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4 Medications FDA-Approved to Treat Alzheimer’s & Other Dementias:
How They Work & FAQs

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. 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.

I also have a video discussing this topic, along with newer discoveries in Alzheimer’s care and non-drug related approaches:

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.)

Worried about the health & safety of an aging loved one? I explain how to address driving and other safety issues here: How to Help Your Parent with Memory Loss Be Safer (Even if They’re Resisting).

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:

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Cerebral Small Vessel Disease:
What to Know & What to Do

by Leslie Kernisan, MD MPH

Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults. (This is also called “white matter disease.”)

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? Is this the same as vascular dementia? And how they can best help their parents with cognitive decline?

Well, these types of brain lesions don’t happen to every older person, but they do happen to the vast majority of them. In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

Cognitive decline,
Problems with walking or balance,
Strokes,
Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

White matter disease
Small vessel ischemic disease
Brain lesions
Periventricular white matter changes
Perivascular chronic ischemic white matter disease of aging
Chronic microvascular changes, chronic microvascular ischemic changes
Chronic microvascular ischemia
White matter hyperintensities
Age-related white matter changes
Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

What is cerebral small vessel disease (SVD)?
What are the symptoms of cerebral SVD?
How is cerebral small vessel disease related to vascular dementia and cerebrovascular accidents?
What causes cerebral SVD?
How can cerebral SVD be treated or prevented?
Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

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Q&A: How to Diagnose & Treat Mild Cognitive Impairment?

by Leslie Kernisan, MD MPH

Q: I realize that I sometimes have difficulty connecting a name and a face. I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it. These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation.

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

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7 Common Brain-Slowing Anticholinergic Drugs Older Adults Should Use With Caution

by Leslie Kernisan, MD MPH

Want to keep your brain — or the brain of someone you love — as healthy as possible?

Then it’s essential to know which commonly used medications affect brain function.

In this article, I’ll go into details regarding a type of medication that I wish all older adults knew about: anticholinergic drugs.

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How We Diagnose Dementia: The Practical Basics to Know

by Leslie Kernisan, MD MPH

“Doctor, do you diagnose dementia? Because I need someone who can diagnose dementia.”

A man asked me this question recently. He explained that his 86 year-old father, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather quickly, and was hardly returning his son’s calls.

The son wanted to know if I could make a housecall. Specifically, he wanted to know if his father has dementia, such as Alzheimer’s disease.

This is a reasonable concern to have, given the circumstances.

However, it’s not very likely that I — or any clinician — will be able to definitely diagnose dementia based a single in-person visit.

But I get this kind of request fairly frequently. So in this post I want to share what I often find myself explaining to families: the basics of clinical dementia diagnosis, what kind of information I’ll need to obtain, and how long the process can take.

Now, note that this post is not about the comprehensive approach used in multi-disciplinary memory clinics. Those clinics have extra time and staff, and are designed to provide an extra-detailed evaluation. This is especially useful for unusual cases, such as cognitive problems in people who are relatively young.

Instead, in this post I’ll be describing the pragmatic approach that I use in my clinical practice. It is adapted to real-world constraints, meaning it can be used in a primary care setting. (Although like many aspects of geriatrics, it’s challenging to fit this into a 15 minute visit.)

Does this older person have dementia, such as Alzheimer’s disease? To understand how I go about answering the question, let’s start by reviewing the basics of what it means to have dementia.

5 Key Features of Dementia

A person having dementia means that all five of the following statements are true:

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How to Plan for Decline in Alzheimer’s Dementia:
A 5-Step Approach to Navigating Difficult Decisions & Crises with Less Stress

by Leslie Kernisan, MD MPH

Q: My mother is 76 and has Alzheimer’s disease. She had a couple of unavoidable stays last year in the hospital (due to falls). This accelerated her decline due to delirium, which was treated as if she was just being an unruly and difficult patient. Once my sister and I understood what was going on due to this site’s information, we have been able to protect and support her.

Right now things are stable and quiet, so we are trying to plan ahead.

How should we go about planning for the years of decline my mother may experience before her actual last moments near death? It’s hard to imagine this possibility and I need help facing the (to me) not so obvious.

We have a will, power of attorney, and health care proxy in place.

A: Great question, and especially good that you’re taking advantage of a “quiet period” to address these issues.

It’s a little tricky to answer this question without knowing more about your mother’s current ability to participate in decision-making and in planning for her future care.

Since you say she’s declined after hospitalizations for falls and delirium, let me assume that she has moderate Alzheimer’s and can’t manage more than perhaps expressing some of what she likes and doesn’t like. (For more on the stages of Alzheimer’s and related dementias, see here.)

At this point, you’ve been through some health crises already, and you’ve seen her decline. You’ve also probably gotten a sense of just how many decisions have to be made on her behalf. Some are about her medical care and some are about other aspects of her life, like where she lives and how she spends her days.

Planning ahead is an excellent idea. Obviously, it’s simply not possible to anticipate and plan for every decision that will come up.

