Alzheimer's disease affects 5.5 million people in the United States, and the numbers are predicted to rise as more people live into old age. Treatment is usually a combination of cognitive and behavioral interventions, drug therapy specific to Alzheimer's disease and drug therapy for individual symptoms.
Cognitive and Behavioral Interventions
The American Psychiatric Association recommends cognitive and behavioral interventions. Cognitive therapies include reality orientation that prompts a person on time and place and those that use repetition and skill training to overcome practical difficulties. Behavior, mood and sleep problems can be helped with relaxation therapies and age-appropriate exercise.
Pharmaceutical Treatments
Alzheimer's disease medications include the acetylcholinesterase inhibitors donepezil, galantamine and rivastigmine and the non-competitive NMDA-receptor antagonist memantine. While for some people problems improve with medication, for many the main benefit is that the medications slow symptom progression.
AChEIs block an enzyme that breaks down the neurotransmitter acetylcholine, which is involved in memory function. The cells that make acetylcholine are slowly lost in people with Alzheimer's disease, so blocking its breakdown can help retain memory function. Memantine dampens the action of another neurotransmitter called glutamate. Glutamate signaling can be overactive and damage brain cells in people with Alzheimer's disease. As they have different actions, memantine and donepezil are used together for greater effect.
Other symptoms of Alzheimer's disease, including problems with behavior, depression and sleep, can be helped by, respectively, antipsychotics, antidepressants and sleep aids.
Disadvantages
General side effects of the AChEIs may include nausea, vomiting, muscle cramps and bradycardia. Memantine's side effects may include headache, confusion and hallucinations. These normally resolve within a few days and depend on both specific medication and patient reaction. The use of antipsychotics in elderly people is potentially fatal, so they should be given at low doses under close monitoring. Some non-prescription sleep aids contain diphenhydramine, which can inhibit acetylcholine, so it must be avoided.
Considerations
According to the Alzheimer's Association and the APA, treatment should be a collaboration between the patient, the caregiver(s) and healthcare professionals. Pharmaceutical therapy needs to be coordinated between all prescribers to avoid adverse interactions. Some types of cognitive and behavioral therapies need to be carried out by professionals, but caregivers can be trained in some therapies for use at home.
Time Frame
Because Alzheimer's disease is progressive, treatment options change over time, and the APA recommends patients be assessed every three to six months. People with mild Alzheimer's disease should have an AChEI along with non-pharmaceutical therapy and stimulating mental and physical exercise.
In moderate Alzheimer's disease, either an AChEI, memantine or both can be given. Behavioral, mood and sleep disturbances become more problematic, and a combination of therapy and medication should be tried. At this stage, caregivers should address safety issues of activities impacted by forgetfulness or agitation, such as cooking, driving, and wandering.
In people with severe Alzheimer's disease, donepezil and memantine are recommended for drug treatment. Treatment for other mood and behavioral problems is normally limited to medications, as a patient can no longer respond to most therapies.
References
- "American Journal of Psychiatry;" American Psychiatric Association Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias, Second Edition; Peter V. Rabins, et al; October 2007
- "Primary Care Companion to the Journal of Clinical Psychiatry"; Treatment Guidelines for Alzheimer's Disease: Redefining Perceptions in Primary Care; David S. Geldmacher; March/April 2007
- "Seminars in Neurology"; Alzheimer's Disease; Roy Yaari and Jody Corey-Bloom; February 2007
- Alzheimer's Association: Treatment For Alzheimer's Disease
