showing no significant improvement 3, 6

The magnitude of benefit may seem small, but these medications can delay symptomatic progression of the disease 5, which is clinically meaningful given the progressive nature of dementia.