But let me offer you an approach that you can use both now as well as “in the heat of the moment” when specific issues arise. This is a framework to help you navigate all kinds of care decisions and future crises that you may encounter.

The following five steps will give you a foundation for anticipating, processing, and reacting to the complications and problems of later-stage Alzheimer’s, with less anxiety and more confidence. These steps are:

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7 Steps to Managing Difficult Dementia Behaviors
(Safely & Without Medications)

by Paula Spencer Scott

(This article is by my colleague Paula Spencer Scott, author of the book Surviving Alzheimer’s: Practical Tips and Soul-Saving Wisdom for Caregivers. I invited her to share an article on this topic, since many in our community are coping with dementia behaviors. — L. Kernisan)

The odd behaviors of Alzheimer’s and other dementias can be so frustrating and stressful for families.

I’m talking about the kinds of behaviors that try patience, fray relationships, and drive us in desperate search of help:

“First she thinks the caregiver is stealing her sunglasses and now she accused me of having an affair.”

“When I tried to help Dad wash up, he hit me.”

“My husband follows me so closely I can’t stand it. But if I go in another room he’ll wander out of the house.”

“Mom started unbuttoning her shirt in the middle of the restaurant!”

“Just when I’m completely exhausted at the end of the day, he seems to get revved up. He keeps peeking out the windows, convinced that someone is trying to break in. Now he won’t sleep.”

A common approach to difficult behaviors is to go right to medicating them with tranquilizers, sedatives, or antipsychotics. But that’s risky and often not what’s best.

In fact, experts recommend trying behavior management first, and for good reasons: It tends to be more effective in the long run than “chemical restraints,” has no dangerous side effects, and leads to a better care relationship. But people often don’t know how to do this.

I’ve learned how.

I’ve lived through five close family members’ experiences with Alzheimer’s and other forms of dementia. Lots of trial and error, and insights from dozens of top dementia experts (whose brains I’ve been lucky to pick as a journalist and dementia educator), got me through regular scenes with…

My father-in-law, who needed a walker to move yet spent hour after hour for several days straight hauling all his clothes and toiletries from his room to our driveway, insisting that his (imaginary) new wife was about to pick him up
My dad, a formerly sharp dresser who wore the same shirt and pants every day no matter how dirty
My grandmother, who insisted on going “home,” when she was home
And other relatives, in dozens of similar scenes.

In this article, I want to share what I wish someone had explained to me early on: the “Why-This, Try-This” approach to dealing with difficult behaviors.

This is a mental framework that can help you get unstuck from unproductive responses that get you nowhere or make things worse.

It can bring calm -– to both of you — whether the issue is verbal or physical aggression, agitation, confusion, wandering, disinhibition, delusions, hallucinations, or a restless or repetitive behavior (like pacing, shadowing, rummaging). It also works well with milder irritants like repetitive questions and indecision.

Then, I’ll boil down the Why-This, Try-This concept to a 7-step process you can use every time. These “7 R”s give you a basic platform for responding to any frustrating behavior:

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Q&A: Hospice in Dementia, Medications, & What to Do If You’re Concerned

by Leslie Kernisan, MD MPH

Q: Dear Dr. K,

With all the news about opioids and benzodiazepines, and their risk of death, I would love to hear your take on the use of these drugs in hospice.

We’ve had two family experiences now (my Mom and my Aunt) who were given these drugs right away when they went on hospice…without hospice trying anything else first that would be less dangerous. My Mom was up and about walking one day at her memory care facility, even laughing. The next day, when hospice put her on morphine and Ativan, she was in a coma. She died 13 days later without ever regaining consciousness. When I protested and asked why she wasn’t waking up, the hospice nurse said, “It’s not the drugs, it’s the disease.” (Mom had dementia.) The nurses wouldn’t let us give her fluids (“you don’t want your mother to aspirate, do you?”) or feed her (“you don’t want your mother to choke, do you?”).

With my Aunt, she had also been in the memory care facility and got to the point of needing a two-person assist. Her power of attorney (POA) was given the choice of moving my Aunt into a nursing home or bringing in hospice. Hospice immediately gave her morphine and Ativan, then backed off the Ativan and gave her morphine every two hours until she died 3 days later.

Now the third sister, also with dementia, has been in hospice for two months and counting. She is lucid most days, eating/drinking, comfortable—all without the opioid/benzo drug combo, because of our experience.

How can family members identify a hospice that doesn’t use this troubling combination of drugs from the start, without first trying something less dangerous, to make a patient “comfortable”?

A: Thanks for sending in this question. I’m very sorry to hear that your experiences with hospice have left you concerned.

It is indeed extremely common for hospice to use morphine and lorazepam (brand name Ativan) to treat end-of-life symptoms. That’s because many people on hospice are suffering from troubling symptoms that these medications can relieve, such as pain, shortness of breath, anxiety, and agitation.

Still, these medications are not always necessary. They are supposed to be prescribed and used as required to relieve the dying person’s symptoms, not by default. So the situation you describe with your mother and your aunt does sound potentially concerning. At a bare minimum, the hospice personnel should have done a better job of discussing their proposed care plan with your family.

