What are the Elements of Nonpharmacologic Treatment of Dementia?

In most instances, dementia is due to Alzheimer's or Multiple infarcts. In these patients, treatment is palliative rather than curative. However, over 30% of patients with dementia have more than one illness contributing to the dementia state. Treatment of these concomitant disorders provides temporary improvement in 28% of 200 patients and improvement is sustained for at least one year in 14%. Thus patients with irreversible dementia due to Alzheimer's and MID may improve in function with comprehensive management, although their cognitive status continues to inexorably deteriorate. In the case of Alzheimer's Disease, practitioners should assist the patient's family in providing a supportive environment to compensate for the patient's disabilities, minimize the cognitive side effects of medications, and maximize function of organs other than the brain by treating concomitant illnesses. Maintenance of nutrition, and exercise are vital, as is social stimulation. Additionally, one must assist and counsel caregivers, by providing respite when needed as well as consultation on the legal and ethical issues that arise over the course of dementia.

Family and caregiver counseling is a critical component of he management of the demented patient. Families must be advised of the community support services and day care centers and other forms of respite. To avoid crises, families should be given advance notice of potential legal and ethical issues that arise over the course of dementia. Therefore, issues of durable power of attorney and other forms of advance directives should be discussed early in the illness. One of the difficult but predictable issues for families is whether to use artifical feeding when the demented patient progresses to the point that oral intake is insufficient or unsafe because of aspiration. The physician should try to get the caregivers to decide whether artifical feeding will be used before a decision has to be made.

What Drugs are Useful in Treating Dementia?

Drug useful in treatment of dementia fall in to two categories: drugs aimed at managing behavioral problems, such as combativeness, agitation and sleeplessness; and drugs aimed at improving cognition. A review of controlled trial of neuroleptic treatment in dementia showed that 18% of dementia patients benefited but only modestly. No single neuroleptic is superior. Although there is little scientific evidence for the widespread use of these agents, neuroleptics are superior to placebo in controlling anxiety, suspiciousness, uncooperativenes and hallucinatory behaviors. It is safest to use these drugs only if signs and symptoms of psychosis or significant excitement and agitation complicate management. On the contrary, repetitive behaviors such as aimless wandering, pacing and calling out are usually less responsive to neuroleptics and they have little effect on poor self care, social withdrawal, wandering and cognition. In these instances, the adverse effects of neuroleptics (sedation, orthostatis, Parkinsonism, falls and urinary retention) may reduce functional status outweighing any benefit. When antipsychotic agents are used, butyrophenones or other high potency agents rather than the more sedating phenothiazine agents are indicated. The latter may be preferable if sedation is needed. Other psychotropics including benzodiazepines, betablockers and the antidepressant, trazodone, have been used also to induce sleep and control agitation. In summary, agents for behavioral control should be used as a last resort. When used, the practitioner should avoid combining more than of these agents concurrently.

Drugs aimed at altering the progressive cognitive decline in dementia have been the subject of multiple clinical trials. In multi-infarct dementia (MID), the principal aim is to prevent further brain infarcts by use of aspirin and antihypertensives, though data to support efficacy are lacking. Vasodilators in MID have shown little benefit. Recently attention has been directed at developing effective therapy for Alzheimer's Disease. Categories of medications proposed to treatment Alzheimer's include cholinomimetics to restore deficiencies of acetyl choline in the brain; neuropeptides to induce cortical interneuronal transmission, nootropic agents to stimulate neuron metabolic activity; vascular agents to improve blood flow; calcium blockers to prevent the accumulation of calcium in injured neurons; and miscellaneous agents including nerve growth factors and cell membrane stabilizers.

What is the Benefit of Acetylcholine Esterase Inhibitors?

For clinical use, most progress in the treatment of Alzheimer's Disease has been made with acetylcholine esterase inhibitors. Tetrahydroaminoacridine (Tacrine), recently released in the United States, has been marketed for patients with mild to moderate disease. Recent randomized trials of tacrine in England, Canada, and the United States provide a basis for using this medication in some patients. Of note, patients studied have had mild to moderate dementia (mean Mini-Mental State Examination score of 16 to 18). When seen, improvements have been in cognitive rather than in behavioral function. In summary, studies show that tacrine in doses of 40 to 160 mg per day :

1. benefits a small subgroup of patients with Alzheimer's Disease;
   
   
2. improves cognition or slows rate of cognitive decline over a short period, but the magnitude of the improvement is small ;
   
   
3. commonly causes hepatotoxicity that is usually reversible; and most important,
   
   
4. clinical use requires a clear commitment from patients, caregivers, and clinicians because of the need for careful monitoring.

On the other hand, the duration of the effect of Tacrine is unknown since studies have been of short duration and because study populations have been highly selected, its effectiveness in severe dementia or in demented patients with co-morbidities is unknown.