Information
Editors
Treatment of a Patient with Memory Disease
Essentials
- In the treatment of memory disorders, individual guidance, provision of correctly timed, constant support and security for patients and their families, and specific pharmacotherapy are essential.
- Factors that stress the patient should be avoided, as well as changes that may worsen the symptoms.
- The patient should be supported and encouraged to be physically, mentally and socially active, to have good nutrition as well as to get enough nocturnal sleep.
- Appropriate treatment of behavioural symptoms and other diseases (non-pharmacological treatment, and pharmacological treatment, as necessary)
- Regular assessment (at least every 6-12 months), including assessment of the efficacy of and need for pharmacotherapy of the memory disorder and other disorders, and updating of the care and service plan.
- A decision to transfer the patient to institutional care should be made if there are risk factors that cannot be influenced even with frequent visits from the home care services or if caregiving proves to be too strenuous.
Symptomatic pharmacotherapy
- Symptomatic pharmacotherapy is already recommended even in the very mild stages of Alzheimer's disease (AD), memory disorder associated with Parkinson's disease (PD), Lewy body dementia (LBD) or mixed AD with features of cerebrovascular disease or other conditions listed above.
- For early and mild AD, the recommended first-choice drug is an acetylcholinesterase (AChE) inhibitor (donepezil, galanthamine or rivastigmine in doses shown to be effective in various studies). If AChE inhibitors are not suitable (because of contraindications, for instance), treatment can be started with memantine.
- In very mild or mild AD, use of the nutritional supplement Souvenaid® can be considered.
- AChE inhibitors and memantine are the primary treatments for moderately severe to severe AD.
- In a memory disorder associated with a cerebrovascular disease, or vascular cognitive impairment (VCI), drugs for memory disorders may be useful for cognition but not for maintaining self-sufficiency. VCI or vascular dementia (VD) is not an official indication for any pharmaceutical ingredient that has been studied in Europe or in the United States.
- Galanthamine is at least as effective in the treatment of mixed memory disorder (AD + VCI) as in the treatment of AD alone.
- AChE inhibitors are the first-line treatment for symptoms of PD memory disorder. Of this group of drugs, rivastigmine is officially indicated in the treatment of PD memory disorder.
- AChE inhibitors are useful in the treatment of LBD symptoms but this is not their official indication.
- Drugs indicated for memory diseases are not indicated in the treatment of frontotemporal degeneration and should not be used for this purpose.
- The aim of Alzheimer's medication at every stage of the disease is to maintain any remaining self-sufficiency for a longer time - supporting even modest functional ability even in the severe stage of the disease - and to prevent or treat various symptoms of the disease, such as behavioural symptoms.
- A validated method should be used for assessing treatment response and the need for support and services. This is best shown by coping with daily tasks. The ADCS-ADL inventory (interview of caregiver on the daily performance capacity of the person with memory disorder) shows that the daily performance capacity decreases by an average of 5-7 points/year (representing what is said to be the normal response to treatment) during the first 3 years in patients with AD on medication, and later by an average of 9 points/year.
- Mood and other behavioural symptoms should also be monitored (using BDI, GDS, NPI, FBI inventories).
- Treatment with drugs for memory disorders should be discontinued if it cannot be successfully monitored, if severe adverse effects appear that are irreversible despite change of medication, if the patient's state deteriorates rapidly on all drugs or drug combinations or if pharmacotherapy is not considered beneficial in terms of functional ability or behavioural symptoms in severe dementia.
Support of care at home
- Regular visits to the health centre or home visits (every 6-12 months or more frequently as indicated), help to detect any problems as they arise and to predict future needs.
- It is important to support the people caring for the patient at home. Even patients living alone can be supported by home care services or dementia care coordinators. See also Choosing the Place of Care for an Elderly Patient with a Long-Term Illness.
- Arrange for visits from home nursing and home care services, as well as any other necessary services (such as meals on wheels, cleaning services). Keep in mind that as the memory disorder progresses, patients can no longer make decisions in their best interests on issues such as the need for care. It is important to listen to the caregivers; if there is an objective need for support, it should not be denied even if the patient does not feel it is necessary.
- The family caregiver's situation and coping should be checked (depressive symptoms and other disorders, relative strain). Family caregivers of patients with memory disorders should be supported, with an attempt to give them some time of their own free from their care duties.
- Day care centres and clubs for people with memory disorders have been shown to be beneficial, affording family caregivers some time off Medical Day Hospital Care for Older People Versus Alternative Forms of Care.
- Arrange care at a day hospital or other short-term care according to the needs of the family caregiver. Rehabilitative short-term care may help to maintain the patient's functional ability.
- Write the required medical certificates for care allowances and medication reimbursements (antipsychotics and antidepressants), as necessary.
- Provide information about the activities of the local memory associations, such as groups for family members.
- A legal guardian should be arranged for the patient if it is otherwise impossible to settle financial and other matters. A legal guardian should be authorized in advance, at an early stage of memory disorder when the patient is capable of making decisions in his/her best interests.
- Local outpatient memory clinics can provide follow-up at least for patients who require intensive support. They also serve as consultation centres for care.
Decision on long-term care
- The most common reasons for permanent institutionalization are
- behavioural disturbance, aggression in particular (the most common cause)
- stress or illness of the caregiver
- loss of motor functions
- loss of activities of daily living (toileting, washing)
- incontinence
- inability to recognize relatives and home environment
- restlessness at night.
- Due to the lack of insight into their condition, people with memory disorders often want to stay in their own home even if the prerequisites for this no longer exist. If a family member wishes to stop caring for the patient at home, the reasons for the decision should be discussed with him/her. If these reasons cannot be resolved, long-term institutional care must be arranged. A caregiver with knowledge of the support available is the best expert when the possibility of continuing home care is being evaluated.
