Dementia: Treatment

Treatment of dementia begins with treatment of the underlying disease, where possible. The underlying causes of nutritional, hormonal, tumor-caused and drug-related dementias may be reversible to some extent. Treatment for stroke-related dementia begins by minimizing the risk of further strokes, through smoking cessation, aspirin therapy, and treatment of hypertension, for instance. There are no therapies that can reverse the progression of AD. Aspirin, estrogen, vitamin E, and selegiline are currently being evaluated for their ability to slow the rate of progression.

Care for a person with dementia can be difficult and complex. The patient must learn to cope with functional and cognitive limitations, while family members or other caregivers assume increasing responsibility for the person's physical needs. In progressive dementias such as AD, the person may ultimately become completely dependent. Education of the patient and family early on in the disease progression can help them anticipate and plan for inevitable changes.

Symptoms of dementia may be treated with a combination of psychotherapy, environmental modifications, and medication. Drug therapy can be complicated by forgetfulness, especially if the prescribed drug must be taken several times daily.

Behavioral approaches may be used to reduce the frequency or severity of problem behaviors, such as aggression or socially inappropriate conduct. Problem behavior may be a reaction to frustration or overstimulation; understanding and modifying the situations that trigger it can be effective. Strategies may include breaking down complex tasks, such as dressing or feeding, into simpler steps, or reducing the amount of activity in the environment to avoid confusion and agitation. Pleasurable activities, such as crafts, games, and music, can provide therapeutic stimulation and improve mood.

Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches or Dutch doors may be used to limit access as well. Lowering the hot water temperature to 120°F (48.9°C) or less reduces the risk of scalding. Bed rails and bathroom safety rails can be important safety measures, as well. Confusion may be reduced with simpler decorative schemes and presence of familiar objects. Covering or disguising doors (with a mural, for example) may reduce the tendency to wander. Positioning the bed in view of the bathroom can decrease incontinence.

Two drugs, tacrine (Cognex) and donepezil (Aricept), are commonly prescribed for AD. These drugs inhibit the breakdown of acetylcholine in the brain, prolonging its ability to conduct chemical messages between brain cells. They provide temporary improvement in cognitive functions for about 40% of patients with mild to moderate AD. Hydergine is sometimes prescribed as well, though it is of questionable benefit for most patients.

Psychotic symptoms, including paranoia, delusions, and hallucinations, may be treated with antipsychotic drugs, such as haloperidol, chlorpromazine, risperidone, and clozapine. Side effects of these drugs can be significant. Antianxiety drugs such as Valium may improve behavioral symptoms, especially agitation and anxiety, although BuSpar has fewer side effects. The anticonvulsant carbamazepine is also sometimes prescribed for agitation. Depression is treated with antidepressants, usually beginning with selective serotonin reuptake inhibitors (SSRIs) such as Prozac or Paxil, followed by monoamine oxidase inhibitors or tricyclic antidepressants. Electroconvulsive therapy may be appropriate for some patients with severe depression who are unresponsive to drug therapy. In general, medications should be administered very cautiously to demented patients, in the lowest possible effective doses, to minimize side effects. Supervision of taking medications is generally required.

Long-term institutional care may be needed for the person with dementia, as profound cognitive losses often precede death by a number of years. Early planning for the financial burden of nursing home care is critical. Useful information about financial planning for long-term care is available through the Alzheimer's Association.

Family members or others caring for a person with dementia are often subject to extreme stress, and may develop feelings of anger, resentment, guilt, and hopelessness, in addition to the sorrow they feel for their loved one and for themselves. Depression is an extremely common consequence of being a full-time caregiver for a person with dementia. Support groups can be an important way to deal with the stress of caregiving. The location and contact numbers for caregiver support groups are available from the Alzheimer's Association; they may also be available through a local social service agency or the patient's physician. Medical treatment for depression may be an important adjunct to group support.

— Richard Robinson