Dementia

Treatment

If the cause of the dementia is known it is possible to tailor the treatment accordingly. For example, for the main cause of dementia, Alzheimer's disease (AD), medication is available to manage the behavioural symptoms of the disease and treat the symptoms of cognitive deterioration, although, there is currently no cure for AD.

Drug Treatment

Cognitive deterioration can be treated using medication that increases the level of acetylcholine in the brain, enabling neurons  to communicate with one another more effectively. These drugs block the action of acetylcholinesterase, the key enzyme involved in the breakdown of acetylcholine in the synaptic cleft , and may also improve some non-cognitive symptoms, such as delusions. Acetylcholinesterase inhibitors include rivastigmine, donepezil and galanthamine.

In addition to drugs that increase the level of acetylcholine in the brain, manipulating the NMDA receptor  (a part of the neuron receiving a specific chemical signal at the synapse) seems a promising new treatment opportunity. Excessive stimulation of NMDA receptors may cause neuronal cell death. Recent studies suggest that memantine, a compound that blocks such excessive stimulation, slows the progression of moderate to severe AD.

Recent studies have suggested that estrogens, anti-oxidants and anti-inflammatory drugs could delay the onset of AD. The benefit of the anti-oxidant vitamin E and the monoamine oxidase B inhibitor deprenyl is currently being investigated in people with AD. Studies suggest that a good diet may also help to slow the progression of the illness. All of these approaches require further research before they can become recommended treatments.

Treatments for the Non-Cognitve Symptoms of Dementia

Dementia is a complex syndrome with many symptoms other than memory loss or the loss of functional abilities. These symptoms include depression, anxiety, agitation and occasionally aggression, altered sleep and psychotic symptoms. Psychotic symptoms include visual hallucinations (seeing things that are not there), hearing voices or false smells or taste, delusions (often a conviction that something has been stolen) and mistaken identity (believing a relative has been replaced by an impostor for example). Most people with dementia suffer from some form of non-cognitive symptom at some point in their illness and these symptoms are collectively often known as Behavioural and Psychological Symptoms of Dementia (BPSD).

Treatment of BPSD is at least as important as treating the cognitive symptoms, because the non-cognitive symptoms can cause immense stress and anxiety to both the person with dementia and their carer. BPSD is also a major factor in decisions relating to long term care, nursing homes and when a person with dementia needs more intensive care.

The first stage of treatment is always an assessment of the nature and timing of the symptoms. BPSD can be exacerbated, or even caused, by concurrent physical illness or environmental influences. Thus a urinary tract infection might cause disturbed sleep; influenza might increase a depressive mood, arthritic pain cause anxiety or aggression and a chest infection precipitate psychotic symptoms. In each case the appropriate treatment might be for the underlying physical state not the BPSD. Environmental triggers of BPSD include a change in the daily routine or a new carer or BPSD might only emerge during a particular care task – e.g. agitation when helped in the toilet. In these cases treatments are usually directed towards making the environment more conducive, to helping the carer to adapt to the patient, or by developing a distraction regimen or behavioural intervention. Sleep disturbance can be treated effectively by adopting optimum sleep hygiene – no naps in the day, appropriate expectations for bed time and duration of sleep, no caffeine late afternoon onwards and increased physical activity.

In many cases treating underlying physical illness or an environmental or behavioural intervention will be sufficient to treat the BPSD; although, drug treatment is still often required. The approach adopted should be ‘first do no harm’ and treatments should be chosen that are well tolerated by the elderly and those with dementia. For example many psychoactive drugs, including some tricyclic antidepressants (TCAs), have an anti-cholinergic action and would be predicted to adversely affect the cognitive abilities of people with AD (where cholinergic function is compromised). There is some evidence that this is the case and equal evidence that the selective serotonin reuptake inhibitors (SSRIs) have relatively fewer side effects in people with dementia.

Other drugs used to treat BPSD include anti-psychotic medication including both older and newer ‘atypical’ anti-psychotics. These drugs should be used to treat specific symptoms and not to sedate people with dementia. Their use should be kept under regular review and best practice would be to use these drugs only when essential, in the smallest possible dose for the shortest possible time. Other drugs sometimes used to manage BPSD and sleep disturbance in particular are highly sedating and include the benzodiazepines (BDZs). Many physicians find that these types of drugs can increase confusion in patients with dementia and avoid prescribing them for these patients whenever possible. More recently evidence is beginning to emerge that the anti-cholinesterase drugs might have a beneficial effect not only on memory and functioning but also on some BPSD.

Read more about TCAs, SSRIs and BDZs

The use of drugs to treat BPSD should always be secondary to treating the underlying physical illness or to behavioural or environmental modification and the use of psychoactive drug treatment should be kept as low and as brief as possible. However, there is no doubt that judicious and effective treatment of BPSD is central to management of dementia. Effective treatment can enable a person to remain at home with their family rather than be admitted to long term care with all the consequences for quality of life that inpatient care implies.

Psychosocial Treatment

Psychosocial treatment is extremely important in AD, not only for the patient but also the caregiver. Support for family caregivers is essential as they may suffer from depression, anxiety and sleep disorders , as a result of providing continuous care to a family member who may be severely ill. All caregivers need support, but some become depressed or anxious and might need treatment such as counselling or behavioural therapy to improve, for example, the quality of their sleep. Psychoeducation programmes can promote better patient management. Many people with AD eventually require nursing home care, and family members need support during this difficult time.

People with AD sometimes receive therapy to improve their cognitive impairment. For example, training should be given in the use of memory aids, such as mnemonics, computerised recall devices, or use of note taking, as these may assist communication in people with mild dementia.

The best therapy is to keep the patient in his or her most familiar surroundings for as long as possible. The more active the person, mentally and physically, the longer the symptoms of the disease can be kept at bay and the better the quality of life.