Medication and treatment for dementia

Dementia medication

Medicines for dementia are used firstly as a treatment to help with symptoms that affect thinking and memory (cognitive symptoms). Secondly, they are used as treatment to help with symptoms that affect mood and how someone behaves (non-cognitive symptoms).

These medicines do not cure dementia and they may only work for some people. They also may only work for a short time (6-12 months) and generally slow the deterioration rather than preventing it. Medicines for dementia are always started by a doctor who specialises in treating dementia.

There are four medicines available in the UK which can be prescribed for dementia. These are donepezil, rivastigmine, galantamine and memantine. They are available as tablets, liquids, tablets that dissolve in water, or patches. They come in various brand names.

In addition, there are a number of other medicines that may be prescribed to people who have dementia. For example:

• An antidepressant may be advised if depression is suspected. Depression is common in people with dementia and may be overlooked.

• Aspirin and other medicines to treat the risk factors for stroke and heart disease may be appropriate for some people. This is especially the case for those with vascular dementia.

• Sleeping tablets are sometimes needed if difficulty sleeping is a persistent problem.

• A tranquilliser or an antipsychotic medicine is sometimes prescribed as a last resort for people with dementia who become easily agitated.

Research continues looking for new medicines to help with dementia and there is some promising research with drugs known as 'mabs' which are a form of immunotherapy. They target amyloid in the brain, which is part of the disease process that causes dementia, and the hope is that by clearing amyloid plaques more rapidly symptoms may reduce. However, none of these drugs are close to being used in routine clinical care.

Alternative treatment for dementia

Support and care is the most important part of treatment

When someone is diagnosed with dementia, a full assessment may be suggested to look at their practical skills, their ability to look after themself, their safety in their home, etc. This usually involves assessment by a number of different healthcare professionals. An individual care plan may be drawn up that outlines the person's specific needs. The aim is to maintain the independence of someone with dementia as much as possible and for as long as possible.

Most people with dementia are cared for in the community. Often, the main carer is a family member. It is important that carers get the full support and advice which is locally available. Support and advice may be needed from one or more of the following healthcare and allied professionals, depending on the severity of the dementia and the individual circumstances:

• District nurses can advise on day-to-day nursing care.

• Occupational therapists can advise on changes to the physical environment, which may help a person with dementia. For example, handrails and grab bars, labelling of objects, removing items that are not needed in the home.

• Physiotherapists can help. For example, with exercises to help maintain mobility.

• Community psychiatric nurses can advise on caring for people with mental illness. Sometimes a specialist assessment by a psychiatrist may be needed.

• Social Services can advise on local facilities such as daycare centres, benefits, help with care in the home, sitting services, respite care, etc.

• People who can advise on financial and legal matters, such as Lasting Power of Attorney.

• Voluntary organisations can be a good source of advice. If you care for a person with dementia, it is well worth getting information about the help that is available in your local area. In most areas of the UK there are organisations that provide support and advice for carers of people with dementia. Your local library or Citizens Advice Bureau will often have contact details.

The level of care and support needed often changes over time. For example, some people with mild dementia can cope well in their own home which is very familiar to them. Some may live with a family member who does most of the caring. If things become worse, a place in a residential or nursing home may be best. The situation can be reviewed from time to time to make sure the appropriate levels of care and support are provided.

Many carers struggle on beyond the point where they need more help. If you are a carer, you can ask a GP or district nurse to assess a person with dementia if you feel that you need a greater level of support. There are a number of local carer support groups on the internet, which may also be able to provide support and advice. For example, information about respite/short-break services for carers.

Other possible treatments

There are some other treatments and options that may be helpful for some people with dementia, particularly in certain situations. These include the following:

• Measures to help simplify the daily routine and enhance memory.

• Reality orientation.

• Cognitive stimulation.

• Regular physical activity.

• Reminiscence therapy.

• Cognitive behavioural therapy (CBT).

• Behavioural therapy.

• Animal-assisted therapy.

• Sensory stimulation.
  

Measures to help simplify the daily routine and enhance memory

This may be as simple as planning out and writing down a daily routine. This may include writing reminders to do certain things such as putting the rubbish out, locking the door at night-time, etc. Making sure that clothing, keys, glasses or other things that are used often are put in prominent places where they can be found easily may also be helpful. Labelling of commonly used objects may be another useful tool. An occupational therapist may be able to advise.

