How Does Alzheimer’s Medication Work
Current treatment options for Alzheimers disease focus on reducing the severity of its symptoms and helping a person with the condition live a functioning life.
There are two major classes of drugs used to slow cognitive decline in people with Alzheimers cholinesterase inhibitors and NMDA receptor antagonists.
There are also drugs used to treat the symptoms of Alzheimer’s disease such as depression and anxiety.
What Everyone Can Do Today
I am hopeful that this medication will work to slow Alzheimers and reduce the suffering it causes individuals and their families. We should remember that the other FDA-approved medications for Alzheimers can also be helpful , as can controlling blood pressure, engaging in aerobic exercise, eating a Mediterranean menu of foods, staying socially active, keeping a positive attitude, and using memory strategies.
About the Author
Andrew E. Budson, MD, Contributor
How Do Alzheimer’s Drugs Work
Acetylcholine is a chemical that helps pass messages between certain brain cells involved in memory. In Alzheimer’s disease, these brain cells start to die and the amount of acetylcholine is very much reduced.
Memory starts to suffer. Cholinesterase Inhibitors reduce the breakdown of acetylcholine and increases its levels in the brain. This reduces some of the symptoms of Alzheimer’s disease.
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Are There Any Side Effects
Most people can take cholinesterase inhibitors and memantine without too many side effects. Not everyone has the same side effects, or has them for the same length of time.
The most common side effects of donepezil, rivastigmine and galantamine are:
- loss of appetite
Other side effects include muscle cramps, headaches, dizziness, fatigue and insomnia. Side effects can be less likely for people who start treatment by taking the lower prescribed dose for at least a month .
The side effects of memantine are less common and less severe than for the cholinesterase inhibitors. They include:
Anticholinergic Drugs Can Increase Dementia Risk By 54%
Seniors who dont have Alzheimers or dementia still need to be careful of anticholinergic medications.
Thats because these drugs can increase the risk of developing dementia in the future.
A study of adults aged 65+ found that those who took an anticholinergic drug for three or more years had a 54% higher dementia risk.
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Is It Common To Take More Than One Medication For Dementia At The Same Time
Its quite common for patients to be prescribed a cholinesterase inhibitor plus memantine.
This combination therapy has been studied in people with moderate-to-severe Alzheimers, and some research suggests a small benefit compared to treatment with just one medication. However, the benefit again appears to be modest at best.
A study of combination therapy in people with mild-to-moderate Alzheimers did not show benefit.
Although there is no good research evidence indicating that combination therapy is beneficial in mild Alzheimers, in my experience its common for people with mild Alzheimers to be prescribed combination therapy. Probably this happens because patients and doctors want to try anything that might work. In most cases, combination therapy for people with mild Alzheimers doesnt seem to be harmful. But, its probably not doing much, other than increasing medication costs.
There is no reason to take more than one cholinesterase inhibitor at the same time.
How Should This Medicine Be Used
Donepezil comes as a tablet and an orally disintegrating tablet to take by mouth. It is usually taken once a day with or without food, in the evening just before bedtime. Take donepezil at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take donepezil exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.
Donepezil helps control the symptoms of Alzheimer’s disease but does not cure it. Continue to take donepezil even if you feel well. Do not stop taking donepezil without talking to your doctor.
Your doctor may start you on a low dose of donepezil and increase your dose after 4 to 6 weeks. Your doctor may increase your dose again 3 or more months later.
Swallow the 23-mg tablet whole do not split, crush or chew it. Tell your doctor if you are unable to swallow the tablet whole.
To take the orally disintegrating tablet, place the tablet on your tongue and wait for it to dissolve. Drink some water after the tablet dissolves.
Ask your pharmacist or doctor for a copy of the manufacturer’s information for the patient.
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How Does The Drug Work
Aducanumab is a monoclonal antibody engineered in a laboratory to stick to the amyloid molecule that forms plaques in the brains of people with Alzheimers. Most researchers believe that the plaques form first and damage brain cells, causing tau tangles to form inside them, killing the cells. Once aducanumab has stuck to the plaque, your bodys immune system will come in and remove the plaque, thinking its a foreign invader. The hope and expectation are that, once the plaques are removed, the brain cells will stop dying, and thinking, memory, function, and behavior will stop deteriorating.
How Can I Find Out More About How To Receive Aducanumab
If you are already being treated for mild cognitive impairment or Alzheimers at Duke, talk to your doctor at your next, regularly scheduled appointment. If you dont have an appointment scheduled, contact your doctor via MyChart. If you are not an existing Duke patient, ask your primary care provider, neurologist, or memory disorder specialist for a referral to one of our Alzheimer providers.
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Medications That Can Treat Alzheimer’s Disease
Many people believe that Alzheimers disease can’t be treated. The truth is that medications are available that may help treat symptoms. Although these drugs dont work for everyone, they offer some hope for the more than 5 million people who have AD.
