A Better Approach To Treatment
Recently, researchers at Weill Cornell Institute of Geriatric Psychiatry in New York studied the effectiveness of a new home-delivered therapy called Problem Adaptation Therapy, or PATH, in participants with depression and dementia or mild cognitive impairment.
In the PATH intervention, therapists meet with the participants in 12 weekly sessions to teach them how to solve problems contributing to sadness, through a personalized approach often involving caregivers. The therapist and patient develop a plan, which includes avoiding negatively charged situations and identifying stimuli that trigger positive emotions, such as scheduling pleasurable activities.
Therapists also help participants develop compensatory strategies, such as the use of calendars and checklists, to bypass functional limitations due to memory impairment. When compared to a control therapy, in which participants received 12 weeks of supportive therapy , participants treated with the PATH approach experienced a greater decrease in depressive symptoms and disability at week 12.
Although research on psychosocial interventions is still sparse, this new research is encouraging, as nonmedication treatments are desperately needed. Research is also emerging on psychosocial interventions to in people with cognitive disorders.
Dietary Supplements For Dementia
Many dietary supplements have been studied for dementia treatment, including ginkgo biloba, vitamin B, and omega-3 fatty acids. However, results havent shown significant benefits. Talk to a doctor before giving your loved one with dementia any dietary supplements or herbal medicine. This will help prevent side effects and interactions with other drugs.
Check Hearing And Vision
Seeing and hearing properly are especially important for someone with dementia. Trouble seeing can make it harder to recognize familiar people or things. Vision or hearing problems can also make dementia symptoms like confusion worse as well as make your loved one feel more alone.
Schedule a vision checkup with your loved oneâs eye doctor to see if they need a new eyeglass prescription. Also, ask their primary doctor to refer you to a doctor who can do a hearing test to give them a new hearing aid, if needed.
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Treatment For Frontotemporal Disorders
As with Lewy body dementia, frontotemporal disorders, also known as frontotemporal dementia, are complicated and potentially involve a team of medical experts as well as speech, language, and occupational therapists.
Certain antidepressants, such as trazodone , may somewhat relieve behavioral symptoms, such as social disinhibitions and impulsive behavior. Selective serotonin reuptake inhibitors , such as sertraline and fluvoxamine , may also help.
As with Lewy body dementia, doctors need to prescribe antipsychotics with caution.
Cholinesterase inhibitors have been studied in clinical trials to see if they might be effective in treating frontotemporal disorders. Results have been mixed. In some cases, these drugs have made symptoms worse.
Types Of Medication For Difficult Behaviors In Dementia
Most medications used to treat difficult behaviors fall into one of the following categories:
1.Antipsychotics. These are medications originally developed to treat schizophrenia and other illnesses featuring psychosis symptoms.
Commonly used drugs: Antipsychotics often used in older adults include:
- For a longer list of antipsychotics drugs, see this NIH page.
Usual effects: Most antipsychotics are sedating, and will calm agitation or aggression through these sedating effects. Antipsychotics may also reduce true psychosis symptoms, such as delusions, hallucinations, or paranoid beliefs, but its rare for them to completely correct these in people with dementia.
Risks of use: The risks of antipsychotics are related to how high the dose is, and include:
- Increased risk of falls
- Increased risk of stroke and of death this has been estimated as an increased absolute risk of 1-4%
- A risk of side-effects known as extrapyramidal symptoms, which include stiffness and tremor similar to Parkinsons disease, as well as a variety of other muscle coordination problems
- People with Lewy-body dementia or a history of Parkinsonism may be especially sensitive to antipsychotic side-effects in such people, quetiapine is considered the safest choice
2. Benzodiazepines. This is a category of medication that relaxes people fairly quickly. So these drugs are used for anxiety, for panic attacks, for sedation, and to treat insomnia. They can easily become habit-forming.
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Medicines To Treat Related Conditions
There are some conditions, such as heart problems, that can affect symptoms of dementia, particularly vascular dementia. It’s important that these are diagnosed and treated.
These conditions include:
These changes in behaviour can be very distressing, both for the person with dementia and for the person caring for them. However, there are coping strategies that can help.
If coping strategies do not work, antipsychotic medicines such as risperidone or haloperidol may be prescribed for those showing persistent aggression or extreme distress.
These are the only medicines licensed for people with moderate to severe Alzheimer’s disease and vascular dementia where there’s a risk of harm to themselves or others.
Risperidone should be used at the lowest dose and for the shortest time possible as it has serious side effects. Haloperidol can be used only if other treatments have not helped.
The decision to prescribe a medicine should be taken by a consultant psychiatrist.
Antidepressants may sometimes be given if depression is suspected as an underlying cause of anxiety.
Impact On Families And Carers
In 2019, informal carers spent on average 5 hours per day providing care for people living with dementia. This can be overwhelming . Physical, emotional and financial pressures can cause great stress tofamilies and carers, and support is required from the health, social, financial and legal systems. Fifty percent of the global cost of dementia is attributed to informal care.
