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How are Neurocognitive Disorders treated?
It is useful to consider the A-B-Cs of dementia:
- affect,
- behavior, and
- cognition
The cognitive deficits of dementia include memory loss, disorientation, apraxia, anomia, etc.
Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) are the mainstays for treating the cognitive symptoms in mild to severe Alzhemiers Disease.
Rivastigmine also has butyrylcholinesterase inhibiting properties, but the clinical significance of that is unclear.
Memantine, an N -methyl- d -aspartate receptor antagonist, is also useful for AD, especially when there are behavioral problems, and it acts synergistically with the cholinesterase inhibitors.
These medications may improve cognition and functioning in the first few months of treatment and delay or improve behavioral symptoms.
They may then slow cognitive decline during the remainder of the disease.
There is increasing evidence for clinical efficacy of these drugs in other dementias like VaD and DLB. Some investigators have found donepezil to be useful in MCI.
Acetylcholinesterase inhibitors are generally not used in FTLD.
Affect is frequently altered in the dementias, presenting as depression and anxiety.
These symptoms are treated the same as in persons without dementia except that the doses required to be efficacious may be higher.
On the other hand, since these dementias frequently occur in the elderly who are more sensitive to medications, it may be difficult to increase their doses.
Selective serotonin reuptake inhibitors are most commonly used for mood and anxiety-related symptoms but are initiated at lower doses than in young patients.
How are Neurocognitive Disorders associated neurobehavioral syndromes treated?
Behavior is commonly altered in dementia and includes the development of aggression, agitation, apathy, disinhibition, hallucinations, delusions, and illusions, etc.
Behavioral issues worsen as the disease progresses, contribute significantly to caregiver burden, and can be a major factor in nursing home placement. It is important that they are identified and treated effectively to reduce suffering.
Effective agents include antiepileptics, antidepressants, and atypical antipsychotics.
There is a black box warning regarding increased rate of death associated with the use of atypical antipsychotics in dementia patients, so other agents should be used if possible, and the side effect profile should be discussed with the family.
Impulsive and irritable behaviors respond well to mood stabilizers like lamotrigine or valproic acid.
There are other treatments associated with the individual dementias where there is another underlying process.
For example, controlling vascular risk factors is an important treatment strategy for preventing progression of VaD.
