If someone in your family has been diagnosed with Alzheimer’s or another dementia, chances are that they’ve been prescribed one of the “memory medications,” such as donepezil (brand name Aricept) or memantine (brand name Namenda).
But were they told what to expect, and how to judge if the medication is worth continuing?
I’ve noticed that patients and families often aren’t told much about how well these medications generally work, their side effects, and how to determine if it’s likely to help in their situation.
So in this post, I’ll explain how the four Alzheimer’s medications in wide use work. Â I’ll also address some of the frequently asked questions that I hear from older adults and families.
If someone in your family is taking one of these medications or considering them, this will help you better understand the medication and what questions you might want to ask the doctors. It’s especially important to understand the pros and cons if finances or medication costs are a concern.
Note: This article is about those drugs that have been studied and approved to treat the cognitive decline related to dementia. This is not the same as treating behavioral symptoms (technically called “neuropsychiatric” symptoms) related to dementia, such as paranoia, agitation, hallucinations, aggression, sleep disturbances, wandering, and so forth. Until 2023, there were no drugs FDA-approved to treat the behavioral problems of dementia. The use of psychiatric medications, such as quetiapine and brexpiprazole (Seroquel and Rexulti, respectively), in dementia and is covered here: 5 Types of Medication Used to Treat Sundowning & Difficult Dementia Behaviors.)
4 Oral Medications FDA-Approved to Treat Dementia
FDA-approved medications to treat Alzheimer’s and related types of dementia basically fall into two categories:
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)
These help increase the amount of the neurotransmitter acetylcholine in the brain. Acetylcholine helps neurons function well.
- Three such medications are FDA-approved to treat Alzheimer’s in “mild to moderate” stages:
- Donepezil (brand name Aricept)
- Rivastigmine (brand name Exelon); this drug is also available as a patch
- Galantamine (brand name Razadyne)
- Tacrine is a fourth cholinesterase inhibitor which was FDA-approved but is no longer in use due to a much higher risk of side effects
- Donepezil and rivastigmine have also obtained FDA approval for the treatment of more advanced dementia
(For more on what “mild-to-moderate Alzheimer’s disease” means, see “How to Understand the Stages of Alzheimer’s & Other Dementias.”)
Memantine
This is the name of an actual drug rather than a class of drugs, but since it’s the only one available of its type, experts consider it the second category of dementia treatment drug.
- Memantine (brand name Namenda) is FDA-approved to treat “moderate to severe” Alzheimer’s disease
- Memantine is an “N-methyl-D-aspartate (NMDA) receptor antagonist.” It dampens the excitatory effect of the neurotransmitter glutamate in the brain.
Since over-excitation of the neurons has been associated with neurodegenerative disease, memantine is considered a “neuroprotective” drug. Hence it is potentially a “disease-modifying treatment.”
In comparison, cholinesterase inhibitors are considered “symptomatic treatment,” as they affect the function of neurons but not the underlying health of neurons.
In other words: memantine might slow down the underlying progression of Alzheimer’s, even if it doesn’t appear to be helping a person. Cholinesterase inhibitors don’t change the underlying progression of Alzheimer’s, but they can potentially help a damaged brain work a little better.
What about the “new” antiamyloid Alzheimer’s drugs (Aduhelm and Leqembi)?
As of May 2024, two newer drugs for Alzheimer’s have some form of FDA approval: aducanumab (Aduhelm) and lecanemab (Leqembi). (Note: In January 2024, the maker of aducanumab announced they will be discontinuing the drug by the end of 2024.) These drugs are given as an IV infusion, and require monitoring.
Aducanumab (Aduhelm)
On June 7, 2021, the FDA approved a new drug for the treatment of Alzheimer’s disease, aducanumab (Aduhelm). The approval was controversial, as the FDA’s scientific advisory panel had recommended not approving this treatment. In 2022, Medicare announced limited coverage and essentially will only cover the cost of the drug for those who are in clinical trials and meet certain other criteria.