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Can Some Medications Cause Dementia Symptoms
Long-term use of some types of medication can cause problems with memory and thinking. They can slow down some of the chemical signals in your brain, so if you have any cognitive problems it can sometimes make these worse. The impact on brain chemicals is known as an anticholinergic effect. Several types of medication have an anticholinergic effect. They include some types of strong antihistamines, anti-depressants and muscle relaxants. They are used in treatments for conditions like depression, allergies, insomnia, and bladder and bowel problems.
The effect of each medication varies between individuals, and also depends on how long you use them. Your GP or pharmacist can help you understand the pros and cons of any treatment you need. Dont stop taking any medication without speaking to your GP.
Behavioural Therapy For Dementia
Behavioural therapy works to understand the source of the behaviour, and then suggest alternative strategies to address the underlying cause.
For example, a person with dementia may have a history of wandering out of their home because they feel restless. Therefore, encouraging such people to find another outlet for their restlessness, such as regular physical activity, might address the problematic behaviour.
Behavioural therapy is not a solution to the many behavioural problems associated with dementia , but it is a useful tool in lessening their impact. Behavioural therapy is supervised by a healthcare professional, but can often be given by a trained friend or relative, usually the main family carer.
As in all treatments for any disease, everyone is different and reacts differently results can vary by day or even parts of days. It is, therefore, important to keep checking in with the medical team if you notice any changes in your parents behaviour. It may be possible to change the dementia drugs or try a new dementia therapy to support their condition as it progresses.
To help make sure you know what to look out for, weve put together a list of the most common early signs of dementia, which you can take a look at in more detail. You can also download our free guide to dementia for information on diagnosis, legal considerations and support available.
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Initiating Treatment With Cholinesterase Inhibitors
Once a diagnosis of AD has been made it is important to discuss in detail with the patient and their relative/carer what treatment will entail. For most the diagnosis of a dementia can be devastating and understandably they may have high expectations, sometimes unrealistic, of any treatments offered. It is therefore important to be clear from the outset on several key points:
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The medications are not a cure.
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The medications do not work for everyone. The rule of thirds in medicine applies approximately: one third get better, one third do not deteriorate further, and in one third it makes no difference and the patient deteriorates at the rate as if untreated.
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The medication will be discontinued if the patient does not respond to it.
The NICE guidance published in 2001 provided a structure which includes systematic monitoring which, although under review, provides a sensible template for the prescription of the drugs.
Initiating treatment with cholinesterase inhibitors
Why Its Important To Know The Type Of Dementia
While no two people have the same experience of dementia, identifying the type of dementia in individuals helps families, carers and care workers to provide the right care and support. If we were given a diagnosis of cancer, we would expect to know what type we have so that the best possible treatment and management programmes can be put in place. It is no different for people with dementia.
As a simple illustration of the differences, someone with Alzheimers disease or vascular dementia would expect to experience memory and communication problems while a person with fronto-temporal lobe dementia would be more likely to show changes in personality rather than memory. Consequently, this could well involve a different approach to care and support provided.
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Which Provider Is Best For Me
It is recommended that everyone with suspected dementia should see a specialist to receive a proper examination and diagnosis. There are many different kinds of medical professionals including primary care physicians, nurse practitioners, physicians assistants, neurologists, etc., and trying to find the right one can be a long and tedious experience. There are many different dementia-specific specialists:
- Geriatricians are primary care internists or family practitioners who specialize in complex conditions of older people. They can provide care for all of an older adults medical needs, but do not specialize in brain or memory problems.
- Geriatric psychiatrists specialize in the mental and emotional needs of older individuals. They conduct thorough memory, mood, sleep, and thinking evaluations, and are particularly good at assessing memory problems associated with life stress, depression, anxiety, excess drinking, or family conflicts.
- General neurologists and psychiatrists perform memory evaluations, but do not specialize in Alzheimers and may treat few people with dementia.
- Behavioral neurologists specialize in cognitive problems such as memory loss, and are very good at detecting subtle brain injuries such as a small stroke or an infection that may be causing the memory problems. They also conduct very thorough neurological and cognitive exams.
Drugs To Treat The Cognitive Symptoms Of Dementia
A number of drugs are currently available in Australia for use by people with dementia. These drugs fall into two categories, cholinergic treatments and Memantine.
Cholinergic
Cholinergic treatments offer some relief from the symptoms of Alzheimers disease for some people for a limited time. Drugs known as acetylcholinesterase inhibitors work by blocking the actions of an enzyme called acetylcholinesterase which destroys an important neurotransmitter for memory called acetylcholine.
Current cholinergic treatments are approved for use for people with mild to moderate Alzheimers disease. A number of the acetylcholinesterase inhibitors are available as subsidised medicines under the Australian Pharmaceutical Benefits Scheme.
People may receive these drugs at nominal cost if a physician or psychiatrist has found them to have a diagnosis of Alzheimers disease.
They must show improvement on a commonly used test of mental function in the first six months of treatment in order to receive further supplies of subsidised medication.
