Can it be treated?
The treatment of dementia begins with establishing the diagnosis and level of memory impairment (as discussed above).
The treatment of dementia can be divided into the medication treatments specifically directed at memory function and the treatment of all of the other symptoms that a person with dementia can develop. If the underlying dementia is thought to be related to vascular disease then controlling all of the vascular risk factors (such as high blood pressure, diabetes, high cholesterol etc- for more detail see the stroke page) will form an important part of the management plan.
Medication to treat the cognitive decline in dementia- There are medications that are used to treat the underlying memory problems in a patient with dementia. The first group are the “cholinesterase inhibitors” these slow down the breakdown of important chemicals in the brain that are used by nerve cells for communicating with each other. The benefit in terms of memory function is considered to be modest only. However studies do show that once the medication is tolerated patients who are on it do better overall than those who are not- especially if they have been on it and are then taken off it.
- There are a few different ones available
- Donepezil - This is a once daily medication. The starting dose is 5mg once daily increasing to 10 mg once daily after 4-6 weeks. The most common side effects are gastrointestinal such as diarrhoea, nausea and vomiting. This does not occur in everyone who takes it. It can cause vivid dreams and so is best taken in the morning. It should not be taken by patients who have heart rhythm abnormalities (this can be easily established with your GP).
- Galantamine - This tablet can be taken twice daily or else once daily as an extended release formulation. The starting dose is 8mg once daily (or 4mg twice daily) and increasing after 4 weeks to 16mg once daily (or 8mg twice daily) and then again after another 4 weeks to 24mg once daily (or 12mg twice daily). The most common side effects of this medication are also gastrointestinal.
- Rivastigmine - This is available as either a tablet to be taken twice daily or as a patch that is applied to the skin. The starting dose of the patch is 4.6mg and this can be increased every 4 weeks to a maximum of 13.3mg. The dose of the tablet is 1.5mg twice daily and this can also be increased every 4 weeks. Again gastrointestinal side effects are the most common ones encountered.
When gastrointestinal side effects are bad they can lead to a lot of nausea and reduced appetite with associated weight loss. Therefore, if these side effects occur it is wise to contact your GP or neurologist and make a plan from there.
The other type of medication used to treat the memory problems in dementia is an “NMDA receptor blocker”- this means that a particular chemical in the brain (called glutamate) which is thought to be responsible for some of the nerve damage in dementia is blocked from taking its effect.
- Memantine - This is taken twice daily starting at 5mg and then increasing to 10mg twice daily after a few weeks. There is also an extended release formulation that is taken once daily starting at 7mg and increasing in 7mg increments every few weeks to a maximum of 28mg once daily. This medication is well tolerated although dizziness is a known side effect and on occasion it can cause or worsen hallucinations.
Inadequate nutrition is common in patients with dementia and is associated with worsening of other symptoms of dementia. Interventions such as oral nutritional supplements may improve weight. It is important to adequately assess why nutrition is poor. Some patients with dementia have a poor sense of smell and this can be associated with a reduced appetite. Trying stronger smelling spices may improve palatability of food and thereby improve appetite. Low mood can also be another common reason for poor appetite and weight loss so addressing this is very important (discussed below).
Patients with dementia will often suffer from depression. This is because firstly depression is a common illness but secondly, and more importantly, patients will have knowledge of their progressive loss of independence and ability to communicate which can lead to mood problems. The diagnosis of depression can be complicated also in older patients as some patients have memory impairment that is actually a reflection of their depression and further to that dementia itself can actually produce some of the common symptoms of depression such as apathy (described above). Therefore, it is of the utmost importance to always seek this in the history and treat it. Treatment may not make a significant change to overall memory function but it will make a difference to the mood of the patient and this is a positive change for both the patient and carer. The choice of medication to be used should be made very carefully. Certain anti -depressants can worsen confusion and should be avoided- these are called tricyclic antidepressants. The family of medications called SSRIs (or selective serotonin receptor inhibitors- which increase serotonin levels in the brain and treat depression in this way) are a better option. Again, there are many kinds and your neurologist will choose one with the lowest amount of side effects possible.
When patients with dementia are suffering from pain they may be unable to communicate this very well- especially in advanced dementia. Therefore, if they seem a bit more agitated or withdrawn than usual or don’t seem to be moving one of their arms or legs or are generally less mobile it is always important to consider the fact that there may be pain that is not controlled. Careful observation and discussion with the primary carer will be useful here. Pain can be controlled quite easily in most scenarios so always give it consideration. In circumstances where it is difficult to say there is pain with certainty a pain medication trial could be started. Here pain medications are prescribed to be taken regularly for a defined period of time with low doses to begin with and a gradual increase to ensure a dose expected to give benefit is reached. Observing the patient and getting regular reports from the carer will give a good indication as to whether or not pain was contributing to these symptoms.
