Text adapted from "The patient with dementia" in Psychiatry in primary care by Kenneth Le Clair, Dallas Seitz and Julia Kirkham. (CAMH, 2019).
Managing Care and Addressing Critical Issues
Three groups of medications are used to manage Alzheimer’s dementia (also see Table 2 in Diagnosing Dementia):
- cholinesterase inhibitors
- memantine, an NMDA-receptor antagonist
- medications to treat risk factors, behaviour and psychological symptoms associated with dementia.
Three cholinesterase inhibitors (also known as acetylcholinesterase inhibitors) are available in Canada:
- donepezil (Aricept)
- rivastigmine (Exelon)
- galantamine (Reminyl).
These medications are approved for treating mild to moderate Alzheimer’s dementia. Donepezil is approved for severe Alzheimer’s dementia. All have equal efficacy.
Clinical Considerations for Cholinesterase Inhibitors
- The goal of cholinesterase inhibitors is to slow the rate of decline.
- All cholinesterase inhibitors can cause similar side-effects.
- Consider behavioural and functional outcomes in addition to cognitive scores when evaluating the effects of cholinesterase inhibitors.
- Cholinesterase inhibitors may be of benefit in vascular dementia, mixed vascular and Alzheimer’s dementia, dementia with Lewy bodies and dementia associated with Parkinson’s disease.
- Cholinesterase inhibitors should not be used in frontotemporal dementia because they may worsen symptoms.
Various clinical improvements have been noted with cholinesterase inhibitors:
- Modest improvements occur in cognition and functioning.
- Most patients return to pre-treatment baseline levels of dementia after six to 12 months of treatment.
- Most evidence is for treating mild to moderate stages of dementia, with emerging evidence to support the use of cholinesterase inhibitors in advanced stages.
- This newer medication targets NMDA receptors (glutamate) and reduces neurotoxicity accompanying Alzheimer’s dementia.
- Most studies have evaluated the effects of memantine as an adjunct to treatment with cholinesterase inhibitors.
- Memantine is approved for treatment of moderate to severe dementia.
- Memantine tends to be well tolerated. Typical side-effects include confusion, dizziness and nausea.
- Dose adjustment is required in renal failure.
- Memantine is not covered under most public prescription plans.
- ASA: not indicated for dementia, but used to treat comorbid cardiovascular or cerebrovascular disease
- Statins: no consistent evidence that they modify dementia risk in the absence of other indications for their use
- Vitamin E: not recommended at present
- Estrogen: not recommended
- No natural products have been demonstrated to have effects on Alzheimer’s dementia.
Health Promotion and Preventing Unnecessary Disability
- Identify and treat cardiovascular risk factors and optimize cardiovascular health. This is critical not only in vascular dementia, but also in Alzheimer’s and other dementias.
- Encourage the patient to keep active in mind and body.
- Educate the patient and caregivers about early signs of delirium and common changes, including psychosis and depression.
Managing Challenging Behaviours Associated with Dementia
In addition to experiencing cognitive changes, it is also common for people with dementia to develop behavioural and psychological symptoms of dementia (BPSD). BPSD affects between 40 and 80 percent of people with dementia, and is associated with increased caregiver burden and likelihood of being placed in a nursing home.
BPSD can emerge at any stage of dementia. It includes behaviours and psychological symptoms such as:
- agitation and restlessness
- apathy/failure to participate, withdrawing/crying
- defensive behaviour
- hearing and seeing things that do not exist
- hoarding and rummaging
- inappropriate sexual behaviour
- resistance to care
- suspicion, accusing others
- vocal disruptiveness
- The Primary Care Practitioner Role
- Screening & Assessment
- Resources & References