Therapeutic approaches in cases of dementia
Most medication available for the treatment of Alzheimer’s disease focus on the symptoms and can contribute to a stabilisation of cognitive as well as functional capacities.
Medications that are intended at treating the dementia-related loss of cognitive capacities are known as anti-dementia drugs. These medicines are used to treat the main symptoms caused by Alzheimer’s disease and prevent cognitive impairment as well as slow down the progression of the disease.
At present, four active substances are authorised in the treatment of Alzheimer’s disease:
Acetylcholinesterase inhibitor (often abbreviated as AChEI)
This medication is used for treating mild to moderate forms of Alzheimer’s disease.
• Donepezil (for ex. Aricept®)
• Galantamine (for ex. Reminyl®)
• Rivastigmine (for ex. Exelon®)
Side effects caused by these medications include nausea, diarrhoea, vomiting, digestive upset, stomach ache, appetite loss, weight loss, and more rarely sleep disturbances, dizziness, fatigue and muscular cramps. These side effects usually disappear within a few weeks after the beginning of the treatment.
Acetylcholine is responsible for the signal transmission from one neuron to another. In a person with Alzheimer’s disease, this substance is not produced in sufficient quantities. These “inhibitors” help ensure that the breakdown of acetylcholine is delayed at the synaptic connection. In this way, the shortage of acetylcholine is made up for, at least in the early and middle phases of the illness. Improved cognitive and functional faculties enable the patient to benefit from the treatment. However, as regards treatments of challenging behaviours, from which patients with Alzheimer’s often suffer, acetylcholinesterase inhibitors are often not efficient.
Glutamate receptor antagonist
This medication is used for patients with moderate to severe forms of Alzheimer’s disease.
• Memantine (for ex. Axura®, Ebixa®)
Side effects include mostly weak symptoms such as dizziness, confusion, headaches and constipation. However, care should be taken not to administrate this medication to patients suffering from a kidney affliction.
The messenger substance called glutamate is indispensable for learning and memorizing processes. However, a too large quantity of glutamate can have a negative impact on neurons and cause their death. Glutamate receptor antagonists protect the neurons from an excessive influx of glutamate. In moderate to severe stages of the illness, learning and memory capacities can be maintained for a longer time. For patients with mild cognitive impairment, no effect has been observed, for which reason the treatment is not recommended.
Memantine is often used in case of Alzheimer’s disease, and is known under various trade names.
Therapy for emotional and behavioural disorders
In order to address the issue of challenging behaviours, which often appear as a reaction to a feeling of loss, it is recommended to first aim at social integration. In case of depressive states however, a treatment based on antidepressants and neuroleptics is almost unavoidable.
Besides cognitive and memory disorders, all cases of dementia illnesses are also accompanied by emotional and behavioural disorders (also known as non-cognitive symptoms or challenging behaviours), such as depression, aggression or anxiety. These symptoms often appear as a reaction to a feeling of loss, which is associated with this illness. In an initial phase, it is recommended to intervene with non-medicated therapy, such as using auxiliary resources that facilitate daily activities, or measures that help promote and maintain social integration. Should these measures prove not to be helpful, or the challenges associated with the illness too heavy a burden, it is then advised to consider a medicated treatment.
This group of medication includes the following:
- Citalopram (for ex. Cipralex®)
- Fluoxetine (for ex. Fluctin®)
- Paroxetine (for ex. Paroxat®)
- Sertraline (for ex. Seroquel®)
Appetite loss, nausea, xerostomia (dry mouth), gastrointestinal disorders, tension and headaches.
Side effects of paroxetine: confusion, hallucination
Side effects of fluoxetine: sleep disorders
The changing life conditions associated with Alzheimer’s are not easy to accept. This situation can lead to depression, in which case it should absolutely be treated, for it can have a negative impact on the cognitive capacities of the patient and intensify the Alzheimer’s related symptoms. Inversely, depression can also be the cause for loss of memory – which a diagnosis will help clarify. The treatment of a depression is based mainly on antidepressant medication. These medications are suited for the treatment of patients with Alzheimer’s, but also for patients with sleep disorders, mild psychomotor disorders and anxiety. The choice of medication however is limited, as the tricyclic antidepressants, already widely used, are known to weaken the effects of acetylcholine, and should therefore not be administered to people with dementia.
These medications reduce the concentration of dopamine, a neurotransmitter present in the brain, thus introducing a calming effect.
They can include the following:
- Clozapine (for ex. Leponex®)
- Quetiapine (for ex. Seroquel®)
Sleepiness, urinary tract infection, incontinence, increased risk of stroke.
Additional side effects of Risperidone and Haloperidol: movement disorders, limited mobility
Additional side effects of Clozapine: confusion and changes of the blood composition
Further, dementia patients who also suffer from Parkinson’s disease or from Lewy-Body dementia are more susceptible to undesirable effects.
Neuroleptics are used against the secondary symptoms of Alzheimer’s disease. They have a calming and antipsychotic effect and can be effective in the treatment of problematic behaviours such as restlessness, aggressivity, disconnection from reality, hallucinations or sleep disorders. However, because of the undesirable effects of these medications, the use of neuroleptics is contested – the benefits for the patient should always be the priority. As the symptoms may subside with time, the patient should be examined on a regular basis in order to verify whether the medication is still appropriate.
Text: Helga Grafe – 12/2016
Translation: MyH – 01/2017