- Where possible, the underlying cause of dementia should be treated
- In case the disease cannot be cured, the goal of treatment is to improve and/or control the symptoms of dementia
- A combination of psychotherapy, environmental modifications, and medication is the best approach, but this can still be complemented by other therapies
Treatment of dementia begins with the treatment of the underlying disease, where possible. The underlying causes of nutritional, hormonal, tumour-caused or drug-related dementia may be reversible to some extent. For many other diseases, such as Alzheimer's disease (AD), no cure has yet been discovered. However, improvement of cognitive and behavioural symptoms can be achieved through a combination of appropriate medications and other treatments, including psychotherapy.
The goal of treatment is to slow down the progression of dementia-related impairments and to control behavioural symptoms, which may be treated with a combination of psychotherapy, environmental modifications, and medication1.
Psychotherapy, in particular behavioural approaches, can be used to reduce the frequency or severity of problematic behaviours, such as aggression or socially inappropriate conduct. Identifying what might be triggering a problematic behaviour and then devising an intervention that either changes the person's environment or the caregiver's reaction to the behaviour can be effective. Other strategies may include breaking down complex tasks, such as dressing, into simpler steps, or reducing the amount of activity in the environment to avoid confusion and agitation.
Modifying the environment can increase safety and comfort while decreasing agitation. Home modifications for safety include removal or lock-up of hazards such as sharp knives, dangerous chemicals, and tools. Child-proof latches may be used to limit access. Bed rails and bathroom safety rails can be important safety measures as well. Another example is lowering the hot water temperature, which reduces the risk of burning or disabling the stove and/or using stove childproof knobs may be necessary to prevent cooking accidents.
Medication can be prescribed to reduce dementia symptoms. There are a number of drugs available today for improving brain function. Typically, anti-dementia or other psychotropic drugs are prescribed.
The more recent anti-dementia agents belong to the so-called acetylcholinesterase inhibitors3. Acetylcholine is one of the chemical substances that allow brain cells to communicate with one another, the so-called neurotransmitters. Research suggests that acetylcholine is reduced in the brain of AD patients. These kinds of drugs prevent acetylcholine being eliminated too quickly, prolonging its ability to conduct chemical messages between brain cells. It could be shown in clinical trials that, with these kinds of drugs, the deterioration of the disease could be delayed by at least 12 months. Apart from preserving and partially improving mental capacities, and coping with daily activities, a delayed onset of behavioural disturbances and a reduction in caring time could also be demonstrated.
Psychotropic drugs4 can be used as a supportive therapy in the treatment of behavioural problems in dementia. For instance, antipsychotic medications (typically used to treat disorders like schizophrenia) can be effective in reducing persistent aggression, and in patients who have been unresponsive to non-pharmacological approaches, and where there is a risk of harm to themselves or others; however, such treatments should be used on a short-term up to six weeks rather than a systematic basis4
Anti-anxiety medications (typically used to treat anxiety disorders) can also be prescribed to help treating agitation and restlessness. Likewise, antidepressant medication can be prescribed to alleviate symptoms of depression. Treating depression symptoms is particularly important, as depression makes it harder for a person with dementia to remember things and enjoy life. It also adds to the difficulty of caring for someone with dementia. Significant improvements can be made by treating depression, as the patient's mood and their ability to participate in activities may be improved5.
In general, medications should be administered very cautiously to patients with dementia and in the lowest possible effective doses, to minimise side effects. Supervision of taking medications is generally required. With each of these medications, there are associated side effects and risks. Therefore, a careful risk-benefit evaluation should be conducted before treatment initiation and on a regular basis throughout treatment. However, one must bear in mind that these medications do not cure dementia or reverse someone's symptoms. There is no evidence that life is prolonged by taking medications. Rather, these medications can help some patients functioning better for a longer period of time6.
Psychosocial intervention for Alzheimer's disease patients
Psychosocial interventions can be beneficial to patients suffering from AD. Such treatments generally fall under four categories:
- Behaviour-oriented therapies are used most often with patients who exhibit behaviours that are difficult to manage. The therapies consist of changing environmental factors thought to affect the patients and to reduce the patients' behavioural problems. There is some evidence for the benefits of such therapies, but additional clinical trials are necessary.
- Emotion-oriented therapies include options like psychotherapy. They are often used to address issues of memory loss and to improve mood and behaviour.
- Cognition-oriented therapies include reality orientation, cognitive retraining and skills focusing on cognitive deficits. This type of treatment provides some improvements, but they are generally short-term.
- Stimulation-oriented therapy includes therapies related to pleasurable activities, such as art, music or exercise. Some data demonstrates its relative effectiveness in reducing behavioural problems.
Other therapies may also help persons with dementia with activities of daily living. Physical therapy may improve mobility by teaching patients to use canes or walkers properly and showing them how to get in and out of chairs or beds. Aroma, music, reminiscence, or occupational therapy, as well as art activities, may be beneficial and have a calming or rewarding effect for the person with dementia.
Finally, a growing number of herbal remedies, vitamins and other dietary supplements are promoted as treatments for AD and related diseases. They can be appealing to some people as they come from natural ingredients. Although many of these remedies may be possible treatment options, using these drugs as an alternative to or in addition to physician-prescribed therapy raise legitimate concerns. For instance, the efficacy, tolerability and safety of these products are not established and need to undergo further scientific testing. Further, they may not be manufactured consistently by all vendors or always contain the ingredients listed on the label. Moreover, herbal and nutritional supplements can interact with prescribed medications in harmful ways. Therefore, no supplement should be taken without first consulting a physician or informing the doctor treating the dementia patient.
Apart from treating the specific symptoms of dementia, it is important to observe the general state of health because a good general condition improves the feeling of well-being and might prevent or delay the onset of the disease.
- J. Hort&alii, EFNS Guidelines for the diagnosis and management of Alzheimer's disease, European Journal of Neurology, 2010, 17: 1236 – 1248.
- Ola Junaid & Soumya Hegde, Supportive psychotherapy in dementia, Advances in Psychiatric Treatment (2007), vol. 13, 17–23