Agitation and Aggression
Often patients with dementia, especially when it is advanced, will suffer from increased levels of agitation and aggression. They also may suffer from delusions (for example the belief that their loved one is being unfaithful or that their carer is stealing from them) and hallucinations (seeing or hearing things or people who are not there). Obviously, all of this can be a huge source of stress for both the patient and carer. The first step in trying to manage these symptoms is to search for an underlying cause. Agitation may be the first sign of a brewing infection- most commonly either a urinary tract infection or chest infection- both easily identifiable and treatable. Pain may cause agitation. Medication side effects may be a source of agitation and older people with dementia are more susceptible to the side effects of medications. For example, if the patient was recently started on a medication to help sleep- especially if it is from the benzodiazepine family- the agitation may be a side effect from this. Poor sleep, confusion and fear of new surroundings are all other potential causes of agitation and aggression in patients with dementia. Once all of these possibilities are considered and managed as necessary the actual symptom of agitation and/or aggression along with possible delusions and hallucinations needs to be managed. Opting for non-medication approaches is ideal in the first instance. These could include introducing more social stimulation during the day, music therapy, massage therapy and aromatherapy to name a few examples. Exercise training with a goal of a minimum 30 minutes per day has been shown to improve physical functioning and lessen mood related symptoms. Surrounding patients with things they are known to enjoy is also helpful and educating care givers in patient centred communication may help also.
There will be instances, however, where there is a need for medication to treat these symptoms. These should be used very carefully looking for side effects, in low doses to begin with and ideally for just short periods of time. The scenario in which they become necessary is when the symptoms compromise patient and carer safety, well-being and quality of life. The medications that are chosen are based on the patient and experience of the doctor who will prescribe the medication. The goal of the medication is to lessen the levels of agitation and aggression as well as treat any of the delusions and hallucinations so careful monitoring whilst on these medications is necessary.
Patients with dementia commonly suffer from sleep disorders. One of the most common sleep disorders in this group of patients is difficulty either falling asleep or staying asleep. It is important once again to look at potential underlying causes of either of these. For example, patients with dementia may simply be far less physically active during the day and find it difficult to fall asleep because of this. Pain may be worse at night and interfere with ability to fall asleep. Needing to get up to go to the bathroom at night is another common cause of sleep interruption. Patients with dementia who are living in nursing homes get far less exposure to natural light during the day than those living at home- this can also interfere with sleep quality. Trying to improve sleep hygiene should help with some of these symptoms. Examples of how to do this are:
- Limit evening beverages
- Limit alcohol and caffeine in the evening time
- Introduce some exercise or physical activity during the day
- Increase natural light exposure in the morning
- Ensure pain is adequately controlled
- Make sure the medications the patient is taking are not responsible- for example the medication called donepezil (described above) can cause vivid dreams occasionally which could interfere with sleep so make sure this is taken early in the day.
- Aim for some social stimulation during the day.
Restless legs syndrome can interfere with sleep also. This occurs in greater frequency with age and so patients with dementia may suffer from this as well. This is described as the feeling of the need to move the legs and is unpleasant and uncomfortable. This can be treated with medication.
A sleep disorder that is largely exclusive to patients with dementia (most commonly the lewy body dementia mentioned above) is what is referred to as REM sleep behaviour disorder. This is where the usual loss of muscle tone that naturally occurs during dreaming sleep does not happen. This can lead to symptoms that can range in severity from brief, non-forceful hand or arm gestures to violent thrashing, punching or kicking. In other words the patient may act out their dreams and the manifestation depends on what the dream is about. These symptoms will be most apparent to the bed partner. Obviously, they can be a source of distress for the bed partner or carer but more serious is that they can pose a risk to safety. There is medication that can be used to treat this.
Sometimes patients with dementia can have excessive daytime somnolence. This is defined as sleepiness that interferes with daily activities. This may occur because their sleep quality is insufficient, they are on sedating medications, it can be part of the dementia process itself or it can relate to other sleep disorders such as obstructive sleep apnoea- where patients stop breathing for a few seconds during the night and then with a big gasp resume breathing- which overall leads to very poor quality sleep. Therefore, if the patient is suffering from this it may be worth considering an investigation to check for sleep apnoea and evaluating the need for any sedating medications that the patient may be taking.