- Daily visits by a nurse and night patrol prolong the home treatment period of patients with dementia-level memory disorder who live alone. Electronic surveillance methods may be used in some cases. A demented person is not able to use personal alarm devices. Accidental fire and getting lost (cold exposure in the winter) represent the biggest dangers.
- A decision for institutional care should be made if risk analysis reveals dangers that cannot be mastered even with frequent home care visits. When the disease progresses, a group home or a housing unit providing round-the-clock supervision is the best solution.
Factors increasing the symptoms of memory disorder
- As the memory disorder (particularly one of dementia level) progresses, factors secondarily impairing the patient's functional capacity should be determined and eliminated, as far as possible. Things to be avoided include
- strange places (travel only with a familiar person)
- being alone for a prolonged time
- too many stimuli (e.g. lengthy occasions with too many strange people)
- darkness (suitable lighting also at night-time)
- all infections (urinary infection being the most common)
- low blood pressure
- operations and anaesthesia: only when unavoidable (spinal anaesthesia is not any safer than general anaesthesia)
- hot weather, sunny beaches in the south (heat, fluid loss)
- using a lot of medication.
- See also article Reviewing an elderly patient's medications Reviewing an Elderly Patient's Medications.
- The management of behavioural symptoms should primarily non-pharmacological Massage and Touch for Dementia, Physical Activity Programs for Persons with Dementia, Respite Care for People with Dementia and Their Carers, Snoezelen (Multi-Sensory Stimulation) for Dementia, Exercise Programs for People with Dementia, Psychological Treatments for Depression and Anxiety in Dementia, Aerobic Exercise to Improve Cognitive Function in Older People Without Known Cognitive Impairment, e.g. by managing factors like infections, pain or feeling of insecurity that may trigger the symptoms, together with appropriate respectful conduct towards the patient.
- Confusion may be due to hypotension, for example. Hypotension commonly occurs at night-time, and blood pressure should also be measured in the upright position Brief Orthostatic Test. Systolic blood pressure should exceed 125 mmHg.
- Confusion is often aggravated by orientation problems in a dimly lit environment, problems with place orientation when travelling or procedures differing from the patient's routine (during periodic treatment, for example). These issues should be considered when planning the treatment.
- Donepezil, rivastigmine, galanthamine and memantine also have an effect on behavioural symptoms in patients with AD. Early treatment with AChE inhibitors has a positive effect on the onset of behavioural symptoms in patients with AD.
- Psychopharmacological drugs should be used only in low doses and for short periods (less than 6 weeks). The evening dose may be higher, as restlessness at night is quite harmful for the treatment.
- Antidepressant therapy should be tried if depression or anxiety is also suspected in patients with AD or vascular dementia Antidepressants for Depression in Dementia. Restlessness and aggression may be caused by anxiety, in which case antidepressants may be effective Antidepressants for Agitation and Psychosis in Dementia.
- If other treatment measures prove ineffective, second generation antipsychotics may be prescribed. The primary choice is risperidone which is the only drug indicated in the treatment of behavioural symptoms of dementia. The response is individual and to achieve the best effect it may be useful to test several drugs. When a rapid response is required in emergency situations, parenteral haloperidol may also be administered either intravenously or intramuscularly in a low dose (2.5-5 mg). Haloperidol should not be prescribed as regular medication.
- If antidepressants are not sufficiently effective, the patient is sensitive to adverse effects of antipsychotics, and temporary or continuous quick relief from restlessness or anxiety is needed, benzodiazepines with an intermediate duration of action, like oxazepam, may be used either continuously or as needed.
- Benzodiazepines
- Oxazepam 7.5-15 mg as necessary, also for the night
- Temazepam 10-30 mg for the night, as necessary; for treatment of anxiety, also 5-10 mg during the day; rapid effect
- Antipsychotic drugs (mainly at night)
- Risperidone for aggression and psychotic symptoms 0.25-0.5 mg twice daily
- Quetiapine 12.5-25 mg once daily, increased up to 25 mg twice daily, especially for patients in whom risperidone causes adverse effects (such as patients whose disease has features of Lewy body disease). In exceptional cases, the dose of quetiapine may be increased up to 25 + 25 + 50 mg for a short time.
- Haloperidol for anxiety and restlessness at doses 0.25-0.5 mg 2-3 times daily, as necessary; effective, but extrapyramidal adverse effects are common Haloperidol for Agitation in Dementia.
- Antidepressive drugs
- Citalopram 10-20 mg or escitalopram 5-10 mg once daily; activating
- Sertraline 25-50 mg once daily
- Mirtazapine 7.5-15-30 mg once daily, in the evening (sedative effect at low doses, antidepressant and activating effect at higher doses)
- Treatment of insomnia Pharmacotherapies for Sleep Disturbances in Dementia
- For disturbances of the circadian rhythm, light therapy in the morning in combination with melatonin 2-6 mg for the night may be tried.
References
- Scheltens P, Twisk JW, Blesa R et al. Efficacy of Souvenaid in mild Alzheimer's disease: results from a randomized, controlled trial. J Alzheimers Dis 2012;31(1):225-36. [PubMed]
- Hallikainen I, Hänninen T, Fraunberg M et al. Progression of Alzheimer's disease during a three-year follow-up using the CERAD-NB total score: Kuopio ALSOVA study. Int Psychogeriatr 2013;25(8):1335-44. [PubMed]
- Välimäki TH, Martikainen JA, Hallikainen IT et al. Depressed spousal caregivers have psychological stress unrelated to the progression of Alzheimer disease: a 3-year follow-up report, Kuopio ALSOVA Study. J Geriatr Psychiatry Neurol 2015;28(4):272-80. [PubMed]