September 1st, 2010
08:44 AM ET

Better understanding of dementia leading to more effective therapies

Every weekday, a CNNHealth expert doctor answers a viewer question. On Wednesdays, it's Dr. Otis Brawley, chief medical officer at the
American Cancer Society.

Last week, I answered a question about the symptoms of Alzheimer's disease. Today I want to talk a little about how dementia is treated.

Just a decade ago when a diagnosis of dementia was given, very little could be done for most patients except for treating behavioral disturbances and changing the environment to support safety and functioning.

Better understanding of the biology of these illnesses has led to some treatments that can improve cognition. For most, the current treatments are far from satisfying, but they do give us hope that better drugs can be developed.

The dementia should evaluated and diagnosed by a physician with special training in cognitive disorders. This may be a neurologist, a psychiatrist or, in certain instances, an internist or geriatric physician with specialized training. A precise diagnosis is important for effective management.

There are several types of dementia other than Alzheimer's disease. Drugs used in the treatment of one type of dementia can actually worsen other forms of dementia. Haloperidol (Haldol) is indicated in the treatment of behavior issues in a patient with Alzheimer's disease, but can be harmful to a patient with dementia caused by Parkinson's disease.

Acetylcholine is a neurotransmitter in the brain, meaning it is a chemical used to send messages from nerve to nerve. Researchers have found that patients with Alzheimer's disease and several other types of dementia have lower levels of this acetylcholine.

Drugs that stop the action of cholinesterase, the enzyme that breaks down acetylcholine, are useful in the treatment of Alzheimer's disease. These "cholinesterase inhibitors" include tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne, formerly called Reminyl).

They are approved by the U.S. Food and Drug Administration for use in several types of dementia and widely available internationally. These drugs come in pill and liquid form. Some are even available as a skin patch for transdermal application.

A cholinesterase inhibitor should usually be started in early dementia and, if possible, be continued throughout the disease.

In clinical study, they appear to slow the progression of the dementia in some patients. These drugs have significant side effects, such as slowing of the heart, gastric upset, nausea and vomiting, as well as difficulty urinating.

Memantine (Namenda) is another oral medication. It is widely available for patients with moderate to severe Alzheimer's. It blocks stimulation of a specific receptor in the brain, an NMDA receptor. When stimulated, these receptors cause a cascade of events that lead to dementia. Memantine is also especially useful in the treatment of patients with Alzheimer's disease and patients with vascular dementia. Vascular dementia is a disease caused by decreased blood flow and oxygenation to parts of the brain.

In a 28-week study of Alzheimer's patients, 250 were in a randomized trial to memantine or placebo. Compared with the group taking placebo, memantine-treated patients had less deterioration in mental function over the 28 weeks. This drug appears to provide a small but significant benefit in terms of cognition. Unfortunately there was no effect on behavior or ability to perform activities of daily living. Scientific study has proved this drug generally useful for six months, but the long-term benefit is unknown.

Memantine has fewer side effects than the cholinesterase inhibitors. Dizziness is the most common side effect associated with memantine. A very small number of patients have auditory and visual hallucinations because of the drug. It also may to increase agitation and delusional behaviors in a small number of patients.

Memantine should be started in patients with moderate to severe Alzheimer's. It is often used in combination with a cholinesterase inhibitor. Since it may be disease-modifying, many physicians suggest it be continued even when there is no clinical improvement.

Much attention has been given to Alzheimer's disease. Less is known about the treatment of other common dementias.

In general, cholinesterase inhibitors have shown some benefit for patients with vascular dementia, those with mixed Alzheimer's and vascular dementia, patients with the disease known as "dementia with Lewy bodies," and dementia from Parkinson's disease. These drugs are useful in certain variants of frontotemporal dementia. Cholinesterase inhibitors are not useful in dementia caused by Huntington's disease or traumatic brain injury. While cholinesterase inhibitors are useful in many early dementias, studies have not shown that treatment of patients with mild cognitive impairment, which is the condition before dementia, prevents or slows progression to dementia.

Studies of treatment with estrogen, ginkgo biloba, vitamin E and vitamin B supplementation have been done. These drugs do not appear helpful. Some antidepressants have been shown to be effective in treating mood disorders associated with dementia, but they do not improve cognitive function.

Several studies have demonstrated that dementia patients given structured exercise programs and occupational therapy have a less severe decline in activities of daily living and improved quality of life. These benefits have been observed over periods of years.

soundoff (15 Responses)
  1. Wet Wolf

    Fish oil ( not codliver oil) has been found to aid cognitive ability.

    September 1, 2010 at 08:55 | Report abuse | Reply
  2. Army man

    I would be highly interested in studies of dementia and Cholecalciferol and Calcium. I can't imagine this road has not been explored? Me the answer is simple....Wet Wolf you are correct, but cut to the quick Cholecalciferol and Calcium IS the answer. For those who read this and have a loved one who has dementia, try Cholecalciferol (Vitamin D3) Calcium and moderate sunshine 1/2 hour to an hour in the early morning. Get with a doctor to have the Cholecalciferol levels checked, chances are they are very very low. I have too much to say and not enough space to say it all. I challege any doctor/scientist who reads this please send me ANY studies that have been done in this area. If there are none, then the work is cut out, you'll be a hero!