Aducanumab is an antibody treatment that works by reducing amyloid-beta plaques in the brain. In the studies that led to FDA approval, it was only used in patients who had proven amyloid in the brain on PET scan, and were otherwise in the “mild cognitive impairment” stage or early stage of Alzheimer’s disease.
In studies, aducanumab did seem to reduce amyloid-beta in the brain. However, it’s not yet known if this will translate to meaningful improvements in cognition or if this will delay the progression of Alzheimer’s. (It certainly is not going to reverse or “cure” Alzheimer’s.) Furthermore, serious side effects such as brain swelling or small bleeds in the brain affected at least 10% of patients.
Here is a good overview of the aducanumab controversy: Aducanumab for Alzheimer’s disease?
In January 2024, the maker of aducanumab (Biogen) announced they would be voluntarily discontinuing this drug by the end of 2024. The stated reason was to “reprioritize resources” related to Alzheimer’s treatment.
Lecanemab (Leqembi)
Lecanemab (Leqembi) received accelerated approval from the FDA on January 6, 2023. It is another antibody treatment against amyloid-beta, and its Phase 3 clinical trial results were published in November 2022. It is also associated with serious side effects and it’s unclear whether the treatment will meaningfully change the progression of Alzheimer’s, so this approval has also generated some controversy. In July 2023, Medicare announced that it will cover lecanemab provided there is participation “in a qualifying registry with an appropriate clinical team and follow-up care.”Â
I cover the effects and side effects of Leqembi in this video:
The remainder of this article will focus on cholinesterase inhibitors, memantine, and other options widely available to people with Alzheimer’s and other forms of dementia. I will also explain what is known about these medications for mild cognitive impairment.
Frequently Asked Questions About Dementia Medications
How well do cholinesterase inhibitors work?
This is a topic that has been intensively studied and somewhat debated. Of note, most major studies of donepezil and other cholinesterase inhibitors are industry-funded; only the AD2000 trial was not industry-funded.
Overall, in mild to moderate Alzheimer’s disease, the average benefit seems to be a small improvement in cognition and ability to manage activities of daily living. The effect has been sometimes compared to a few months delay in progression of symptoms. (It is not clear that treatment with cholinesterase inhibitors affects long-term outcomes such as the need for nursing home level of care.)
A 2008 review of the scientific evidence concluded that the effect of these drugs is statistically significant but “clinically marginal.” This conclusion was also reached by a 2018 review of the evidence.
But there’s a catch to consider: studies also suggest that although a fair number of people (30-50%) seem to experience no benefit at all, up to 20% may show greater than usual response. So there seems to be some individual variability in how these drugs work for people.
It may also depend on the type of dementia a person has, with some studies suggesting cholinesterase inhibitors have an effect in many people with Parkinson’s disease dementia, and perhaps also dementia with Lewy bodies.
To date, we have not developed any good ways to tell ahead of time who will respond to these drugs.
So it’s important to follow a person’s cognitive symptoms, and side-effects, once they start taking a cholinesterase inhibitor. If it doesn’t seem to be helping, it’s reasonable to consider stopping the medication after a few months.
How well does memantine work?
In people with moderate to severe Alzheimer’s, memantine seems to provide some benefits, in terms of slowing the deterioration of Alzheimer’s. But again, the benefit overall seems to be fairly modest.
It’s not at all clear that people with mild to moderate Alzheimer’s benefit from memantine; a 2011 review concluded that the scientific evidence doesn’t support this claim. This was confirmed by a 2019 review of memantine for dementia.
Do these medications work for dementias other than Alzheimer’s disease?
These medications have been studied for other forms of dementia, including vascular dementia, Lewy Body dementia, Parkinson’s dementia, and mixed dementia.
Bear in mind that the older people get, the more common it is to have mixed dementia, and the harder it is to make a specific determination of the underlying cause of dementia. In geriatrics, we generally assume there is mixed dementia if people are over age 85. (For more on how common mixed dementia is, see this article about the Religious Orders Study and Rush Memory and Aging Project.)