Memantine
Memantine targets a neurotransmitter called glutamate that is present in high levels when someone has Alzheimers disease. Memantine blocks glutamate and prevents too much calcium moving into the brain cells causing damage. It is the first in a new class of therapies and acts quite differently to the acetylcholinesterase inhibitors that are currently approved for treatment in Australia.
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Treating Other Types Of Dementia
Unfortunately, patients with other types of dementia, such as Parkinsons disease dementia, Lewy body dementia, or vascular dementia, dont tend to respond as well to the treatment options listed above, but some patients with mild to moderate dementia might.
Memantine, acetylcholinesterase inhibitors, and haloperidol can sometimes help mitigate the symptoms of vascular dementia and Lewy body dementia. Occasionally, patients with Parkinsons disease dementia might also be prescribed medications to try and lessen symptoms, but non-drug treatments like psychological therapies can often prove to be the most effective way of managing dementia symptoms for these patients.
People with dementia sometimes have other health conditions that need to be managed in line with their condition, but some of the treatments can impact dementia symptoms. Such conditions may include:
- Cardiovascular disease
- High blood pressure
Its important that other medications are carefully prescribed so as not to contribute to the functional decline of the patient. This may involve trying different medications or prescribing a higher/lower dose at the recommendation of your health care professional.
Treatment Of Behavioural And Psychological Symptoms Of Dementia
Behavioural and psychological symptoms of dementia refer to a group of symptoms and behaviours summarised in table 5.
Table 5
Types of behavioural and psychological symptoms of dementia
BPSD are common in all types of dementia, and 80% of patients will experience them during the course of their illness. They are more common in patients with severe dementia and certain types of dementiafor example, DLB, where psychotic symptoms occur in more than 80% of patients. BPSD cause distress for both the patient and carer and are associated with increased carer burden and institutionalisation.
The first line treatment for BPSD has been psychotropic medication, particularly antipsychotic drugs. There has, however, been growing concern over the use of the medications as they are associated with:
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increased cognitive decline
Table 7
Management of behavioural and psychological symptoms
An assessment needs to be made of what the current symptoms are. It is imperative that the clinician excludes an underlying medical cause. Agitation, for example, can often occur when a patient has a urinary tract infection or is constipated. The patient may also be in pain and it is reasonable if suspicion is high and the patient, because of their cognitive impairment, is unable to confirm that they are in pain to give a trial of an analgesic to see if the BPSD improves.
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Early Diagnosis And Drug Treatment
Talking about being diagnosed with dementia at the age of 50, Norman McNamara says on his YouTube video:
Being diagnosed with something like this absolutely devastates you, but for me diagnosis and this is going to sound really strange was probably the best news I had at the time. Because… I thought I was losing my mind. I thought there was a conspiracy against me. I was right and everybody else was wrong. An early diagnosis of dementia is so, so important. Once diagnosed, I knew what I was up against. As they say: know your enemy. If I hadnt been diagnosed early and I hadnt been seen by consultants on a regular basis, I wouldnt be as well as I am today. I dont know what my future holds, but at least Im prepared for it.
You may also be interested to read Supporting carers at the time of diagnosis in the section on Carers of people with dementia.
Ways To Reduce The Risk Of Dementia
There is no way to prevent all types of dementia however, having a healthy lifestyle and managing chronic conditions help improve overall health and reduce the risk.
Studies suggest that about a third of dementia cases might be delayed or prevented by addressing potentially modifiable risk factors.
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Drug Therapies May Be Used Too
Doctors may prescribe one of the FDA-approved drugs for Alzheimers disease to treat other forms of dementia.
Cholinesterase inhibitors are one example. They are a category of medication that includes donepezil , rivastigmine , and galantamine .
By boosting levels of certain neurotransmitters , these drugs help Alzheimers patients who are experiencing mild to moderate problems with memory, motivation, or concentration and are struggling to meet the demands of daily living.
Cholinesterase inhibitors are also commonly prescribed to people with Lewy body dementia to help with disturbing hallucinations or troubling behaviors.
Some researchers believe that people with Lewy body dementia may see even more improvement than patients with Alzheimers.
Doctors may also prescribe a wide array of other kinds of medication, ranging from antidepressants and sleeping aids to antipsychotics. But not all of these drugs help manage all types of dementia, and some can have severe side effects.
Medications For The Treatment Of Alzheimers Disease
There are two types of medications: acetylcholinesterase inhibitors and NMDA receptor antagonists. The two types work in different ways.
Below we provide details of both types of dementia medication, how they are administered, as well as who may benefit from them, and any side effects to look out for.
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Why Early Diagnosis Of Dementia Is Important
Dementia is a profoundly life-changing condition and reactions to a diagnosis can range from dismay and deep sadness to anger and despair. But for many people, it can also come as a relief. A diagnosis may well provide long-awaited answers for a failing memory, communication problems and changes in behaviour.
An early diagnosis opens the door to future care and treatment. It helps people to plan ahead while they are still able to make important decisions on their care and support needs and on financial and legal matters. It also helps them and their families to receive practical information, advice and guidance as they face new challenges.