There are four FDA-approved drugs available to treat symptoms due to Alzheimers disease. While the drugs may modestly improve memory and reduce confusion, they are not curative and are unable to stop the disease from worsening over time. The drugs are most effective when a person takes them in the mild to moderate stages of the disease. It may take two to six weeks before any results appear.
Three drugs used to treat AD are all in one family, called cholinesterase inhibitors, which boost brain levels of acetylcholine:
Another drug, memantine , is the only drug approved by the FDA for moderate to severe stages of AD. It can be taken alone or with a cholinesterase inhibitor.
Certain side effects may prevent people from using medication for AD. Donepezil, galantamine, and rivastigmine can cause nausea and vomiting. Memantine may cause dizziness and headache.
But Does The Drug Work
In a prior blog post I reviewed the publicly available data and the daylong FDA hearing on aducanumab. In a nutshell, there were two large clinical trials to assess effectiveness, side effects, safety, and how the drug might be used in clinical practice. One of the studies was positive, meaning that the drug worked to slow down the decline of thinking, memory, and function that is usually impossible to stop in Alzheimers. The other large study was negative. In my view and that of the FDA advisory panel these results mean that we dont know if the drug works or not.
Another factor to consider is that the potential benefit if the drug works as well as it did in the positive study was fairly small. Looking at the two objective measures, in the positive trial, the high dose made a 0.6-point change on the 30-point Mini-Mental State Examination. On the 85-point Alzheimers Disease Assessment ScaleCognitive Subscale-13, the high dose made a 1.4-point change.
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Which Medications Are Anticholinergics
You might be surprised to know that anticholinergic medications include seemingly harmless over-the-counter medications like antihistamines and sleep aids .
To help you understand which prescription and over-the-counter drugs have anticholinergic effects, we found a helpful list from ElderConsult Geriatric Medicine of common medical conditions and the anticholinergic medications typically used to treat them.
Medical conditions include a wide variety of common issues like overactive bladder, sleep issues, coughs, colds, allergies, behavior issues, mood disorders, chronic obstructive pulmonary disease , and Parkinsons disease.
This list might not include every single condition or medication, but its a good start to finding out if any of your older adults medications are anticholinergics.
Use this list to have an informed conversation with your older adults doctor about the risks and benefits of taking that medication.
- Constipation / urine retention
These side effects can make existing dementia symptoms worse or make someone without cognitive issues behave as if they have Alzheimers or dementia.
Who Is A Candidate For Aducanumab
Based upon the clinical trials in which it was studied, the drug can be potentially considered for use in individuals with early-stage Alzheimers disease. This means individuals who have Alzheimers in its mild cognitive impairment or mild dementia stage. Individuals in this early stage of Alzheimers may be able to function normally, or they may require a little bit of help with complicated activities like paying bills, grocery shopping, preparing meals, or balancing their checkbook. Individuals who need help with dressing, bathing, or other basic activities would be beyond the early stage and the drug would not be indicated for them.
Note that not everyone with mild cognitive impairment or mild dementia has Alzheimers disease. There are other causes of these problems as well. To determine if Alzheimers is present, you need to get either an amyloid PET scan or a lumbar puncture to be sure you have the amyloid plaques of Alzheimers. Currently, a lumbar puncture is generally covered by insurance, but an amyloid PET scan is not.
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What Facts Should I Know About Dementia Medication
Can Dementia Be Treated with Medication?
Most diseases that cause dementia are progressive, which means that persons with the disease get worse over time. Unfortunately, no curative treatment for dementia is currently available. Some medications, however, can temporarily improve symptoms and functioning and may slow the progression of the basic disease process. Efforts to find effective drug therapy for dementia have frustrated scientists.
Can Dementia Be Treated with Medication?
Many drugs used for dementia are limited by side effects, short duration of action, and the need for frequent monitoring of blood levels or other laboratory values to prevent toxicity. Many assessment tools have been used to measure the effectiveness of dementia drugs, but effectiveness remains difficult to evaluate. Additionally, an enormous amount of dementia-related treatment information from a wide variety of sources is directed to consumers, including information on medications, herbal products, diet, exercise, and nutrition. The vast amount of material and its sometimes-questionable reliability make it difficult to distinguish fact from rumor. Despite these difficulties, researchers continue to search for drugs with improved effectiveness and better tolerability.
Other Ways To Preserve Cognition And Brain Function In Dementia
Heres the most important thing to keep in mind, when it comes to managing the cognitive decline of Alzheimers and other dementias:
Medications are only a small part of the solution.
In fact, there are many non-drug ways to optimize brain function. They work for people who dont have dementia too, so Ive listed them in this post: How to Promote Brain Health: The Healthy Aging Checklist Part 1.
If youre concerned about preserving brain function and delaying cognitive decline, youll want to review the ten approaches I cover in the brain health article.