Studies generally find that cholinesterase inhibitors are associated with modest improvements in symptoms in Lewy Body dementia and Parkinson’s dementia.
A 2021 review of cholinesterase inhibitors for vascular cognitive impairment concluded that there is evidence of “a slight beneficial effect on cognition in people with VCI, although the size of the change is unlikely to be clinically important.” (Of note, the mean age of participants in those studies was 73.)
For memantine, some research suggests it can help with vascular dementia, although the benefits again seem to be quite modest.
The effect of memantine on Lewy-Body dementia and Parkinson’s dementia is less clear, with some research suggesting a small benefit but also reports that some people experience worsening hallucinations and delusions with memantine.
Do these medications work for mild cognitive impairment?
Not as far as we know. The research evidence so far indicates that dementia medications do not improve outcomes for mild cognitive impairment.
However, it remains very common for patients with mild cognitive impairment to be prescribed donepezil (brand name Aricept) or another cholinesterase inhibitor.
In principle, this should be done as a trial, meaning that the patient and clinician decide to “try” the medication, see if it’s helping with memory or other thinking difficulties, and stop if it doesn’t appear to be helping.
In practice, many people with mild cognitive impairment end up taking the cholinesterase inhibitor indefinitely. They may be reluctant to stop, but in other cases, it may be that the prescribing doctor doesn’t get around to checking on whether the medication is helping or not.
For more on mild cognitive impairment, see How to Diagnose & Treat Mild Cognitive Impairment.
What are the side effects of donepezil and other Alzheimer’s medications?
Doctors — including geriatricians — consider these medications to be “well-tolerated.” This means that most people don’t experience more than mild side effects, and serious adverse events are rare.
Side-effects of cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine:
- The most common side effects are gastrointestinal and include nausea, diarrhea, and sometimes vomiting. These affect an estimated 20% of people.
- People tend to adjust to gastrointestinal side effects with time. It helps to start with a small dose and gradually increase. Rivastigmine is also available in a patch formulation, which tends to cause less stomach upset.
- In the oral formulations, donepezil tends to cause fewer side effects than rivastigmine and galantamine.
- Some people also experience dizziness, a slowed heart rate, headaches, or sleep changes.
Side-effects of memantine:
- Dizziness is probably the most common side effect.
- Some people seem to experience worsened confusion or hallucinations.
- Memantine generally seems to cause fewer side effects than cholinesterase inhibitors do.
Is it common to take more than one medication for dementia at the same time?
It’s quite common for patients to be prescribed a cholinesterase inhibitor (such as donepezil) plus memantine.
This “combination therapy” has been studied in people with moderate-to-severe Alzheimer’s, and some research suggests a small benefit compared to treatment with just one medication. However, the benefit again appears to be modest at best.
A study of combination therapy in people with mild-to-moderate Alzheimer’s did not show benefit.
Although there is no good research evidence indicating that combination therapy is beneficial in mild Alzheimer’s, in my experience it’s common for people with mild Alzheimer’s to be prescribed combination therapy. Probably this happens because patients — and doctors — want to try anything that “might” work. In most cases, combination therapy for people with mild Alzheimer’s doesn’t seem to be harmful. But, it’s probably not doing much, other than increasing medication costs.
There is no reason to take more than one cholinesterase inhibitor at the same time.
At what point do you stop dementia medications? We’re not sure it’s making a difference.
Many patients and families feel these medications don’t have much effect. This isn’t surprising, since the research results usually find that the effect in most people is small to non-existent.
As cholinesterase inhibitors are “symptomatic” treatment and not disease-modifying, if there’s no sign of improvement after a few months on the maximum dose, many experts agree that it’s reasonable to stop the medication.
That said, as these medications are well-tolerated by most patients and are unlikely to cause harm to anything more than one’s wallet, it’s common for people to remain on cholinesterase inhibitors indefinitely.