    September 1, 2010 at 10:07 | Report abuse | Reply
    • Don

      I would be interested to know why you believe that there is a connection between dementia and Cholecalciferol & Calcium. Could you respond to this by providing a little more information? Thanks

      September 1, 2010 at 14:41 | Report abuse |
  3. bobbydelray

    The Alzheimers Reading Room has clear, concise, usable news, research, insight and advice for the entire Alzheimers community. The website focuses on those suffering from Alzheimers disease and Dementia, Alzheimers caregivers, and the art of Alzheimers caregiving.


    September 1, 2010 at 11:03 | Report abuse | Reply
  4. CutTheCarb

    What leads to Alzheimer's and vascular dementia? Perhaps it’s better to find the root cause instead of studying treatments. In this post http://bit.ly/cW3jpD a cause and an alternative treatment are given.

    September 1, 2010 at 11:23 | Report abuse | Reply
    • Mark C

      On the other hand maybe you need to stop playing doctor on the Internet and practicing medicine without a license.

      September 1, 2010 at 15:02 | Report abuse |
    • IMHO

      This is just a blatant plug for business for his website.

      September 1, 2010 at 16:25 | Report abuse |
  5. Kyle

    I think the answer is in early detection, then aiding the hippocampus during neurogenesis.

    September 1, 2010 at 11:36 | Report abuse | Reply
    • Kyle

      ...and gene therapy

      September 1, 2010 at 11:42 | Report abuse |
  6. Tom

    I think what they meant to say is Recreational Therapy. Recreational Therapists provide most of the structured programming for Dementia residents in Nursing Homes and Living Centers. Programming which taps into their interests, needs and abilities and those things which are familiar. Quality of Life is important at this point. Occupational Therapists? Really

    September 1, 2010 at 12:46 | Report abuse | Reply
  7. adh

    There's a study that suggest a link between Alzheimer's with Down syndrome: http://www.sciencedaily.com/releases/2010/01/100115182639.htm. Interestingly, a third copy of the 21st chromosome have been found in some of the cells in tissues of Alzheimer's patients. Perhaps a cure may be preventing the cells from dividing improperly in the first place.

    September 1, 2010 at 13:35 | Report abuse | Reply
  8. NJ Jaeger

    I read exactly the opposite of this report in the latest medical journal. There was no difference when using memantine.

    September 1, 2010 at 14:09 | Report abuse | Reply
  9. John

    Drugs aside, the best thing you can do for dementia patients is stop putting them in places with other dementia patients. Their brains atrophy and they go downhill fast. I have watched this happen to family members and it is a very distressing thing to witness. They need to be mentally stimulated.

    September 1, 2010 at 15:46 | Report abuse | Reply
    • Jia

      9. JMichael wow good details where did you get that iniormatfon?10. annegb yes at times some of the brethren do seem a little shaky at times in General Conference.11. Left Field correct on this one. However, President Romney was not emeritus 12. MCQ yep that would work.13. living in zion yes the President Benson thing was pretty ugly. Too bad it ended that way.14. Stephen M (Ethesis) good point on President Benson. I guess the illness did benefit the rest of us 15. NewlyHousewife there are a lot of 70s who are emeritus The key is that members of the 12 can NEVER be emeritus, although I think they should if they are mentally unable to do the job. I agree with your 60% conference assertion!

      August 1, 2012 at 19:32 | Report abuse |
  10. Joyce

    My mother, 85, was diagnosed almost 4 years ago with dementia and initially not treated properly. An issue people are not discussing is whether the patient KNOWS what is going on and I am here as a witness to tell everyone they indeed DO know. The unfortunate thing is they become anxious knowing SOMETHING is wrong but no one can help them because they lack the ability to convey their symptoms therefore, unless a doctor is proactive and compassionate, they can go untreated for many months until the disease progresses to the point of the obvious. My mother was in a rehabilitation facility for several weeks and became quite paranoid to the point I would go stay with her after visiting hours and leave in the wee hours of the morning when I felt she was sleeping soundly. It would start over again each night until she was released. The administrator wanted to put her in a nursing facility and we, the children, all opposed saying she needed to be HOME... where she recognized things and felt comfortable and more at ease. We found it best to hire a live-in caregiver to be with her 24/7 and it has made all the difference in the world for my mother. She is very healthy otherwise and remains as happy as she can possibly be given the circumstances. It also allows us [family] the opportunity to continue our jobs and not be exhausted burning both ends of the candle. Granted, there will be those who can not afford to pay for a live-in but if you put yourself in THEIR shoes.... how would YOU want to be treated?? Discarded and put in a home with like kind people because you "have lived a long life" anyway? I think not! We as a society have to remember these older folks are OUR FAMILY! Often times they are the ones who raised us to be who we are and I think it's unconscionable to think of the older generation as "disposable". Remember... we TOO will be there someday.... if we're lucky to live that long!

    September 1, 2010 at 19:29 | Report abuse | Reply

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Get a behind-the-scenes look at the latest stories from CNN Chief Medical Correspondent, Dr. Sanjay Gupta, Senior Medical Correspondent Elizabeth Cohen and the CNN Medical Unit producers. They'll share news and views on health and medical trends - info that will help you take better care of yourself and the people you love.