Reality orientation

This is thought to help in some cases. It involves giving regular information to people with dementia about times, places, or people to keep them orientated. It may range from simple things, such as having a board in a prominent place, giving details of the day, date, season, etc, to staff in a residential home reorientating a person with dementia at each contact.

Cognitive stimulation

Stimulating the brain may help to improve memory, language and problem-solving ability. For example, by recreational activities, problem-solving activities and talking to the person with dementia. In addition, recreational activities may enhance quality of life and well-being.

Regular physical activity

If possible, such as walking, dancing, etc, may help to slow down the decline in mobility that is common in people with dementia. It may also help if depression is a problem.

Reminiscence therapy

This involves encouraging people to talk about the past so that past experiences are brought into their current thoughts. It relies on long-term memory which is often quite good in people with mild-to-moderate dementia.

Cognitive behavioural therapy

CBT is sometimes tried to help treat depression that is quite common in people with dementia.

Behavioural therapy

Behavioural therapy may also be used to treat any problems related to behaviour that someone with dementia may have. This type of therapy looks for possible reasons for certain behaviours. For example, someone who wanders a lot may in fact be doing this because they are feeling quite restless. In this situation, taking part in regular physical activity may help.

Animal-assisted therapy

Animal-assisted therapy may sometimes be suggested to help people with dementia who have challenging behaviour such as agitation or aggression. For example, allowing the person to spend time with and interact with a trained dog.

Sensory stimulation

For example, using music, lights, sounds, smells, massage and aromatherapy to stimulate the brain. This may also be helpful for some people with dementia - for example, to improve their mood or feelings of restlessness.

How does dementia medication work?

Medicines for dementia work by increasing the levels of certain chemical messengers in the brain.

Acetylcholinesterase inhibitors

These include donepezil, rivastigmine and galantamine. They work by increasing the level of acetylcholine. This is a chemical in the brain that is low in people with Alzheimer's disease. These medicines are not a cure for Alzheimer's disease. However, they may help to treat some of the symptoms affecting thinking and memory in about half of people with Alzheimer's disease.

In the UK, the National Institute for Health and Care Excellence (NICE) recommends that donepezil, galantamine and rivastigmine can be considered as treatment options for people with mild or moderate Alzheimer's disease, providing that:

• The medicine is started based on the advice given by a specialist in the care of people with dementia - after this advice, the first prescription might be given by the GP. For those who are already being treated for dementia, NICE says that a GP who feels confident to do this may start memantine without taking advice from a specialist clinician. However, doctors should never work outside of their skills and many GPs may still want to discuss this decision with a specialist.

• A person receiving treatment has regular reviews and assessments of their condition. (Reviews are usually carried out by a specialist team. Carers' views on the person's condition should also be asked before the medicine is started and should be considered during the reviews.)

Common side-effects of these medicines may include feeling sick, muscle cramps, tiredness, headache and diarrhoea. Your doctor should be able to give you more details about possible side-effects.

The medicine rivastigmine is also licensed to be used in people with mild-to-moderately severe dementia who also have Parkinson's disease. So, doctors may suggest this medicine for this group of people. Also, an acetylcholinesterase inhibitor medicine may sometimes be suggested for people with dementia with Lewy bodies (DLB) who have problems with challenging or disruptive behaviour (non-cognitive symptoms). See also the separate leaflet called Lewy Body Dementia.

Memantine

• Memantine is also licensed for the treatment of Alzheimer's disease in some people. It works by reducing the amount of a brain chemical called glutamate. It is thought that this may help to slow down the damage to brain cells affected by Alzheimer's disease. Like the medicines above, this is not a cure. Some research studies have shown that it seems to slow down the progression of the symptoms in some cases.

NICE recommends that it can be considered as a treatment option for:

• People who have moderate Alzheimer's disease and who for some reason cannot take, or are intolerant to, the acetylcholinesterase inhibitor medicines.

• People who have severe Alzheimer's disease.

See also the separate leaflet called Alzheimer's Disease.

When is medication for dementia usually prescribed?

Your GP will usually refer you to a doctor who specialises in treating dementia, to confirm that you have dementia. The specialist will then decide if you should have treatment and if this should be given in the early stages or later on. The decision making process will also depend on the type of dementia, or whether the person doesn't have dementia but instead has mild cognitive impairment, which is not usually treated with this class of drugs. This decision to start treatment and which treatment to start depends on various things. These include what has caused your dementia, what your symptoms are and how severe your dementia is. Dementia is usually classed as being mild, moderate or severe. See also the separate leaflet called Memory Loss and Dementia.