As for memantine, this drug is potentially “disease-modifying.” So it may make sense to continue memantine for a few years, even if no improvement is noted by the clinician or family.
Experts generally agree that there’s not much value in continuing either category of medication once a person has reached the stage of advanced dementia, at which point a person is bedbound, unable to speak, and shows little sign of recognizing familiar people.
Do people get worse when they stop dementia medications?
Research suggests that some patients do appear to get worse after stopping cholinesterase inhibitors.
If this appears to be the case, it’s reasonable to resume the cholinesterase inhibitor.
The discontinuation of memantine hasn’t yet been rigorously studied. An observational study of nursing home residents suggested some worsening after stopping memantine.
A Canadian consortium of experts published guidelines on the deprescribing of dementia medications in 2022.
Do any vitamins help treat dementia?
Vitamin E — which works as an antioxidant in the body — has been studied for the treatment of Alzheimer’s, and may be beneficial.
In 2014, a large study of patients with mild-to-moderate Alzheimer’s disease found that daily treatment with 2000 IU/day of Vitamin EÂ resulted in less functional decline than treatment with placebo, memantine, or a combination of memantine and vitamin E.
Of note, since the study was conducted in the VA (Veteran’s Affairs) health system, most participants were men. And again, the benefit seen was modest.
It is not clear that vitamin E helps for mild cognitive impairment. Always talk to a doctor before trying vitamin E for brain health, as vitamin E can increase bleeding risk in some people.
No other vitamins have been shown to slow cognitive decline in Alzheimer’s or other dementias. In particular, although low vitamin D levels have been associated with a risk of developing dementia, no clinical research has shown that treatment with vitamin D helps people maintain cognitive function.
A study of vitamin B supplementation in the treatment of people with mild to moderate Alzheimer’s disease did not show any benefit. Note that participants in this study had normal vitamin B12 levels at baseline; the very common problem of vitamin B12 deficiency in older adults can cause or worsen cognitive problems.
A practical approach to dementia medications
It’s easy to get a bit lost in the weeds, when it comes to medications to treat the cognitive decline of Alzheimer’s and other dementias.
Overall, these are medications that seem to offer only a little — if any — benefit to most people.
In particular, using these medications is unlikely to help a person with Alzheimer’s remain cognitively well enough to live at home safely, or otherwise provide the type of improvements that families are often hoping for. (The effect of these drugs is just not that strong.)
These drugs are indeed widely prescribed, because patients are usually anxious to do everything possible to preserve their mental abilities, and because doctors want to be able to offer *something*. And most of the time, they don’t seem to harm patients or cause significant side effects.
I think it’s reasonable for people to take or try these medications, as long as they are aware of the evidence regarding the usually modest benefits.
So what should you do about medications, if you or your older relative has been diagnosed with Alzheimer’s or another dementia?
If you have already been on dementia medications for a while:
If you aren’t experiencing side effects, you may want to continue on the medications indefinitely.
But if you are concerned about medication expenses and pill burden, consider a trial of stopping the medication.
After all, the overall benefit of these medications is small. And you can always restart dementia medications if you think the dementia symptoms got worse off the medication.
If you are just starting the dementia journey:
If you are debating whether to start medications for dementia, keep in mind the following points:
- When it comes to oral medications: only cholinesterase inhibitors such as donepezil are FDA-approved for mild to moderate dementia. You should definitely ask questions if a clinician proposes starting memantine during the early stages.
- Cholinesterase inhibitors are for symptomatic treatment and do not alter the underlying neurodegeneration. They provide a modest benefit to some people but many people don’t seem to benefit. We are not yet able to tell ahead of time whose symptoms will improve with these medications.
- A reasonable and careful approach is to work with the doctor on a “trial” of a cholinesterase inhibitor. This means:
- Carefully documenting cognitive symptoms before starting the medication.
- Starting the medication at a low dose, and increasing to a full dose over time.
