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At the heart of general practice since 1960

The treatment - dementia

Dr Luke Solomons, consultant in old age and liaison psychiatry, advises on managing dementia in primary care

Dementia is a progressive neurodegenerative disorder that presents with memory impairment and symptoms in other cognitive domains – language problems, behaviour or personality changes. This is accompanied by impairment in social and occupational function. The course is characterised by gradual onset and continuing cognitive decline. The cognitive decline impacts on activities of daily living (ADLs), but can also seriously hinder assessment and treatment of physical and mental health.

The symptoms of dementia can be clustered under three domains – neuropsychological, neuropsychiatric and executive function features.

Standard current treatment

Cognitive symptoms and maintenance of function

NICE recommends treatment be initiated in memory clinics by specialists and continued in primary care.1 Once dementia has been diagnosed, the treatment focus is maintenance of function and independence for as long as possible.

Evidence suggests that providing high-quality information about dementia as an ‘information prescription’ increases both patient and carer confidence in their ability to cope. The ‘dementia guide’ is available free and can be ordered from Alzheimer’s Society by surgeries.

As assimilation of new information is impaired in dementia, it is important to ensure there is a system for new treatments – for example, dispensing of medication in dosette boxes or blister packs, and carer visits to supervise medication. Local arrangements vary, but memory clinics and primary care usually offer alternate reviews under shared-care arrangements. Surgeries maintain dementia registers and memory clinics offer annual reviews to assess cognition and global functioning. The GP can request earlier reviews if the person’s condition has deteriorated and they require greater support or medication changes. 

There are currently four drugs licensed for use in Alzheimer’s disease. Donepezil, rivastigmine and galantamine are acetylcholinesterase inhibitors (AChEI) recommended for use in mild to moderate dementia.2 Memantine, a partial agonist of glutamate receptors, is recommended for people with severe dementia or those with moderate dementia who cannot tolerate AChEIs.

Rivastigmine is available as a once-daily transdermal patch that can be used in patients who have swallowing difficulties. 

There is emerging evidence to support use of AChEI medication in dementia with Lewy bodies, and Parkinson’s disease dementia, which is a related condition – rivastigmine is licensed for this condition. But there is currently no evidence to support use of AChEIs in frontotemporal dementia, and little evidence for their use in vascular dementia or mild cognitive impairment.

There has been conflicting evidence about the role of statins, but a recent Cochrane review concluded statins could not be recommended for treatment of dementia, based on the current evidence.3 

Similarly, a Cochrane review in 2012 found no evidence to support the use of aspirin in the treatment of vascular dementia, despite improvements in heart disease and stroke prognosis. Another review found no benefit in the use of aspirin or NSAIDs in Alzheimer’s disease.4,5

Non-cognitive symptoms and challenging behaviour

• Non-cognitive symptoms such as wandering, distress or challenging behaviour can often result from physical discomfort or ill health, side-effects of medication, or psychosocial and environmental factors, as people with dementia can be unable to communicate their distress. Individual care planning can help identify underlying issues.

• Pharmacological approaches include rationalisation of medication, identification and treatment of physical comorbidities.

• Ask the family or carers to help identify pain and treat with simple analgesics like paracetamol on a regular prescription (‘as required’ medication does not help
as patients might not report pain). Augmenting pain medication can help with more serious pain. Constipation is common and must be treated early.

• Antipsychotic medication can be considered when the person is hallucinating, having paranoid delusions, or in severe distress that hasn’t responded to non-pharmacological approaches.6,7 All antipsychotic medications have significant side-effects, including Parkinsonian symptoms, drowsiness, increased risk of falls and cardiovascular events like strokes and cardiac events, so they must be used carefully. 

Haloperidol (0.5-2mg) or risperidone (0.25-1mg), started at the smallest possible dose for a short period (up to six weeks) might help. Older antipsychotics like chlorpromazine or promethazine, and second-generation antipsychotics like olanzapine, quetiapine and aripiprazole are used, but the latter have similar side-effects to the older antipsychotics.

• People with Lewy bodies and Parkinson’s disease dementia are very sensitive to the Parkinsonian side-effects of antipsychotic medication. Quetiapine (25-100mg) is commonly used as a first-choice antipsychotic but can increase drowsiness and risk of falls.

• Response to medication must be reviewed after a few weeks, and antipsychotic medication tapered and stopped as soon as possible.

Comorbid emotional disorders

Depression and anxiety are common comorbidities in dementia, and recognition and treatment can significantly improve quality of life. Psychosocial factors such as boredom, isolation and quality of the environment can contribute to difficulties. Talking therapies like cognitive behavioural therapy (CBT) might not be appropriate due to problems with taking in new information.

Pharmacological treatments for major depressive disorders include use of antidepressant medication. SSRIs such as sertraline and citalopram can be used, but can precipitate hyponatraemia, especially with polypharmacy. Some antidepressants like trazadone and mirtazapine can help with insomnia, but must be used with caution as they can worsen postural hypotension and increase risk of falls. Tricyclic antidepressants like amitriptyline or dothiepin (also known as dosulepin) are to be avoided as their anticholinergic effects worsen cognitive impairment. Antidepressants take a few weeks to start having an effect, and can have adverse effects if stopped abruptly.