Now let me be clear: I cannot say if the way they prescribed morphine and lorazepam was inappropriate or not, because it’s impossible for me to know the specifics of your mother and aunt’s medical situation.

Still, we can certainly review some basics about hospice care for people with Alzheimer’s and related dementias, as well as recommended best practices, when it comes to using opioids and benzodiazepine sedatives.

Here’s what I’ll cover:

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8 Behaviors to Take Note of if You Think Someone Might Have Alzheimer’s

by Leslie Kernisan, MD MPH

Have you been worried about an older person’s memory or thinking skills? If so, you’ve probably found yourself wondering if this could be Alzheimer’s, or another dementia.

What to do next? If you look online or ask people, the advice is generally this: tell the doctor.

This advice isn’t wrong, but it’s incomplete. Yes, you should tell the doctor. But you’ll dramatically improve your chances of getting to the bottom of things if you come to the doctor with useful information on what you’ve observed.

In fact, research has found that interviewing family members about the presence or absence of eight particular behaviors can be just as effective, when it comes to detecting possible Alzheimer’s, as certain office-based cognitive tests.

8 Alzheimer’s Behaviors to Track

For each of these behaviors, try to make note of the following:

Whether there’s been a decline or change compared to the way your parent used to be
Whether this seems to be due to memory and thinking, versus physical limitations such as pain, shortness of breath or physical disabilities
When you – or another person – first noticed problems, and what you observed
What kinds of problems you see your parent having now

If you don’t notice a problem in any of the following eight areas, make a note of this. (E.g., “No such problem noted.”) That way you’ll know you didn’t just forget to consider that behavior.

Have you noticed:

Signs of poor judgment? This means behaviors or situations that suggest bad decisions. Examples include worrisome spending, or not noticing a safety issue others are concerned about.
Reduced Interest in Leisure Activities? This means being less interested and involved in one’s usual favorite hobbies and activities. You should especially pay attention if there isn’t a physical health issue interfering with doing the activity.
Repeating Oneself? Has your parent started repeating questions or stories more than he used to?
Difficulty Learning to Use Something New? Common examples include having trouble with a new kitchen appliance or gadget. This can be a tricky one to decide on, given that gadgets become more complicated every year. But if you’ve noticed anything, jot it down.
Forgetting the Year or Month? Especially once one stops working, it can be easy to lose track of the date or day of the week. But if you notice your parent forgetting the year or month, make a note of this.
Difficulty Managing Money and Finances? Common examples include having trouble paying bills on time, struggling to balance the checkbook, or otherwise having more difficulty than one used to have managing finances.
Problems with Appointments and Commitments? If you’ve noticed that your parent is having more trouble keeping track of appointments and plans, make note of this.
Daily Struggles with Memory or Thinking? It’s normal for older adults to take a little longer to remember things, since many brain functions do slow a bit with aging. But it seems that your parent often can’t remember things that happened, or otherwise seems to be more confused with thinking, make note of this.

For more on diagnosing Alzheimer’s and other dementias

If you’re worried that your older relative might have dementia, I recommend you learn more here: How We Diagnose Dementia: The Practical Basics to Know
My book, “When Your Aging Parent Needs Help“, also comes with worksheets to help you check for signs of dementia, a handy checklist of what information to bring to the doctors, and more.
In this Youtube video I share 10 early warning signs of Alzheimer’s Disease that often catch my attention, and what to do if you’ve noticed these warning signs.
In this Youtube video, I cover 21 signs and behaviors that families sometimes assume are “normal aging,” but in fact are usually signs of a brain health disorder. It includes the 8 behaviors listed in this article, and many more.

Remember, being proactive usually leads to better results and less stress overall!

Delirium: How Caregivers Can Protect Alzheimer’s Patients

by Leslie Kernisan, MD MPH

This week’s Q & A call was about how to better manage health and healthcare issues, when you’re taking care of someone with a dementia such as Alzheimer’s.

Most of the caregivers’ questions were about delirium. This is the state of worse-than-usual confusion that people can develop when they are sick or under serious stress.

I love talking to Alzheimer’s caregivers about delirium, because this is a really common problem that family caregivers absolutely can do something about!

The key is to know that people with dementia are especially prone to get delirium when they fall ill (especially in the hospital). And then you’ll want to know the basics on how to spot this problem, and how to get the doctors to address it properly.

A fact I wish more caregivers of elders knew: delirium can be the only obvious sign of a potentially serious health problem, such as a heart attack, a urinary tract infection, or a pneumonia. (Especially when it comes to older people with Alzheimer’s, they often don’t voice focused complaints the way younger people do.)

The trouble is, even though delirium is very common in older adults, studies have shown that it’s often missed by doctors and nurses. This is a important problem in healthcare, for three key reasons:

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4 Oral Medications FDA-Approved to Treat Dementia

What is Mild Cognitive Impairment?

5 Key Features of Dementia

8 Alzheimer’s Behaviors to Track

For more on diagnosing Alzheimer’s and other dementias

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