Currently, there is no cure for Alzheimer's. But drug and non-drug treatments may help with both cognitive and behavioral symptoms.
Researchers are looking for new treatments to alter the course of the disease and improve the quality of life for people with dementia.
Drugs used to treat people with Alzheimer’s fall into two broad categories–drugs to treat cognitive symptoms, such as memory problems and other mental deficits of Alzheimer’s, and drugs to treat behavioral symptoms that do not respond to non-pharmacological behavioral-management approaches. These drugs might include a variety of types of drugs broadly categorized as anti-agitation drugs.
Currently, there are more than 100 clinical trials being conducted in Alzheimer’s and dementia. The government requires that all new medicines undergo rigorous testing in the laboratory, first in animals and then in human volunteers, before they can be prescribed by doctors or sold in pharmacies. Once the required clinical trials are completed, companies submit an application to the FDA, the government agency responsible for the safety of foods and drugs sold in the U.S. Together with an independent panel of medical advisors, the FDA reviews the scientific data and determines whether the drug is safe and effective for people with Alzheimer’s.
In addition, there are a number of other health conditions that compound the symptoms of Alzheimer’s disease because they affect one’s cognition. People with Alzheimer’s may not be able to communicate such health problems to others. Their reactions may be interpreted as part of the Alzheimer’s disease process. With proper treatment of the underlying cause, such behaviors may improve or resolve. These conditions need to be identified and treated. People with Alzheimer’s should receive ongoing medical care to identify and, if necessary, receive treatment for specific health problems. For example, the depressed may benefit from antidepressants; those with arthritis might need to take anti-inflammatory drugs for pain relief; and frequent urinary tract infections might require treatment with antibiotics to address the underlying infection. Correcting these disorders often greatly improves mental function.
What Drugs are Approved for Alzheimer’s Disease?
Five drugs have been approved by the U.S. Food and Drug Administration (FDA) for treating the cognitive symptoms of Alzheimer’s disease. Reminyl, Exelon, Aricept and Cognex belong to a class of drugs known as cholinesterase inhibitors. Each acts in a different way to delay the breakdown of acetylcholine, a chemical in the brain that facilitates communication among nerve cells and is important for memory. Alzheimer’s disease is associated with inadequate levels of this important neurotransmitter. Namenda acts by a different mechanism. It shields brain cells from overexposure to another neurotransmitter called glutamate, excess levels of which contribute to the death of brain cells in people with Alzheimer’s. Click on the fact sheets below to view specific usage information, dosage guidelines, precautions, interactions, and side effects.
Cognex®*Generic Name: tacrineWhen Approved: 1993More Information: Fact sheet* Cognex is rarely prescribed due to serious side effects, including possible liver damage.
In general, Reminyl, Exelon and Aricept are most effective when treatment is begun in the early stages. Namenda is the only drug shown to be effective for the later stages of the disease. They have all been shown to modestly slow the progression of cognitive symptoms and reduce problematic behaviors in some people, but at least half of the people who take these drugs do not respond to them. While the overall “treatment effect” of these medications is modest, studies show that when they do work, they can make a significant difference in a person’s quality of life and day-to-day functioning (“activities of daily living”). The drugs have different side effects. Some are taken once a day (Aricept), others twice a day (Exelon, Reminyl and Namenda).
Are there other treatments for Cognitive Decline in Alzheimer’s disease?
Strong evidence indicates that vitamin E, taken at a dosage of 1,000 I.U. twice a day, may slow the progression of Alzheimer’s in some people, although the overall impact is minimal. Studies are ongoing, and vitamin E should be used only under a doctor’s supervision.
There has been research into the use of other drugs to treat, stop, or prevent Alzheimer’s, but most have not proved to be effective. Some population-based research studies – called epidemiological studies – have suggested that the female hormone estrogen, statins used to treat high cholesterol, the steroid prednisone, and a group of drugs used to treat arthritis, called non-steroidal anti-inflammatory drugs (NSAIDs) may be protective against Alzheimer’s. While these agents may prove to be effective in preventing or delaying Alzheimer’s – recent studies support such a role for NSAIDs, in particular – studies completed to date indicate that they are not effective treatments for Alzheimer’s. This apparent contradiction may be explained by the fact that once symptoms of Alzheimer’s are evident, the disease processes in the brain may have progressed too far for such agents to be effective. However, if used before symptoms are apparent, these drugs may be able to alter the progression of nerve cell loss and other disease-related changes in the brain, though research proving this effect is inconclusive. More research is needed to determine the effects that these other treatments may have on Alzheimer’s.
Is estrogen an effective treatment for Alzheimer’s disease?Many recent studies have found that estrogen hormone replacement therapy does not have much effect on the symptoms of Alzheimer’s disease. Estrogen, a hormone that is produced by the ovaries during a woman’s reproductive years, affects brain regions relevant to memory, such as the hippocampus. A large body of data gathered over the past 25 years in animal studies supports the notion that estrogen has some positive effects on memory function. In population-based observational studies (called epidemiologic studies), estrogen use has been associated with a decreased risk of Alzheimer’s and with enhanced cognitive function. It also has both antioxidant and anti-inflammatory effects and enhances the growth of nerve fibers from particular neurons important for memory function. These data have created intense scientific interest in the relationship between estrogen, memory, and cognitive function in humans.