- Monitoring for side effects, such as nausea, vomiting, or diarrhea. These do usually get better with time. Consider lowering the dose or switching to a patch formulation if the side effects are difficult to handle.
- Working with the clinician to reassess cognitive symptoms after 2-3 months. If no improvement has been noted by the patient, family, or clinician, consider stopping the cholinesterase inhibitor.
Other ways to preserve cognition and brain function in dementia
Here’s the most important thing to keep in mind, when it comes to managing the cognitive decline of Alzheimer’s and other dementias:
Medications are only a small part of the solution.
In fact, there are many non-drug ways to optimize brain function. They work for people who don’t have dementia too, so I’ve listed them in this post: How to Promote Brain Health: The Healthy Aging Checklist Part 1.
If you’re concerned about preserving brain function and delaying cognitive decline, you’ll want to review the ten approaches I cover in the brain health article.
For instance, people often don’t realize that many commonly used medications are “anticholinergic,” meaning they interfere with acetylcholine in the brain and worsen thinking. In other words, these medications essentially have the opposite effect of the cholinesterase inhibitors. Which is not so good for the brain.
In a perfect world, your doctors and pharmacists would notice this problem and stop the anticholinergic medications, or at least discuss the pros and cons with you. But as our healthcare system is still highly imperfect, this may not happen unless you ask for a medication review.
Delirium is another common problem that can worsen dementia and often accelerates cognitive decline. So to manage dementia and delay cognitive decline, it makes sense to learn about delirium prevention.
The bottom line on medications to treat dementia
In short: the medications we currently have available to treat Alzheimer’s disease and other medications may help a little. The main harm people experience will be to their wallets. Don’t expect these drugs to work miracles and consider stopping them if you are concerned about drug costs or pill burden.
And above all, don’t forget to think beyond medications, when it comes to optimizing brain function and delaying cognitive decline in dementia.
This article was first published in 2016. It was reviewed and updated in May 2024.
Nitesh Budhlani says
Hi Dr. Leslie, my Mother is suffering from vascular Dementia/Alzheimer’s from the past 6 years.
She is currently on Aricept,Admenta for the same.
She is getting a bit agitated and seems restless so our doctor has also prescribed Qutan(Quetiapine) 25 -1 tab daily
Can you suggest is it ok to take Qutan(Quetiapine) as from what I read online , this medicine shouldn’t be given to dementia patients.
Nicole Didyk, MD says
Hi Nitesh. Sorry to hear about your mother’s difficulties. Quetiapine is an atypical antipsychotic, a tranquilizer that can be used when an individual is experiencing hallucinations or delusions, but is also used to boost the effect of an antidepressant, and in odler adults with dementia, it is sometimes used to treat the symptoms you describe. Dr. K has discussed alternatives to medications to treat the responsive behaviours that you mention, here.
In Geriatrics, we try to avoid using quetiapine for this purpose, related to the increase in risk of stroke or death that they can confer (compared to adults with dementia who are not on atypical antipsychotics). You can read more about why we try to avoid certain medications in older adults here.
Having said that, every individual is different and your mom’s doctor may have other reasons for choosing that medication, and may be using it in conjunction with other treatments (like modifying the environment or the approach of her caregivers).
And finally, it is always important when there is a change in behaviour of a person with dementia to ensure that it isn’t due to another medial issue, even something as seemingly simple as a urinary tract infection.
Patricia MacIver says
So my husband’s Nero did this because he got a brain fog after surgery. It worked but now I feel it is time to get off it. He is 82 yr old will getting off hurt him? He is taking 10mg 2 a day. Last night he was sleeping and was talking very normal in his sleep. He did not talk slow and it was awesome! During the day he talks very low and slow. So I think it is doing something that is blocking him being normal again.
