Dementia Treatment: Know Your Options

Article Highlights

• Dementia is a progressive neurodegenerative disease that causes a decline in cognitive function, including memory loss.
• Although there are several therapies (massage, aromatherapy, vitamins, supplements, and many more) that can help ease certain symptoms of the disease, treatments invariably take the form of medication.
• The medications that are commonly prescribed to treat the cognitive symptoms of dementia may also be used to treat other underlying symptoms such as anxiety, depression and sleeplessness.
• Several holistic or alternative therapies are available, but research is inconclusive so further studies are needed.

Introduction

Receiving a dementia diagnosis can be overwhelming and lead family members to wonder what, if anything, can be done to help. Because there currently is no cure for dementia, the primary goals for treating people with dementia are focused on mitigating the symptoms and delaying the disease’s progression. Even so, medications can offer some short-term relief and must constantly be monitored and updated by a physician. Physician evaluation of a person’s need for medication is on a case-by-case basis and depends largely on:

• The Type of Dementia
• The Stage of the Dementia
• The Patient’s Medical History
• The Severity of Dementia Symptoms

Current Drug Therapies for Alzheimer’s Disease

The Food and Drug Administration (FDA) has approved two classes of medications to treat Alzheimer’s Disease:

1. Cholinesterase Inhibitors (AChE Inhibitors): drugs that block the action of Acetylcholine Esterase (AChE)
2. Memantine (brand name Namenda): a N-methyl-D-aspartate (NMDA) antagonist

Both these classes of drugs are used to treat Alzheimer’s symptoms and are referred to as cognitive enhancers. Even though they target cognitive faculties specifically, they are meant to slow down the process of cognitive decline. Medications may also be prescribed to treat non-cognitive issues that accompany dementia, such as anti-depressants for depression or agitation, sleep aids for insomnia, and hypertension medications such as statins for vascular dementia.

Quick Fact: There are currently no FDA-approved medications for dementias other than Alzheimer’s (Fronto-Temporal Dementia, Vascular Dementia, Lewy Body Dementia, etc.). This does not rule out medication as a form of treatment for non-Alzheimer’s dementias. Physicians are known to prescribe off-label medications for the treatment of different dementias. Only one drug, Rivastigmine (a cholinesterase inhibitor) is FDA-approved for use in treating Parkinson’s disease dementia.

1. Cholinesterase Inhibitors (AChE inhibitors)

These medications work to regulate levels of acetylcholine, the chemical messenger important for learning and memory. The brain’s chemical messengers, also known as neurotransmitters, communicate between neurons and allow the brain to function. With Alzheimer’s disease, the neurons and their synapses (the location where these chemical messengers are released) are destroyed, causing communication to be disrupted.

Acetylcholine

Acetylcholine (ACh) is a chemical messenger, or neurotransmitter, that plays a crucial role in learning and memory. As Alzheimer’s disease progresses and causes increasing damage to the brain, the level of acetylcholine declines. Cholinesterase inhibitors (AChE inhibitors) partially correct the deficit of ACh in the brains of individuals with Alzheimer’s disease by blocking the action of Acetylcholinesterase (AChE). This prevents the breakdown of acetylcholine, thus allowing for higher levels of ACh and proper function of the communication network. The use of cholinesterase inhibitors may not be appropriate for the treatment of certain dementias such as Vascular Dementia, Mixed Dementia, or Frontal Temporal Dementia, as the source of cognitive symptoms for these dementias is not attributed to the lack of acetylcholine in the brain.

Types of Cholinesterase Inhibitors

The AChE inhibitors that are FDA-approved to be used to treat mild to moderate Alzheimer’s disease are Donepezil (brand name Aricept), Galantamine (brand name Razadyne), and Rivastigmine (brand name Exelon). Another cholinesterase inhibitor, Tacrine (Cognex), is now used less frequently due to its unfavorable side effects and frequent dosage requirements. The most common side effects of these drugs include nausea, diarrhea, fatigue, and loss of appetite, but are tolerated by most individuals.

Donepezil (Aricept)

Besides Tacrine (Cognex), Donepezil (Aricept) has been around the longest as a dementia treatment medication. It is FDA-approved to treat Alzheimer’s disease in all stages. It has an effective starting dose that does not need to be built up in the body, and has to be taken only once daily. Donepezil is thus considerably easier to administer. Its side effects may include:

• Gastrointestinal issues
• Weight loss
• Insomnia
• Nightmares or intense dreams
• Fatigue

To avoid the side effects of insomnia and nightmares, Donepezil is often prescribed to be taken after breakfast. For patients with swallowing issues, Donepezil is offered in the form of disintegrating tablets.

Galantamine (Razadyne)

Galantamine is FDA-approved for the treatment of Alzheimer’s disease in the mild to moderate stage. It is derived from the snowdrop flower, making it a good option for patients who prefer natural remedies. In addition, Galantamine is a good option when gastrointestinal problems have occurred due to other drugs, and when skin sensitivities preclude the option of a skin patch.

