Therapy target
- Slowing down the disease process
Note: 84% of all vascular dementia (VD) sufferers also have detectable AD pathology. In these cases, it is justified to treat them as Alzheimer’s dementia (AD) with AChE inhibitors [S3 guideline recommendation].
Therapy Recommendations
- In Alzheimer’s dementia, drug therapy can be used to try to slow the disease process.
- For mild to moderate dementia: acetylcholinesterase inhibitors (AChE inhibitors; e.g., donepezil, galantamine; lose their effect after 6-12 months).
- No sufficiently evident study results are yet available on a combination (e.g., donepezil) with N-methyl-D-aspartate antagonists
- In moderate to severe dementia: memantine (N-methyl-D-aspartate recptor antagonist; postponement of the disease process by 6-12 months).
- For mild to moderate dementia: acetylcholinesterase inhibitors (AChE inhibitors; e.g., donepezil, galantamine; lose their effect after 6-12 months).
- Note: For patients with Parkinson’s dementia, Lewy body dementia, and related disorders, classic and many atypical neuroleptics are contraindicated because they can exacerbate Parkinson’s symptoms and trigger attacks of somnolence. Usable neuroleptics in these disorders are clozapine and, with less evidence, quetiapine.
- For agitation or psychosis in the context of dementia:risperidone, aripiprazole (antipsychotics (neuroleptics)); also citalopram (selective serotonin reuptake inhibitors, SSRIs), if appropriate.
- For depression requiring therapy in the context of dementia: e.g., citalopram, escitalopram, sertraline (SSRI).
- Treatment of relevant vascular risk factors and underlying diseases leading to further vascular damage is recommended in vascular dementia.
- Patients with mixed dementia should be treated according to Alzheimer’s dementia.
- No convincing evidence exists for the treatment of cognitive or behavioral symptoms in patients with frontotemporal dementia. No treatment recommendation can be made.
- No approved or adequately supported medication exists for the antidementive treatment of Lewy body dementia.
Further notes
- Nootropics (drugs used to treat dementia) cannot be recommended.
- No recommendations are currently available for drugs such as glucocorticoids, NSAIDs, estrogens, secalealkaloids, selegelin, or HMG-CoA reductase inhibitors (statins).
- Tricyclic antidepressants should not be used for depression in dementia (because of anticholinergic side effects).
- No recommendation for antidementive therapy in fronto-temporal dementia or Lewy body dementia.
- In a study of more than 45,000 dementia patients taking antipsychotics (neuroleptics), increased mortality (compared with the control population) during a 180-day observation period was found for the following drugs:
- Haloperidol: mortality 20% with medication versus 8.4% without medication; adjusted risk difference 3.8%; NNH (Number Needed to Harm) 26
- Olanzapine: 13.9% versus 9.8%; 2.5%; 40
- Quetiapine 11.8% versus 8.2%; 2.0%; 50
- Risperidone 13.9% versus 8.5%; 3.7%; 27
- Valproic acid: 12.2% vs. 7.2%; 4.1
- Antidepressants (excluding tricyclics and MAO inhibitors): 8.3% vs. 8.0%; 0.6%; 166
- Wg. Antihypertensive (blood pressure-lowering) drug reduction: in one study, 385 at least 75-year-old female patients with mild cognitive deficit (MMS E 21-27 points) had 4 months of antihypertensive drug discontinuation. Compared with a control group, there were no differences in dementia parameters thereafter; the two groups also performed equally in individual cognitive domains (e.g., memory, executive functions, and psychomotor speed).
- Treatment of agitation and aggression with valproate is not recommended.
- Alzheimer’s disease patients with psychotic behavior, severe agitation, or aggression have an 80% relapse rate after discontinuation of risperidone in hallucinating patients (3-fold increased rate); in patients with very marked irritability at baseline, 4 of 21 (19%) relapsed on risperidone, but almost all (13 of 14) did so without the antipsychotic.
Supplements (dietary supplements; vital substances)
Suitable dietary supplements should contain the following vital substances:
- Vitamins (folic acid, vitamin E (tocopherols), cobalamin (vitamin B12)).
- Fatty acids (omega-3 fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)).
- Other vital substances (acetyl-L-carnitine, N-acetyl-L-cysteine, S-adenosyl-methionine (SAMe)).
In the presence of insomnia (sleep disturbances) due to dementia, see below Insomnia/Medicinal Therapy/Supplements. Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in the particular life situation.