Nicole Didyk, MD says
Hi Patricia. I’m not sure I completely follow your story, and I can’t give specific medical advice, but I can tell you that all of the medications that Dr. K mentions in the article are indicated for dementia, like Alzheimer’s disease, vascular dementia, or a similar disorder, not just “brain fog”. If someone is taking a dementia medication, we usually use it for the duration of the illness, not just for a brief period of time. Here is what Dr. K has had to say about stopping a dementia medication.
I’m not sure what to make of the “talking” issues you describe. Best of luck!
Marianne says
Thanks Dr for your reply. Have a nice day.
Steve Ewing says
Hello Dr. Kernisan
I was diagnosed with Wernicke-Korsakoff syndrome / Alcohol Amnestic Disorder 4 years ago.
I started taking Donepizel 10 mg without severe side effects, It was increased to 23 mg.
I started having severe daytime sleepiness, and saw no improvement with my memory issues,
I was prescribed Memantine and took both meds for about a month. The sleepiness got so bad I could
not function. I have since stopped take both of the medications. I still have all the same memory issues, I
am simply much more aware of my problems now. I have never taken the Memantine alone, and only
took it together for a short time.
Do you think I should try taking the Memantine alone and see what happens?
Thanks
Leslie Kernisan, MD MPH says
As far as I know, the research on using dementia drugs such as donepezil and memantine for Wernicke Korsakoff is preliminary and I don’t believe large randomized studies have been done. I don’t personally have much experience treating this condition, either. I would recommend consulting with a specialist who has more experience with this. You can also periodically check Pubmed for “Wernicke” and the name of the medication, to see if any significant studies have recently been published. Good luck!
Marianne says
Hello Dr. Leslie:
I wanted to ask you, do you have any new information related Lithium and if it is effective for Alzheimer disease?
Also, do you know if Lithium it will be recommended used together woth Rivastigmine?
My mother has Alzheimer since 2000/2002 but was correctly diagnosed in 2006. She been taking Exelon since that time.
Also, she started to use Memantine since this year and she had a little improvement.
Thanks in advance
Leslie Kernisan, MD MPH says
Hello,
I addressed lithium a few years ago in this comment, which you may have already seen.
Lithium is still considered very experimental. It’s currently being studied both as a neuroprotective agent to be used in MCI, and then also for treatment of agitation in Alzheimer’s.
Neuroprotective agents are often most likely to be effective before significant damage occurs to brain neurons. If your mother has had Alzheimer’s since 2002, she’s already had significant damage to her brain, so a therapy that works for people with MCI may not work as well for her. But that’s why we do research: to answer these questions. Memantine is also considered neuroprotective and in the associated research, the small effect was actually seen in people with more advanced symptoms and not in people with MCI or early Alzheimer’s.
It will likely be years before we have enough research completed to know whether lithium should be recommended, and under what circumstances.
For your situation, I generally recommend focusing on quality of life and also, I’m sorry to say, planning for future decline. I explain that here: How to Plan for Decline in Alzheimer’s Dementia:A 5-Step Approach to Navigating Difficult Decisions & Crises with Less Stress
good luck!
Dr Deepak Anand says
Hello Dr Leslie
Thanx for this wonderful article; my mother is in 4th stage of Alzheimer’s n has been on donep 10 mg (morning) n 5 mg (4pm)
Admenta 10 mg bid
Just 2 days back I visited a neurophysician for a second opinion n he advised me to decrease donep 5 mg bid n Admenta 5 mg bid
For behaviour management he advised qutan 25 mg 1/2 bid
I am really confused as she has bn on donep ( this) dose for last almost 2 yrs n has bn doin reasonably well
Kindly help !
Also enlighten about the research being goin on on the role of SALSALATE n LITHIUM n oblige !!
Leslie Kernisan, MD MPH says
I would recommend you ask her treating physician to explain why he thinks these decreases in dosages are a good idea. Did it seem like she was experiencing side-effects? Or was it more that he thought she wasn’t responding to the medication?
Regarding the medication for behavior, sounds like he recommended she start on quetiapine, which is an antipsychotic. I explain the considerations for using that type of medication here: 5 Types of Medication Used to Treat Difficult Dementia Behaviors. Good luck!
