From the Guidelines
Late-stage dementia treatment should focus on comfort care, symptom management, and quality of life rather than attempting to slow disease progression. Medications like donepezil (Aricept) or memantine (Namenda) may be continued if already prescribed, but their benefits are limited at this stage 1. For behavioral symptoms, low-dose antipsychotics such as quetiapine (25-50mg) or risperidone (0.25-1mg) may be used cautiously for severe agitation or psychosis, while being mindful of their increased mortality risk in elderly patients.
Key Considerations
- Pain management is essential, typically starting with acetaminophen (up to 3000mg daily) before considering stronger options.
- Non-pharmacological approaches are equally important, including:
- Maintaining consistent routines
- Creating a calm environment
- Using gentle touch and music therapy
- Ensuring proper nutrition and hydration
- Specialized memory care units or hospice services often provide appropriate support.
- Family education about end-of-life care decisions, including feeding tube considerations and advance directives, should be addressed early.
Recent Guidelines
The most recent guidelines from 2022 suggest that non-pharmacologic interventions, such as cognitive training and activities, music or art therapy, physical exercise, and diet, should take precedence over pharmacotherapy interventions in the treatment of behavioral and psychological symptoms of dementia (BPSD) 1.
Pharmacologic Treatment
Current pharmacologic interventions are used primarily to delay progression of the syndrome and improve its symptoms, but there is no cure for dementia 1. The choice of pharmacologic agents should be based on tolerability, adverse effect profile, ease of use, and cost of medication.
Goal of Care
The goal is to maximize comfort and dignity while minimizing unnecessary interventions, as late-stage dementia is a terminal condition where palliative approaches are most appropriate.
From the FDA Drug Label
Memantine hydrochloride is indicated for the treatment of moderate to severe dementia of the Alzheimer’s type. Study 2 (Twenty-Four-Week Study) ... memantine hydrochloride/donepezil treatment was statistically significantly superior to placebo/donepezil. Study 3 (Twelve-Week Study) ... a statistically significant treatment difference at 12 weeks that favored memantine hydrochloride over placebo was seen on both primary efficacy measures
Treatment options for late-stage dementia include:
- Memantine hydrochloride as a single agent or in combination with donepezil for moderate to severe dementia of the Alzheimer's type 2 2
- Combination therapy of memantine hydrochloride and donepezil may be more effective than donepezil alone in slowing decline in patients with moderate to severe Alzheimer's disease 2
From the Research
Treatment Options for Late-Stage Dementia
The treatment options for late-stage dementia focus on improving the quality of life, dignity, and comfort of the patient. Some of the key considerations include:
- Palliative care: This approach prioritizes the patient's comfort, dignity, and quality of life, rather than curative treatments 3, 4.
- Pharmacologic management: Medications such as anti-depressants, anti-psychotics, and anti-epileptics may be used to manage behavioral and psychological symptoms of dementia, including agitation 5, 6.
- Non-pharmacological interventions: Activities, opportunities to leave the nursing home, and quality of interpersonal care can improve the patient's quality of life 7.
- Hospice care: Referral to hospice care can be associated with improved quality of life and comfort for patients with late-stage dementia 3, 7.
Goals of Care
The goals of care for patients with late-stage dementia should prioritize comfort, dignity, and quality of life. This may involve:
- Focusing on palliative care rather than curative treatments 3, 4.
- Managing behavioral and psychological symptoms of dementia with pharmacologic and non-pharmacologic interventions 5, 6.
- Providing opportunities for activities, social interaction, and quality of interpersonal care 7.
- Considering hospice care for patients with late-stage dementia 3, 7.
Quality of Life
The quality of life for patients with late-stage dementia can be improved through: