Recommended Treatments for Dementia
Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) and memantine are the primary pharmacological treatments for dementia, with selection based on dementia type and severity. 1
Pharmacological Treatment Options
First-Line Medications by Dementia Type and Severity
- Cholinesterase inhibitors (ChEIs) are recommended for mild to moderate Alzheimer's disease (AD), Parkinson's disease dementia (PDD), dementia with Lewy bodies (DLB), and vascular dementia (VaD) 1
- Memantine is indicated for moderate to severe Alzheimer's disease 2
- Combination therapy with memantine and donepezil is recommended for severe AD in many countries 1
- ChEIs should be discontinued for indications other than AD, PDD, DLB, or VaD (e.g., frontotemporal dementia) 1
Specific Medication Evidence
- Donepezil (5-10 mg daily) shows statistically significant improvement in cognitive function and global clinical state in mild to moderate AD, with benefits observed from week 3 of treatment 3, 4
- Rivastigmine has shown benefits for cognitive function in AD and Parkinson's disease dementia, with higher doses (6-12 mg) showing greater improvement than lower doses (1-4 mg) 5
- Galantamine has similar efficacy to other ChEIs but with different pharmacological properties 6
- All ChEIs have modest effects on cognition, with average improvements of 2.7 points on the 70-point ADAS-Cog scale 6
Treatment Considerations and Monitoring
- Treatment decisions should be based on individualized assessment of benefits versus risks 1
- Common adverse effects of ChEIs include gastrointestinal symptoms (nausea, vomiting, diarrhea), with higher incidence at higher doses 6, 4
- Memantine's common side effects include confusion, dizziness, and falls 1
- Medication effectiveness should be assessed by monitoring cognition, function, and neuropsychiatric symptoms 1
When to Consider Discontinuation
Consider discontinuing ChEIs after 12 months if there is:
- Clinically meaningful worsening despite treatment
- No observed benefit at any point during treatment
- Progression to severe/end-stage dementia with limited life expectancy
- Intolerable side effects
- Poor medication adherence 1
ChEIs should not be discontinued in patients with clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized 1
Patients who have shown reduction in neuropsychiatric symptoms with cognitive enhancers should continue treatment even with evidence of cognitive and functional decline 1
Deprescribing Protocol
- Deprescribe gradually with dose reduction by 50% every 4 weeks until reaching the initial starting dose 1
- After 4 weeks at the starting dose, the medication can be discontinued 1
- Consider reinitiation if clinically meaningful worsening occurs after discontinuation 1
- ChEIs and memantine should be deprescribed for individuals with mild cognitive impairment 1
Non-Pharmacological Interventions
- Non-pharmacological approaches include:
- Cognitive training and activities (reading, chess, music therapy, art therapy)
- Physical exercise (both aerobic and anaerobic)
- Brain-healthy diet (Mediterranean diet, nuts, berries, fish, green leafy vegetables)
- Reminiscence therapy 1
End-of-Life Care Considerations
- Palliative care should focus on improving quality of life, maintaining function, and maximizing comfort as dementia progresses 1
- Continuing care should be provided to those who can no longer stay at home 1
- Treatment goals should shift when prolonging life is no longer meaningful 1
Common Pitfalls to Avoid
- Expecting dramatic improvements with medication; benefits are typically modest 1, 6
- Using ChEIs for frontotemporal dementia or other non-indicated conditions 1
- Continuing medications when there's no evidence of benefit after adequate trial 1
- Abrupt discontinuation rather than gradual tapering 1
- Overlooking the importance of non-pharmacological interventions 1
- Failing to reassess medication effectiveness periodically 1