Elizabeth Smith says
Hello Dr. Kernisan,
Thank you as always for this generous comprehensive information. Your articles are always so relevant and helpful.
My father’s dementia has worsened to a stage where he has become quite paranoid and hallucinates a good deal, usually after sundown, of course. He rarely sleeps and has become very anxious and difficult. To make things even worse, he is now completely blind.
I am wondering your opinion of medical marijuana for the treatment of his symptoms. I understand there has been some promising research but I really know very little. I would be most interested in your opinion. Thank you!
Leslie Kernisan, MD MPH says
Thank you for your kind feedback regarding the articles, I’m so glad you find them helpful.
Medical marijuana is indeed being tried for dementia but we don’t yet have enough large well-done trials to know whether it’s likely to be effective, and what the risks might be. I have referred to a PubMed Central article in a comment above. Here is another review of the existing literature:
Cannabinoids for Behavioural Symptoms in Adults with Dementia: A Review of Clinical Effectiveness and Guidelines (2017)
For a person with dementia who has difficult behavior in the evening, I would recommend first looking into non-drug approaches, including avoiding him getting overly tired (yet providing enough exercise, sunlight, and fresh air during the day), and trying to trouble shoot specific difficult behaviors or times of day, as described here: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
If the non-drug approaches have been tried and aren’t working, then you could discuss the possibility of a trial of medical marijuana with your father’s health provider. I also discuss other medications used for difficult dementia behaviors here:
5 Types of Medication Used to Treat Difficult Dementia Behaviors
Ultimately every person is an individual, and a fair amount of trial and error is needed to find a way forward. Good luck and I hope you find a way to improve things soon!
michelle says
thanks so much for the sharing, its really useful. my mum is diagnosed with dementia and she is 63 years old and still running her own business.
we are giving her vitamin b12, asthathxin and dha supplements but she strongly refused to take any medications as her mum has dementia and she think believes that that medication worsened her mum’s condition .
Should we try to convince her to take medication again?
are there other alternatives or activires that are proven to slow down dementia?
thanks so much for your advise
Leslie Kernisan, MD MPH says
63 is fairly young for a dementia diagnosis. Generally I recommend that people of that age get evaluated in a specialized memory center.
The medications described above seem to help some people for a little bit, but they don’t help everyone. If your mother is really reluctant to take medication, I’m not sure it’s worth fighting with her about it.
Exercise seems to help some people with dementia, and is good for many other reasons.
Otherwise, it is not a proven approach but in the book The End of Alzheimer’s, Dr. Bredesen proposes that Alzheimer’s and dementia are multi-factorial, and hence treatment needs to start with a comprehensive evaluation for various contributors and then an extensive individualized treatment plan. His method of assessment has not been validated, nor have his individualized treatment plans, so by usual standards, his science is considered questionable.
That said, I think his book highlights a number of health factors to consider, such as the possibility of sleep apnea, impaired glucose tolerance, etc. So you might read it to get ideas of what kinds of health factors could be optimized for your mother.
Whether she’s likely to benefit from such an approach… no one knows for sure yet. Good luck!
Julie Dlask says
Dear Dr. Kernisan,
I was thrilled to come across your site with all the common-sense, unbiased information you share with families dealing with cognitive decline. Thank you for honest, sensitive responses to concerns that frequently aren’t addressed satisfactorily between Dr./patient.
In the most recent AARP magazine, the editor wrote, in part, “… diseases such as Alzheimer’s, which has not seen a new FDA approved treatment in more than a decade”. How can a disease be treated effectively when the cause is so elusive? It seems each new scientific finding conflicts with earlier ones. I tend to think the Donepezil/Memantine therapy has been over-hyped and over-prescribed, especially considering the possible side effects of confusion, anxiety, malaise, depression, loss of concentration. How does one judge the benefits to a patient when they are always in a medicated state? Could any of the minimal improvement for some patients be attributed to the 30% placebo effect?
