Dementia Medical treatment options

The majority of medical interventions for dementia relate to medication management. Well-established guidelines are available, and medical treatments for the symptoms of dementia continue to develop, mainly in the form of cholinesterase inhibitors. Behavioural and Psychological Symptoms of Dementia (BPSD) may be improved with antipsychotic medication. However, medication plays a small role in the holistic management of dementia, which should involve a focus on psychosocial approaches, education, and social support, as well as ongoing medical care.

Cholinesterase inhibitors (Donepezil (Aricept), Galantamine (Reminyl) and Rivastigmine (Exelon)) delay the rate of functional decline of Alzheimer’s disease and therefore help to maintain activities of daily living. These medications act by boosting levels of acetylcholine in the brain that are depleted by the condition, and while they are not curative, they are a useful adjunct in the management of Alzheimer’s disease. In some people side effects such as nausea, vomiting and diarrhoea may occur. Evidence of improvement must be demonstrated on cognitive assessment for these medications to be subsidised under the Pharmaceutical Benefits Scheme (PBS).

Memantine is another available medication that acts by blocking a specific type of receptor (NMDA) in the brain. It has limited supportive evidence for use in moderately severe cases of Alzheimer’s disease and Vascular dementia. There is also limited evidence for the benefit of cholinesterase inhibitors, particularly Rivastigmine in treating people with dementia with Lewy bodies and Parkinson’s disease. These medications are not subsidised through the PBS.

Atypical antipsychotics, such as Olanzapine (Zyprexa) and Risperidone (Risperdal), may benefit people with behavioural and psychological symptoms of dementia. However, the side effects experienced with long-term use may outweigh the benefits. Aggression, agitation and psychotic symptoms such as delusions and hallucinations are the symptoms most likely to respond to these medications. Wandering, intrusiveness and shouting may not improve. Antipsychotic medications should be considered only after non-medication strategies have been tried. The lowest possible dose is recommended and there should be ongoing monitoring for side effects such as increased confusion and extrapyramidal symptoms (for example, involuntary movements, tremors, and rigidity). Serious side effects including stroke and cardiovascular disease are also possible and therefore pre-existing health conditions should be considered when prescribing these medications. Review of medications every few months to determine ongoing need is always recommended.

Symptoms of depression and anxiety are common in people with dementia and should be considered in the medical assessment. Antidepressants may be considered, though side effects including agitation, sleep disturbance and low sodium levels need to be monitored. (Refer to Depression assessment).

Measures known to be successful in preventing occurrence of stroke are likely to decrease the risk of further stroke in those with Vascular dementia. This includes treatment of hypertension (high blood pressure), high cholesterol and diabetes. Aspirin and other antiplatelet or blood thinning medications such as Clopidogrel (Iscover) and Dipyridamole (Asasantin) are effective in preventing the onset of stroke in those at high risk. Anticoagulants such as Warfarin reduce the frequency of stroke in those with atrial fibrillation. There is little evidence that these medications improve cognition in those with established Vascular dementia. Further research is required in this area.

A number of medications can increase confusion in older people, including anticholinergics, parkinsonian medications, sedatives and others. (Refer to Delirium assessment). Regular review of the need and effectiveness of medications may improve the quality of life for the person with dementia.
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Recommendations

• Ensure an open and informed relationship with the doctor or medical specialist;
• If you have questions about the medical management and you do not understand the doctor’s explanation ask the question in a different way
• Consider using a prepared list of points and questions to discuss with your doctor
• Ensure regular medical and medication reviews
• If a person with dementia is admitted to hospital, keep things as routine as possible. For example, try to use their regular clothing/pyjamas, provide a photo and one or two other items from home. Ensure that the staff are well informed about things the person enjoys, and importantly, the things they find unsettling.

Summary

There are a number of medications that may improve the symptoms and quality of life of patients with dementia. Medication plays a small part in the holistic management of a person with dementia. Non-medication strategies such as ongoing assessment and management of concurrent health conditions and regular review of medications are the mainstays of management. Ongoing research is opening the way for new treatments that may one day improve the care, quality of life and functional capacities of people with dementia.

Source: Department of Health and Ageing