From the Guidelines
Currently, there is no cure for Alzheimer's disease, but several medications and non-pharmacological approaches can help manage symptoms and potentially slow disease progression, as recommended by the most recent study in 2025 1. The primary medications approved for Alzheimer's treatment include cholinesterase inhibitors such as donepezil (Aricept) at 5-10mg daily, rivastigmine (Exelon) at 1.5-6mg twice daily, and galantamine (Razadyne) at 4-12mg twice daily. These medications work by increasing levels of acetylcholine, a neurotransmitter involved in memory and thinking. For moderate to severe Alzheimer's, memantine (Namenda) at 5-10mg twice daily may be prescribed, which regulates glutamate activity. Some key points to consider when treating Alzheimer's disease include:
- The choice of pharmacologic agents should be based on tolerability, adverse effect profile, ease of use, and cost of medication, as stated in the 2008 guideline 1.
- Non-pharmacological approaches such as cognitive stimulation, physical exercise, good nutrition, and social engagement should also be included in the treatment plan.
- Caregivers should establish routines, simplify tasks, ensure safety measures at home, and seek support groups.
- Treatment plans should be individualized based on disease stage, overall health, and potential medication side effects, with regular monitoring by healthcare providers to adjust therapy as needed, as recommended by the 2022 study 1.
- More recent studies, such as the 2023 study 1, highlight the importance of considering the individual's quality of life and overall well-being when making treatment decisions.
- The 2025 study 1 provides the most up-to-date guidance on the management of dementia, including the use of cholinergic agents and memantine. It is essential to prioritize the individual's quality of life and overall well-being when making treatment decisions, and to regularly monitor and adjust the treatment plan as needed, based on the most recent and highest-quality evidence available 1.
From the FDA Drug Label
The effectiveness of donepezil hydrochloride in the treatment of patients with moderate to severe Alzheimer’s disease was established in studies employing doses of 10 mg/day and 23 mg/day The effectiveness of donepezil hydrochloride as a treatment for severe Alzheimer's disease is demonstrated by the results of a randomized, double-blind, placebo-controlled clinical study conducted in Sweden (6 month study) The curves show that both patients assigned to memantine hydrochloride/donepezil and placebo/donepezil have a wide range of responses and generally show deterioration, but that the memantine hydrochloride/donepezil group is more likely to show a smaller decline or an improvement A statistically significant treatment difference at 12 weeks that favored memantine hydrochloride over placebo was seen on both primary efficacy measures
Treatment Options for Alzheimer's Disease:
- Donepezil: effective in the treatment of patients with moderate to severe Alzheimer’s disease, with established doses of 10 mg/day and 23 mg/day 2
- Memantine: in combination with donepezil, shows a smaller decline or an improvement in cognitive function, with a statistically significant treatment difference at 12 weeks 3 Key points:
- Donepezil and memantine are two treatment options for Alzheimer's disease
- Donepezil is effective in moderate to severe Alzheimer's disease
- Memantine, in combination with donepezil, may slow down cognitive decline in Alzheimer's disease 2, 3
From the Research
Treatment Options for Alzheimer's Disease
The current treatment options for Alzheimer's disease include:
- Cholinesterase inhibitors, such as donepezil, rivastigmine, and galantamine, which have been shown to improve cognition and function in patients with mild to moderate Alzheimer's disease 4, 5, 6, 7
- N-methyl-D-aspartte receptor antagonist memantine, which has been shown to improve cognitive functions and behavioral disturbances in patients with Alzheimer's disease 8
- Combination treatments with memantine and one cholinesterase inhibitor, which has been shown to be a useful treatment for Alzheimer's disease 8
Cholinesterase Inhibitors
Cholinesterase inhibitors are the most established treatment strategy for Alzheimer's disease, with three main types:
- Reversible inhibitors of acetylcholinesterase and butyrylcholinesterase, such as tacrine, donepezil, galantamine, and physostigmine 4
- Irreversible inhibitor, such as metrifonate 4
- Pseudoirreversible inhibitor, such as rivastigmine 4 These inhibitors have been shown to improve cognition and function in patients with Alzheimer's disease, but their benefits are not sustained indefinitely and the illness continues to progress even while patients are receiving treatment 5
Switching Between Pharmacological Agents
Switching between cholinesterase inhibitors may help to improve response to treatment and address issues such as lack/loss of efficacy or safety/tolerability in patients with Alzheimer's disease 6 Dose up-titration and switching between cholinesterase inhibitors may also help to improve response to treatment 6
Safety and Efficacy
The safety and efficacy of cholinesterase inhibitors and memantine have been evaluated in several studies, with results showing that:
- Cholinesterase inhibitors are generally well-tolerated, but may cause peripheral cholinergic adverse effects, such as nausea, vomiting, and diarrhea 4, 5, 7
- Memantine is well-tolerated and its safety is comparable or superior to that of the placebo 8
- Combination treatment with memantine and donepezil is considered to be the most useful treatment for Alzheimer's disease 8