Treatment of Alzheimer's disease

Cholinesterase inhibitors (donepezil (Aricept®), rivastigmine (Exelon®), galantamine (Razadyne®/Reminyl®)) can help manage Alzheimer's, but they do not cure or reverse the course of AD. In the Alzheimer-afflicted brain, the cells that transmit the chemical messenger acetylcholine are damaged or destroyed, resulting in lower levels of the messenger. A cholinesterase inhibitor is designed to stop the activity of acetylcholinesterase, thereby slowing the breakdown of acetylcholine. By maintaining higher levels of acetylcholine, the drug may help compensate for the loss of functioning brain cells. Some individuals may experience a mild, temporary improvement in cognition soon after starting the medication. However, the duration of improvement and stability is highly variable. It appears that all individuals with AD will progress over the long-term despite treatment. Generally, cholinesterase inhibitors are well tolerated. Symptoms such as nausea, vomiting, loss of appetite, and increased frequency of bowel movements may occur with any cholinesterase inhibitor. There is no evidence that combining the drugs would be any more beneficial than taking one alone and combining the drugs results in greater side effects. Patients taking acetylcholinesterase inhibitors should be monitored when they have physical conditions that might be worsened by cholinergic drugs such as some heart conditions, and when they are taking other cholinergic drugs. Nausea, dizziness and diarrhea are the most common side-effects, although some patients show worsening of dreams. Several herbals, Chinese club moss also known as huperzine A and galantamine in the herbal form, are found in over the counter memory products possess similar side effects as the Alzheimer's prescription drugs. It is important to report all medications, including herbals, nutraceuticals, etc. to your physicians. In addition, medications with anticholinergic activity should be avoided where possible (examples: Benadryl, Cogentin, Tylenol PM, Ditropan). Ask your pharmacist which medications have significant anticholinergic activity.

Memantine (Namenda®) has been approved for the treatment of moderate-severe AD. As a NMDA antagonist, memantine reduces the excessive excitation of nerve cells by glutamate. Most patients will be prescribed a cholinesterase inhibitor and memantine together. Memantine appears to have few side effects and drug interactions. Memantine is useful for those individuals who cannot tolerate a cholinesterase inhibitor or in those patients with heart disease that affects the timing mechanism of the heart. Side effects are not common, but increased confusion, falls, and headaches may occur. Nausea and vomiting are not typically a problem. The dose of memantine may need to be adjusted downwards for individuals with significantly impaired kidney function.

A variety of medications are prescribed, with variable success, for psychiatric behavioral problems associated with AD and other dementia. Hallucinations, paranoia, delusions, severe agitation with aggressive/combative features and depression may require more potent (and toxic) psychotherapeutic agents, although their use should be considered with caution. Keeping a detailed diary of problem behaviors can greatly assist the health care provider in evaluating these behaviors and selecting an appropriate medication or non-pharmacological approaches to treating the behavior.

Non-pharmacological interventions can be beneficial for people with AD. A regular exercise regimen may increase energy levels, reduce apathy and improve the overall sense of well-being. Since lack of motivation can be significant in AD, a personal trainer may assist in compliance with the exercise program.