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And now let's move on to discuss treatment.

So we'll begin with each of the individual dementias.

And we'll begin with Alzheimer's disease, where

the treatment is a little bit more straightforward.

Cholinesterase inhibitors.

Drugs that are used to boost acetylcholine

have been used for years in Alzheimer's disease.

There are three that are commonly used, Donepizil, rivastigmine and galantamine.

These drugs, again, boost acetylcholine and Alzheimer's

disease, as we talked about, have a deficit of acetylcholine.

And they are modestly effective.

About a third of patients will improve slightly with them.

About a third will stay the same, and

about a third there will be no difference regardless.

Six to 12 months later, typically, there is, decline.

So these can stave off the declines and deficits,

at best, for a matter of a year or so.

But they

are effective and widely prescribed for Alzheimer's disease, and should be done.

They're most effective in mild or moderate cases of the illness.

Now there are other medicines that are used in Alzheimer's disease.

They include Memantine.

Memantine is a glutamate receptor antagonist.

Which is used and is usually added to cholinesterase inhibitors when

progression occurs despite being treated with

an adequate dose of a cholinesterase inhibitor.

Data increasingly is mixed that these that this

drug is particularly effective, but it's still used widely.

Some new data this year suggests that vitamin E at high

doses may be effective in mild to moderate cases of Alzheimer's disease.

But other

drug treatments have not been proven to be effective.

This includes herbal remedies like gingko biloba, and others,

homeopathic remedies that have been used for memory problems.

Interestingly, all of these, compounds, including cholinesterase

inhibitors and Vitamin E have not been

shown to slow down the rate of

conversion from mild cognitive impairment to dementia.

So in practice they're rarely used for mild cognitive impairment.

Sometimes a cholinesterase inhibitor is, but as a general rule we don't have

an effective drug that prevents mild

cognitive impairment from progressing to frank dementia.

These are drugs that are effective and modestly

so, in mild to moderate cases of Alzheimer's disease.

Now, other specific dementias, vascular dementia.

We think in vascular dementia,

cholinesterase inhibitors are again effective.

Maybe not quite as effective as alzheimer,

it's been around the same order of magnitude.

And then probably makes sense to modify vascular risk factors.

So, treat hypertension, hypercholesterolemia,

diabetes, urge quitting tobacco use.

That is likely to help, although we don't have great data that it does.

And we consider antiplatelet medication, which

you'll hear in the stroke lecture are

certainly a important piece of preventing vascular disease would

treating somebody with a medicine like Aspirin or Chlopeterol.

Would that have an effect on vascular dementia?

We're not sure.

But they're commonly used in cases of vascular dementia.

For dementia with Lewy bodies, we think this is

the disease that cholinesterase inhibitors are the most effective.

So,

cholinesterase inhibitors makes sense for dementia

with Lewy bodies, because this is a

disorder as I mentioned, that features

a profound, a profound deficit of acetocholine.

And in fact, trials have showed

that cholinasterase inhibitors are quite effective

in dementia with Lewy bodies, at least for a number of years.

And you can get a lot more quote, bang

for your buck than you would in Alzheimer's Disease.

So, another reason to recognize this relatively under-recognized

form of dementia is to be able to initiate

a drug treatment which is quite effective in many patients.

Now in addition to therapy for these specific dementia's there are some general

therapy that should be considered for all cases of dementia regardless of the cause.

Physical exercise.

Data suggests that aerobic exercise is probably as helpful in dementia

in preventing cognitive decline as any other medical treatment we can prescribe.

Amazing.

So telling patients to exercise when they have

dementia ends up being a really important piece.

But what's increasingly being recognized is that in addition to physical exercise.

Cognitive exercise is probably equally important, sort of

a use it, or lose, lose it mantra.

We're not

quite sure why.

Does this go back to the cognitive reserve hypothesis that I spoke about earlier?

But the ideas of you stay cognitively and socially active, keep reading.

Keep working through puzzles.

Keep learning a new language, etcetera.

That your rate of progressing in dementia will be lower and lower.

Interestingly these are increasingly leveraging technology, web

based programs, computer based technologies where patients

can complete cognitive exercise at their own

time in the comforts of their own home.

And then track their progress on a daily basis.

And this has become a huge industry.

And there's mixed data, but generally the data is positive that these help folks.

We treat depression always, if present.

because as I mentioned, depression can worsen symptoms of dementia.

That can be done with talk therapy, or anti-depressant

medications, like the serotonin Re-uptake inhibitors.

We like to treat patients with dementia

with a multidisciplinary team of healthcare providers.

This includes not just physicians and nurses, which are obviously essential.

But social workers that help the family navigate

when a loved one is losing their facilities.

Therapists, not just therapists for psychiatric disease but physical

therapists, and occupational therapists, and speech and swallowing therapists,

that help patients improve problems that they're currently faced with.

We have to assure homes safety, this is very important when we diagnose

dementia, we often send an occupational

therapist out to the patient's home environment

to make sure that everything's been done to assure that the home environment

is safe, that would include having locks on the oven, in case memory

is a problem.

Having appropriate friction and handles in the bath so that there's

not a fall in the shower or the bath tub, etcetera, etcetera.

It's important early on to have a discussion with the family to

identify decision-makers, both for health care and for finances for the future.

And to make decisions regarding end-of-life wishes and discussions.

Does the patient

wish to be on a breathing tube if it comes to that?

Does the patient wish to have a feeding tube inserted

if it gets to the point that the patient can't swallow?

It is always best to have these last two

discussions prior to the patient losing their facilities, when they

can still participate in this discussion, hopefully, and also it's

important to have these discussions prior to it becoming a

dire need to have these discussions.

It's much easier to decide whether a feeding tube

is something that the patient and the family would want.

Years and years before so rather than the

day that the patient stops being able to swallow.

There's a very interesting story regarding these

feeding tubes and that there are absolutely

no data that in searching, insertion of

these feeding tubes helps patients with dementia.

So increasingly practitioners are advising

families that this shouldn't be a part of the care of loved ones with dementia.

Now behavioral treatments end up being incredibly important.

It turns out that by the late stages of

dementing illnesses, behavioral problems often rear their ugly head.

These are very distressing to caregivers.

These are hallucinations, delusions, aggressive behavior,

striking loved ones, saying mean things, this

can be very distressing to caregivers and

is also a common reason why patients with dementia get placed in a nursing home.

Unfortunately, we don't have great therapies that treat these diseases.

Trials of both cholinesterase inhibitors and anti-psychotic medications

have not shown benefit, and anti-psychotic medications have risk.

There's an increased risk

of sudden death if they are administered to elderly populations.

In the United States, there's a Food and Drug Administration or

FDA black box warning against using these medications in the elderly.

So we don't have good options.

What we do in practice is that we treat patients with low doses of

anti-psychotic medications only if the patient is really posing a harm to

themselves or others as part of these behavioral treatments.

It is a huge part of the management of these patients.

And if you ask families, it ends up being the part of this illness

that is the most distressing, the most sad and that requires the most attention.

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Module 4 Part 6: Treatment, Neurodegenerative Diseases & Dementia

Introduction to Clinical Neurology

Meet the Instructors