Which dementia treatment is usually prescribed?

Your specialist will decide which treatment is right for you. There are national guidelines for people with dementia that can help your specialist decide which treatment to choose.

One of the following is usually recommended: donepezil, galantamine and rivastigmine for people with mild or moderate Alzheimer's disease, providing that:

• The medicine is started by a specialist in the care of people with dementia.

• A person receiving treatment has regular reviews and assessments of their condition. (Reviews are usually carried out by a specialist team. Carers' views on the person's condition should also be sought before the medicine is started and should be considered during the reviews.)

Memantine can be considered as a treatment option for:

• People who have moderate Alzheimer's disease and who, for some reason, cannot take, or are intolerant to, the acetylcholinesterase inhibitor medicines.

• People who have severe Alzheimer's disease.

These medicines are not usually used for people with other types of dementia. However, rivastigmine can be used for people with Lewy Body dementia/dementia with Lewy Bodies (DLB). So, doctors may suggest this medicine for this group of people. Also, an acetylcholinesterase inhibitor medicine may sometimes be suggested for people with DLB who have problems with challenging or disruptive behaviour (non-cognitive symptoms).

How well do dementia treatments work?

It is thought that about half the people treated with a cholinesterase inhibitor will see an improvement in symptoms which affect thinking and memory. Whether they help with other symptoms such as aggression and agitation has still not been confirmed. The improvement in symptoms is usually only seen for about 6-12 months.

For memantine, some studies have shown that it can slow down the progression of symptoms in some cases.

How should dementia medication be taken?

It is usual to start with a low dose. This is then increased over a period of weeks to a target treatment dose. The dose is increased slowly because when you first start taking these medicines you may develop some unpleasant side-effects - for example, diarrhoea, feeling sick (nausea) and being sick (vomiting).

Most people who develop side-effects find that after a period of time these go away. If you are tolerating a low dose well, your doctor will increase your dose, if needed. How often the dose is increased depends upon which medicine you are taking. For example, if you are taking galantamine, the dose is increased every four weeks. If you are taking rivastigmine tablets, the dose is increased at intervals of no less than two weeks.

See the leaflet that came with your medicine for more information.

What is the usual length of treatment?

Medicines for dementia are usually only continued for as long as they are thought to be having a worthwhile effect on symptoms.

Side-effects of dementia medication

Medicines for dementia cause side-effects in some people. However, if side-effects do occur, they are usually minor and often go away after a few months.

The most common side-effects of anticholinesterase inhibitors include:

• Diarrhoea.

• Muscle cramps.

• Feeling tired (fatigue).

• Feeling sick (nausea).

• Being sick (vomiting).

• Not sleeping well (insomnia).

• Headache.

• Being incontinent of urine.

Other less common side-effects include:

• Symptoms of the common cold.

• Loss of appetite.

• Mental health disorders.

• Fainting and seizures.

• Dizziness.

• A thumping heart (palpitations).

• Flushing or sweating.

• Rash.

• Itching.

Memantine may cause:

• Dizziness.

• Headache.

• Feeling out of breath.

• Constipation.

• Drowsiness.

• High blood pressure.

Other less common side-effects include:

• Vomiting.

• Blood clots (thrombosis).

• Heart problems.

• Confusion.

• Feeling tired.

• Seeing things or hearing things which are not real (hallucinations).

• Problems with walking.

The above is not an exhaustive list but highlights the more common possible side-effects. For a full list of side-effects see the information leaflet that comes with the medicine.

Who cannot take dementia medication?

In general, most people are able to take these medicines. Caution may be needed in people with certain medical problems. For example, people with severe liver or kidney problems may not be able to take them, or they may need a lower dose. Care also needs to be taken in people who have had fits in the past. For those who have Lewy Body dementia, a careful balance needs to be achieved between the memory symptoms and the movement symptoms, as a drug which improves one can worsen the other.

Can you buy dementia medication?

No - you cannot buy medicines for dementia. They are only available on prescription.

'They target amyloid in the brain, which is part of the disease process that causes dementia, and the hope is that by clearing amyloid plaques more rapidly symptoms may reduce'