Rivastigmine (Exelon)

Rivastigmine is FDA-approved to treat mild to moderate Alzheimer’s disease. It can be administered as a capsule or skin patch. Side effects of oral Rivastigmine include gastrointestinal issues such as nausea, diarrhea, vomiting, and weight loss. People who experience gastrointestinal issues from oral Rivastigmine or other cholinesterase inhibitors may benefit from the patch. Patch placement itself must be done correctly to deliver an effective dose. The burden of administering this drug thus falls on the caregiver.

2. Memantine (Namenda)

Memantine is the only FDA-approved drug to treat moderate to severe Alzheimer’s disease. Excess glutamate, a chemical in the brain, can cause brain cells to die; Memantine is a NMDA antagonist that regulates glutamate levels in the brain by blocking NMDA receptors with “low affinity.” Its ability to selectively block pathological activation of NMDA receptors blocks glutamatergic activation and chronic neurodegneration, thus facilitating cognitive activity. Memantine may also be effective when used off-label to treat Vascular Dementia, Mixed Dementia, Lewy Body Dementia, and Fronto-Temporal Dementia.

Combination Therapies

Combination therapies of Cholinesterase Inhibitors and NMDA antagonists, such as Donepezil and Memantine, are another treatment option for moderate to severe dementia. Side effects include constipation, headache, confusion, and dizziness. It is important to emphasize that these medications do not stop or reverse the progression of dementia, but they might help slow the disease.

Treating Dementia Mood and Behavior Symptoms

Declining cognitive function is not the only impact that dementia can have on a person. Dementia Mood and Behavior Symptoms can also occur and be just as disconcerting for loved ones. Drastic changes to the way a person acts and feels can manifest differently across the various types of dementias, but common changes include:

• Irritability, anxiety, agitation, anger and outbursts
• Depression
• Hallucinations and delusions
• Sleep disturbance and restlessness

Non-medication approaches can first be explored when these behaviors are severe and may cause harm to the person with dementia or others. Oftentimes, behavior and mood symptoms can be triggered by stressors such as sudden change or misconstrued threats, by drug side effects, or by an untreated infection or illness. Some therapies that can improve cognition in individuals with dementia and potentially slow disease progression are:

• Physical Exercise
• Cognitive Engagement
• Music Therapy
• Pet Therapy

FDA-approved medications are the next treatment option when non-medication approaches are insufficient towards correcting mood symptoms. Medications used to treat mood and behavior symptoms are often used in an off-label fashion and include antidepressants, anxiolytics, and antipsychotic medications. All of these have side effects and a possibility of drug interactions, thus it is critical to carefully evaluate the risks and benefits of starting a treatment protocol to reduce the likelihood of such symptoms.

Dementia Treatment: What to Know

Medications take time to work

Medications used for dementia treatment work within the brain to help alleviate cognitive symptoms. Older adults can be more sensitive to medications and changes in medication regimens. Doctors tend to slowly work up to a drug’s full dosage so they can monitor any potential negative side effects.

It is therefore important not to stop medications simply because “they do not seem to be working”. This can disrupt the proper course of treatment. Always discuss concerns or observed side effects with your loved one’s doctor. It is important to follow the doctor’s instructions and never adjust or stop treatment for your loved one’s treatment without consulting a medical professional.

Inside Look: Anna’s Patience

After being diagnosed with Alzheimer’s disease, Anna’s 75-year-old mother was referred to a specialist and prescribed a new medication. After two weeks Anna became frustrated with seeing no results and discontinued the medication for her mother. When they went to see the specialist again, Anna explained that she stopped her mother’s medication because “it wasn’t working,” and there were no observable changes. The doctor explained to her that these types of medications take time to work and that Anna needed to compare her mother’s behavior, function, and cognition to note any changes after taking the medication for a few months.
A few months later, Anna took her mother to the specialist and noted that her mother’s daily function had shown improvement; she could now carry out tasks like putting on her coat and shoes with more ease than before. Anna also noted that she seemed to show more mental clarity over the past few months compared to the months before diagnosis. Now that her mom was showing improvement without negative side effects, the doctor explained he would continue with this medication and increase the dose. Anna’s mother tolerated the medication and for the next couple of years carried out many functions of daily living without assistance.

Keep an up-to-date medication list

Having a medication list with all the medications your loved one is currently taking can be helpful to take to every doctor appointment. A person with dementia may have additional health issues and multiple doctors, so the possibility of drug-interactions and duplicate medications can occur. Drug interactions can limit the effectiveness of a medication or exacerbate dementia symptoms. Keeping medications in a pill organizer can help you keep track of your loved one’s daily dosages and make it less likely to miss or double up a dose. Multiple medications, coupled with a diminished cognitive capacity that comes with dementia, make it crucial for a caregiver to be actively involved in the dispensing and monitoring of medication.