In recent years, the federal government’s lead agency for research on aging, the National Institute on Aging, has supported one Alzheimer’s clinical trial on estrogen in the hope that it might be able to provide evidence on whether estrogen actually affects the progression of the disease. Results of this study indicated that estrogen replacement therapy (ERT) did not slow progression of Alzheimer’s or improve cognitive or functional outcomes in women who have Alzheimer’s. Even if given for a full year, estrogen was not helpful for these women. It should be noted that the findings apply only to a very specific population of older patients who had had Alzheimer’s for some time.
A closely associated study provided similar results. In this study, postmenopausal women with mild to moderate Alzheimer’s disease were treated for 16 weeks with 1.25 mg/day of estrogen. At both 4 and 16 weeks there were no significant differences between treatment and placebo groups on measures of cognition or caregiver-rated functional status. Estrogen did not slow the functional decline associated with Alzheimer’s, and did not improve mood or other disease symptoms.
Another clinical trial examined the effects of estrogen on cognition, mood, and blood flow to the brain in women with mild to moderate Alzheimer’s disease. Blood flow is important because nutrients such as glucose and oxygen reach the brain through the blood stream. The better the blood flow, the more likely a person is to have good cognitive function. This study tested the effect of 1.25 mg of estrogen given without any progesterone (another hormone sometimes given with estrogen) to women in Taipei, Taiwan, who had a diagnosis of mild to moderate AD. Women were given the hormone for 3 months. Again, there was no beneficial effect, either on blood flow or cognitive decline in these women. When taken with data from clinical trials done in the U.S., the data suggest that the negative estrogen findings might be generalizable to older women with Alzheimer’s who are of different races.
Most recently, in May 2003, a five-year follow-up memory component of the large and rigorous Women’s Health Initiative called WHIMS (Women’s Health Initiative Memory Study revealed that healthy women aged 65 and older who took Prempro, a popular combination of estrogen and progestin, had twice the rate of dementia, including Alzheimer’s, as women who did not take the medication. The new findings, add new fuel to the debate over hormone replacement therapy. However, it is important to keep these risks in perspective. Out of 4,500 women in the study, only 61 developed dementia. Forty of those cases occurred in those on hormone replacement (20 were deemed to be Alzheimer’s disease), while 21 cases of dementia (including 12 cases of Alzheimer’s) occurred in those on a placebo. These results confirm that the vast majority of older women who take estrogen will not develop dementia, just as they will not develop breast cancer or have a heart attack as a result of the medicines. There risk, however, is still slightly increased, and women will want to continue to discuss the pros and cons with their doctors.
These studies have found that estrogen does not have a beneficial effect on older women who already have Alzheimer’s, but it is unclear whether normally aging women who take estrogen after menopause will be protected from developing Alzheimer’s or age-related.
What Medications are Available to Treat Behavioral Problems?
In later stages of the disease, people with Alzheimer’s might experience distinct changes in behavior or personality. In fact, the first recognized case of Alzheimer’s, back in 1906, was in a patient who had suffered paranoid delusions.
Potential behavioral symptoms, which are often lumped together as “agitation,” may take many forms, such as aggressive behavior, wandering or pacing, rummaging as if in search of something, paranoia, suspiciousness, combativeness or resistance to maintaining personal hygiene. These symptoms can significantly decrease the quality of life of all involved – patients and families – and can seem overwhelming to families and caregivers. The inability to manage these types of symptoms is the primary reason that many people with Alzheimer’s must eventually be placed in a long-term-care facility.
Are there ways to treat behavioral problems other than with drugs?Yes. It’s important to understand that many problematic behaviors may be reactions to co-existing medical or psychiatric conditions, or to inappropriate methods of communication or interaction with the person. Identifying and treating co-occurring health problems is therefore critical as a first step in managing behavioral problems. In addition, family and caregivers should learn about proven techniques for communicating with the afflicted person, modifying the home environment and involving the person in therapeutic activities, all of which can minimize problems.
What drugs are used to treat behavioral symptoms?If non-drug approaches fail to adequately manage behavioral problems, talk to your physician about medications that may help. You’ll need to describe any behavioral problems to your doctor, so you might want to use a journal or list to keep track of day-to-day changes in behavior and note when symptoms arise, what might precipitate them and what if anything helps resolve them when they do arise.
Your doctor may recommend appropriate medications, depending on what the symptoms are, from a group of drugs generally referred to as anti-agitation drugs. The types of medications that might be used include antidepressants (if the patient has depression); anti-anxiety drugs (also called anxiolytics), anti-psychotic medications (some of which are also called neuroleptics); sedatives, and sleep medications.
There are many different drugs within each of these classes of medication. Each acts in a somewhat different way and has different side effects, some of which may be severe. As a rule, doctors generally prescribe the lowest dose possible to alleviate symptoms and adjust the dosage as necessary.