What’s newly available

The NICE guidelines on AChEI medication were updated in 2012 – AChEIs had been recommended for use only in moderate-severity Alzheimer’s disease, but this was changed to include mild severity dementia. More patients are now eligible for AChEIs and prescribed medication earlier.

Despite numerous promising trials, there has been no new medication for dementia. A Cochrane review in 2012 suggested that cognitive stimulation therapy has small benefits on commonly used brief measures of cognitive function improvements, as well as possible improvements in quality of life and communication.

What has fallen out of fashion and why

• Antipsychotic medication (‘tranquilisers’) – there have been several studies evaluating the impact of antipsychotic medication use in dementia. The evidence is unequivocal that antipsychotic medication increases the risk of cardiovascular events and death in people with dementia.

• Tricyclic antidepressants – amitriptyline and dosulepin are antidepressants used to help patients with sleep and pain symptoms. However, they have a significant anticholinergic effect that can increase the cumulative burden of cognitive impairment and mortality.

• Benzodiazepines – sleep disturbances are very common in dementia and altered circadian rhythms can increase carer stress. Benzodiazepines significantly increase the risk of falls. A recent study suggested increased risk of dementia with new benzodiazepine use.8

Atypical cases and tailored treatment

Delirium is sometimes hard to differentiate from dementia. It is characterised by acute onset and a fluctuating course of disturbed consciousness, cognitive function or perception, with or without hallucinations and delusional ideas. Untreated delirium is associated with poor outcomes. Early treatment of the underlying cause (for instance UTI or chest infection) is key. NICE recommends verbal and non-verbal de-escalation of distress, and haloperidol or olanzapine for psychotic symptoms, ideally for less than a week.9

Covert medication involves administering medicines in disguised form, for example in food and drink, to a person who is refusing the treatment necessary for their physical or mental health. It is only to be considered in people who lack the capacity to decide on their medication, and best practice is to use it as a last resort, after consultation with friends or family.10 Most care homes have a covert medication policy and forms that ensure recording and review.

Non-drug options and their evidence base

Cognitive stimulation therapy is a brief treatment that usually involves 14 or more sessions of themed activities, which aim to stimulate and engage people with dementia, while providing an optimal learning environment and the social benefits of a group. The NICE guidelines on dementia recommend its use in mild to moderate dementia.

Reminiscence therapy, which uses life histories to improve well-being, is also available through memory clinics.

Aromatherapy is the use of fragrant essences extracted from plants in oil burners, soaked into pillows and tissues or massaged into the skin. There is case study evidence of improved sleep and reduction in agitation, but a recent Cochrane review suggested no clear benefit.

Dr Luke Solomons is a consultant in old age and liaison psychiatry at Royal Berkshire Hospital NHS Foundation Trust.

Dr Solomons would like to thank colleagues Dr Rosemary Croft, Dr Ellora Evans, Dr Angus Tallini and Barbara Moye for help with preparation of this article

 

Click here to download a supplementary document, featuring links to all Cochrane reviews investigating treatments for dementia.

 

References

  1. NICE and SCIE (2006) Dementia: Supporting People with Dementia and their Carers in Health and Social Care. NICE clinical guideline 42. Available at www.nice.org.uk/CG42 [NICE guideline]
  2. National Institute for Health and Clinical Excellence (2011) Donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease (review). NICE Technology Appraisal Guidance 217.
  3. McGuinness, B., Craig, D., Bullock, R., Malouf, R., & Passmore, P. (2014). Statins for the treatment of dementia. The Cochrane Library.
  4. Rands, G., & Orrell, M. (2012). There is no evidence that aspirin improves the symptoms of vascular dementia. Health.
  5. Jaturapatporn, D., MGEKN, I., McCleery, J., & Tabet, N. (2012). Aspirin, steroid and non-steroidal anti-inflammatory drugs use for treating Alzheimer’s disease.
  6. Ballard, C., Creese, B., Corbett, A., & Aarsland, D. (2011). Atypical antipsychotics for the treatment of behavioral and psychological symptoms in dementia, with a particular focus on longer term outcomes and mortality. Expert opinion on drug safety, 10(1), 35-43.
  7. Schneider, L. S., Dagerman, K., & Insel, P. S. (2006). Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. The American journal of geriatric psychiatry, 14(3), 191-210.
  8. Billioti de Gage, S., Bégaud, B., Bazin, F., Verdoux, H., Dartigues, J. F., Pérès, K., … & Pariente, A. (2012). Benzodiazepine use and risk of dementia: prospective population based study. BMJ: British Medical Journal, 345.
  9. National Institute for Health and Clinical Excellence. (2010). Delirium: diagnosis, prevention and management.
  10. Treloar, A., Beats, B., & Philpot, M. (2000). A pill in the sandwich: covert medication in food and drink. Journal of the Royal Society of Medicine, 93(8), 408-411.

 

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