Inside Look: Catherine’s Concern

Catherine’s 70-year-old husband’s dementia seemed to be responding well to treatment until she began noticing a significant decline in his cognition and behavior. Catherine decided to take her husband to his dementia specialist. When visiting the specialist, Catherine described her husband’s significant decline over the past month. She explained that she monitors his medications in a pill organizer and, to help her husband be more comfortable, she too takes her daily medications and vitamins with him. Catherine gives her husband’s medication list to the specialist to look over and he notices a new cardiovascular medication on the list.
The specialist asks about when the medication was started and Catherine explains that about a month ago, her husband’s cardiologist prescribed the medication because her husband was experiencing a slowing of his heart beat. The specialist described that her husband’s cognitive decline may be due to a drug interaction between this new medication and his dementia medications. The specialist wants to discuss an alternative medication with the cardiologist before they discontinue or switch his dementia medication. Catherine makes an appointment with the cardiologist right away and after discussion with the dementia specialist they switch to a different cardiovascular medication. After a few weeks, Catherine began seeing slight improvement in her husband’s cognition and behavior.

Medications have side effects

Every medication comes with the possibility of side effects. Knowing what side effects to look for and how to adjust accordingly can prevent the need to completely stop a medication. For example, if a medication causes insomnia, then a physician may prescribe the medication to be taken in the morning rather than before bedtime. In addition to adjusting timing, the mode in which the medication is dispensed may also be altered. For example, if taking a medication orally causes gastrointestinal issues, then perhaps a skin patch delivery would be a more appropriate option. Another option is to prescribe two medications in combination, such as a Cholinesterase Inhibitor with Memantine, which is known to help with medication tolerance and reduce gastrointestinal symptoms.

Inside Look: Peter’s Father

Peter’s 87-year-old father was recently diagnosed with dementia. At a meeting with his father’s physician, they began discussing medication options. Peter is concerned about some of the side effects of certain medications because his father had suffered problems with constipation in the past. The physician suggested a dementia drug that may cause diarrhea in hopes that it actually may help with his father’s constipation.

After a couple of months of slowly increasing the drug’s dose, not only did Peter’s father tolerate the drug, but it also helped with his constipation problem.

Alternative Therapy

There are many alternative therapies that are known to help treat dementia. Natural supplements, such as caprylic acid, and vitamins, such as vitamin B, D, and E, have shown effective results with regards to improving cognition. More research needs to be done to clinically approve the use of these supplements.

It is also important to remember that supplements, vitamins, and herbs may cause drug interactions that can be harmful or inhibitory. Nutrition, exercise, activities, and socialization have been shown to benefit individuals with dementia.

Diet and Exercise

Maintaining a healthy diet can help slow down the rapid decline of cognitive health in individuals with Alzheimer’s and other dementias. In combination with exercise, a healthy, well-balanced diet helps protect the heart, which in turn supports brain health and cognitive function. Studies have shown that about 80% of individuals with Alzheimer’s disease were found to have cardiovascular disease1. The Mediterranean diet and the Dietary Approaches to Stop Hypertension (or DASH diet) have both been studied and shown to help protect cardiovascular health2. In addition, keeping pre-existing cardiovascular issues such as hypertension, diabetes, and high cholesterol in check through diet, exercise, and proper medication, can preserve brain health.

Stimulating Activities and Socialization

Mental stimulation helps exercise the brain and can improve or maintain cognitive abilities in individuals with dementia. Engaging in stimulating activities that an individual with dementia enjoys can also improve quality of life by promoting a sense of independence and initiative. Activities may include daily walks, crafts, puzzles, and reminiscence. Socialization can also help improve cognitive health by combating isolation, depression, and inactivity.

Final Thoughts

Dementia treatment does not solely depend upon medication. A good treatment plan involves the active participation of caregivers, the individual’s present and past medical history, and a knowledgeable dementia specialist.

Keeping an open line of communication with your loved one’s physician can help maintain an effective treatment plan while also keeping the physician informed of potential adverse effects of medications. It is important to remember that radical improvements are not likely to occur, and that these medications only provide a temporary solution, not a cure. New research on how different dementias progress will offer insight into new treatments, and hopefully one day, a Dementia Cure.

Family and professional caregivers should exercise maximum diligence when it comes to managing individuals’ dementia with medication. Not only is it easy to make mistakes, but mistakes can go unnoticed for a long time as side effects can be perceived as dementia-related inevitable decline. You should work with your loved one’s doctors to differentiate between dementia symptoms and abnormal side effects from medications. Once one identifies that distinction, the appropriate measures can be taken to improve the quality of life for both the caregiver and person with dementia.

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References

1. Hakim, A., N., & T. (2013). Heart disease as a risk factor for dementia. Clinical Epidemiology, 135. Retrieved January 9, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641811/
2. Estruch, R. (2012). Effects of Mediterranean diet on the primary prevention of cardiovascular disease. Retrieved January 9, 2017, from http://www.nejm.org/doi/full/10.1056/nejmoa1200303#t=article

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