For instance, people often dont realize that many commonly used medications are anticholinergic, meaning they interfere with acetylcholine in the brain and worsen thinking. In other words, these medications essentially have the opposite effect of the cholinesterase inhibitors. Which is not so good for the brain.
In a perfect world, your doctors and pharmacists would notice this problem and stop the anticholinergic medications, or at least discuss the pros and cons with you. But as our healthcare system is still highly imperfect, this may not happen unless you ask for a medication review.
Delirium is another common problem that can worsen dementia and often accelerates cognitive decline. So to manage dementia and delay cognitive decline, it makes sense to learn about delirium prevention.
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The Bottom Line On Medications To Treat Dementia
In short: the medications we currently have available to treat Alzheimers disease and other medications may help a little. The main harm people experience will be to their wallets. Dont expect these drugs to work miracles and consider stopping them if you are concerned about drug costs or pill burden.
And above all, dont forget to think beyond medications, when it comes to optimizing brain function and delaying cognitive decline in dementia.
This article was first published in 2016. It was reviewed and updated in May 2022.
Drugs To Manage Dementia
Over the past three decades, several drugs have been developed to manage the thinking and memory problems seen in patients with Alzheimers disease. These include the best medications for Alzheimers patients to date. Overall, these drugs do help with some neuropsychiatric problems but only in the mild stage of the disease. Known as cholinesterase inhibitors, the drugs include:
Some patients with AD do obtain benefits from these drugs, such as better concentration, decreased anxiety, and more motivation, and some are even able to maintain their regular daily activities. But these improvements usually only last 6-12 months. Their main benefit is that they delay disease worsening for some time.
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At What Point Do You Stop Dementia Medications Were Not Sure Its Making A Difference
Many patients and families feel these medications dont have much effect. This isnt surprising, since the research results usually find that the effect in most people is small to non-existent.
As cholinesterase inhibitors are symptomatic treatment and not disease-modifying, if theres no sign of improvement after a few months on the maximum dose, many experts agree that its reasonable to stop the medication.
That said, as these medications are well-tolerated by most patients and are unlikely to cause harm to anything more than ones wallet, its common for people to remain on cholinesterase inhibitors indefinitely.
As for memantine, this drug is potentially disease-modifying. So it may make sense to continue memantine for a few years, even if no improvement is noted by the clinician or family.
Experts generally agree that theres not much value in continuing either category of medication once a person has reached the stage of advanced dementia, at which point a person is bedbound, unable to speak, and shows little sign of recognizing familiar people.
First Things First: Do I Really Have Alzheimer
Diagnosing a patient with Alzheimers disease involves a time-consuming consultation. Unfortunately, many people dont get that kind of attention from their doctors. Elderly patients who show Alzheimers-like symptoms may be incorrectly diagnosed with the disease and then prescribed strong medicines with nasty side effects. Dont hesitate to insist on a thorough consultation with your doctor before starting medication for Alzheimers.
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What Are The Side
Doctors including geriatricians consider these medications to be well-tolerated. This means that most people dont experience more than mild side-effects, and serious adverse events are rare.
For cholinesterase inhibitors:
- The most common side-effects are gastrointestinal and include nausea, diarrhea, and sometimes vomiting. These affect an estimated 20% of people.
- People tend to adjust to gastrointestinal side-effects with time. It helps to start with a small dose and gradually increase. Rivastigmine is also available in a patch formulation, which tends to cause less stomach upset.
- In the oral formulations, donepezil tends to cause fewer side-effects than rivastigmine and galantamine.
- Some people also experience dizziness, a slowed heart rate, headaches, or sleep changes.
For memantine:
- Dizziness is probably the most common side-effect.
- Some people seem to experience worsened confusion or hallucinations.
- Memantine generally seems to cause fewer side-effects than cholinesterase inhibitors do.
Heart And Brain Connection
More evidence seems to link the brain and the heart as an extremely important connection in Alzheimers patients. Population studies reveal that people whose blood pressure is controlled and who lead a healthy lifestyle have a far lower risk of AD compared to populations who have high blood pressure and live an unhealthy lifestyle. Hence, the current emphasis is on adopting a positive lifestyle in the hopes of preventing AD in the first place. This means eating healthy, exercising regularly, discontinuing smoking, maintaining a healthy weight, and keeping blood pressure within normal limits. Speak to your healthcare provider if you want to know more about lowering your risk of getting diagnosed with Alzheimers disease. Preventing AD in the first place is a far better option than treating it later.
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Anxiety And Insomnia Medications
Benzodiazepines, a class of medications used to treat anxiety or insomnia, comprise another group that has been linked with cognitive difficulties. Although these medications are truly a blessing for some individuals immobilized by anxiety, their use can be accompanied by sedation and mental slowing. A recent study even suggested that prolonged use of benzodiazepines might be a risk factor for later dementia, although experts have questioned the significance of this finding and clinicians continue to prescribe anti-anxiety medications such as lorazepam or sleeping pills such as temazepam and consider them very beneficial when used properly.