In 2016, at age 60, my sister was diagnosed with MCI, amnestic vs. mild dementia, underlying cause – probable Alzheimer’s. MRI results: hippocampal, lateral and inferior lateral ventricular volumes of less than 1%, 95%, and 98%, respectively. MMSE: 21. She was prescribed Buspirone for anxiety and mild depression (she had several suicidal episodes in the previous 40 years of living in chronic stress). She was started on Donepezil, then Memantine was added. Recently her neurologist took her off the Buspirone and prescribed Quetiapine 75mg, for “sun-downing” symptoms and agitation. I see very little of that when I visit, and she sleeps like a rock for 8 hours every night. This “Q” med concerns me.
As the stress level in my sister’s life has gone way down in the last 6 months, I suggested to her husband that tapering her off the meds to evaluate her condition might be a viable option. He was not very receptive, and the phone call I had with her Dr. did not go well, as he’s adamant she’s being treated appropriately. Do you have any words of wisdom for this situation?
Thank you for filling a very valuable niche!
Leslie Kernisan, MD MPH says
Thanks for your kind words about the site.
I cover antipsychotics and other medications given for difficult behaviors in detail here: 5 Types of Medication Used to Treat Difficult Dementia Behaviors.
If your sister is rarely agitated and even seems a little sedated, then it might be reasonable to try lowering the dose of her quetiapine, to see how she does.
Separate from what is medically reasonable and medically optimal, there is also the question of negotiating things when multiple family members are involved. So especially, if she is living with her husband and he is the one making decisions, then I would recommend being careful and thoughtful about this suggestion. Perhaps it feels like a godsend to your brother-in-law that at least his wife sleeps “like a rock for 8 hours every night” (many dementia caregivers will be envious), and he can’t bear the thought of tinkering with her medication and possibly changing this. If she lives with him, then his wellbeing has to be factored in, because his mood and patience will affect her.
Of course it’s possible that you are already being very supportive of your brother-in-law and that you are communicating well, but if this situation is creating tension between you, I would suggest the book Difficult Conversations (by Stone and Heen). It is a really good resource to help one discuss emotionally laden topics and negotiate a way forward.
If your sister’s doctor is not very receptive, that is going to be tricky to manage if the primary decision maker is your sister’s husband. Many doctors are too cursory with family, but it’s also hard for the doctor when they are getting requests and input from multiple family members.
Hope this helps. So sad that your sister was affected by Alzheimer’s so young. Good luck and take care.
Glad says
Hello Dr Kernisan, I found this article very enlightening. My husband is 87 and started Namenda & Excelon after a heart attack damaged his memory 10 years ago. We have always wondered if these drugs were worth taking but were afraid of the consequences if he stopped. My husband is still able to take care of himself with a little assistance. But his language skills are poor. It’s the same conversations daily. Do you think it’s time to stop the medications? What if my doctor insists that he continues? Is it harmful to stop cold Turkey? Thanks in advance.
Leslie Kernisan, MD MPH says
So, although it’s not clear that these medications help most people, they also seem to be well-tolerated by many people, and some research suggests that a minority of people get worse when the medications are stopped.
You certainly could tell the doctor that you aren’t sure it’s helping (or perhaps that the expense/burden matters to you, which it might), and ask to try tapering off. My clinical resource suggests tapering over 2-3 weeks. If your husband seems worse, you could resume. There’s no clear evidence that a trial off like this is harmful in the long run.
In terms of when to stop these medications, once someone has been on for a long time (e.g. more than a year), it’s fairly common to continue until the person reaches a truly advanced stage at which point they are bedbound, saying very little, not recognizing anyone, etc. It doesn’t sound like your husband has reached that stage yet.
In general, I would recommend you discuss your interest in discontinuing with your husband’s doctor. A taper off to see what happens would not be unreasonable, if you prefer to minimize medications, and you can always resume if it seems he was better on the medications. Good luck!