No medicine cures dementia. Some medicines may support cognitive symptoms, while others are used only in carefully assessed circumstances to manage severe distress or risk.

Introduction

Dementia is an umbrella term for conditions that affect memory, thinking, communication and the ability to manage everyday activities. The medicine used depends on the type of dementia, the symptoms being experienced, other health conditions and the person's overall treatment goals.

Medicines are only one part of dementia care. Relationships, communication, meaningful activity, a supportive environment, management of pain and physical illness, and help for families and carers remain central to person-centred support.

Medicines at a glance

Medicine groups

Cognitive enhancers
AntipsychoticS
Benzodiazepine

1. Cognitive enhancers

Cognitive enhancers are medicines used to help manage some of the cognitive and functional symptoms associated with particular types of dementia. They do not reverse the condition and do not stop the underlying disease process.

Donepezil

Donepezil belongs to a group called acetylcholinesterase inhibitors. It slows the breakdown of acetylcholine, a chemical involved in communication between nerve cells.

NICE recommends donepezil, galantamine or rivastigmine as options for mild to moderate Alzheimer's disease. Donepezil may also be considered for some people with dementia with Lewy bodies or mixed dementia following an appropriate clinical assessment. It is not routinely recommended for pure vascular dementia or frontotemporal dementia. [1-3]

What it may help with

• Memory and thinking difficulties.
• Attention, concentration or communication.
• Managing some everyday activities.
• Symptoms such as confusion in some people.

The response varies. Some people or their carers notice a meaningful difference, while the benefit may be modest or difficult to identify in others. Treatment should be reviewed in the context of the person's overall wellbeing, daily function, adverse effects and preferences.

Possible adverse effects

• Feeling sick, diarrhoea or reduced appetite.
• Headache.
• Dizziness or daytime sleepiness.
• Sleep disturbance or vivid dreams.

Important Persistent, severe or concerning symptoms should be discussed with the prescriber or pharmacist. Do not stop donepezil solely because dementia has become more severe; any decision to continue or stop should be made through clinical review. [1]

2. Antipsychotic medicines

Antipsychotics do not treat the underlying cause of dementia. In limited circumstances, they may be considered when a person is at risk of harming themselves or others, or when agitation, hallucinations or delusions are causing severe distress. [1]

Assessment and non-medicine approaches first

A change in behaviour may be a form of communication. Before considering an antipsychotic, healthcare professionals should look for clinical and environmental causes and address them where possible.

• Pain, infection, delirium, constipation or urinary problems.
• Hunger, thirst, dehydration or medication adverse effects.
• Fear, loneliness, communication difficulties or unmet needs.
• Noise, unfamiliar surroundings, disruption or changes in routine.

Psychosocial, environmental and person-centred approaches should remain part of the care plan before, during and after any medicine is used.

Risperidone

Risperidone may be considered for the short-term management of persistent aggression in moderate to severe Alzheimer's disease when non-medicine approaches have not been effective and there is a risk of harm. Its UK marketing authorisation for this indication is limited to treatment of up to six weeks. [1,3]

Haloperidol

Haloperidol may be considered for persistent aggression or psychotic symptoms in moderate to severe Alzheimer's dementia or vascular dementia when non-medicine approaches have failed and there is a risk of harm. It requires careful individual assessment and review. [1,3]

Important risks

• Drowsiness, dizziness, low blood pressure and falls.
• Muscle stiffness, shaking, restlessness or involuntary movements.
• Swallowing difficulties or reduced mobility.
• Blood clots, heart-rhythm problems or stroke.

Safety warning Antipsychotic use in dementia is associated with an increased risk of cerebrovascular events and mortality. The lowest effective dose should be used for the shortest possible time, with reassessment at least every six weeks. Extra caution is required in dementia with Lewy bodies and Parkinson's disease dementia because severe sensitivity reactions may occur. [1,4,5]

3. Benzodiazepines

Lorazepam

Lorazepam is a benzodiazepine. It is not a treatment for dementia and is not routinely recommended for dementia-related behaviour. In carefully assessed circumstances, a clinician may use it for a short period to manage severe anxiety or acute agitation.

Lorazepam increases the effect of gamma-aminobutyric acid, a calming chemical in the brain. This can reduce anxiety but can also cause sedation and impair coordination, memory and alertness. These effects are particularly important in older adults and people living with dementia.

Possible adverse effects and risks

• Daytime drowsiness or excessive sedation.
• Increased confusion or memory problems.
• Muscle weakness, poor coordination and falls.
• Slowed breathing, particularly when combined with other sedating substances or medicines.
• Paradoxical agitation, irritability or aggression.
• Tolerance, dependence and withdrawal symptoms with continued use.

Do not stop suddenly Lorazepam can cause withdrawal symptoms, particularly after continued use. It should not be stopped suddenly unless an appropriately qualified healthcare professional advises that this is safe. [6]

Supporting safer medicine use

• Keep an accurate, current list of medicines and allergies.
• Use the pharmacy label and patient information leaflet supplied with each medicine.
• Arrange regular medication reviews and report new adverse effects or falls.
• Check with a pharmacist or prescriber before adding over-the-counter or herbal products.
• Never start, stop, share or change a prescribed medicine without professional advice.

Sudden change A sudden increase in confusion, drowsiness or behavioural change should not automatically be attributed to dementia. It may indicate delirium, infection, pain, dehydration, constipation, an adverse drug effect or another acute health problem requiring assessment.

When to seek urgent help

Contact NHS 111 or an appropriate healthcare professional urgently for a concerning new symptom following a medicine change. Call 999 for signs of a stroke, severe breathing difficulty, a seizure, collapse, inability to wake, a serious allergic reaction, or severe muscle stiffness with a high temperature.

Key points

• Donepezil may help manage cognitive symptoms in selected types of dementia, but it is not a cure.
• Risperidone and haloperidol are reserved for limited circumstances because the potential harms can be serious.
• Lorazepam is not a dementia treatment and requires particular caution because it can worsen sedation, confusion and falls risk.
• Behavioural change should prompt assessment for physical, psychological and environmental causes.
• All dementia medicines require person-centred review alongside non-medicine support.

Further information

For information about a specific medicine, use the pharmacy label and the patient information leaflet supplied with it. A community pharmacist, GP practice, memory service, prescribing clinician or NHS service can provide advice about an individual's medicines.

References

1. National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97). View online source
2. NHS. About donepezil. View online source
3. NHS. What are the treatments for dementia? View online source
4. Medicines and Healthcare products Regulatory Agency. Antipsychotics: initiative to reduce prescribing to older people with dementia. View online source
5. NHS. Side effects of risperidone. View online source
6. NHS. Side effects of lorazepam. View online source

Medical and legal disclaimer

**PillarMeds Pro is an educational medication-management platform.

**This article is provided for general educational purposes only. It does not provide personalised medical advice, diagnosis, prescribing, medicine selection, dose adjustment or recommendations to start, stop or change treatment.

Always use the pharmacy label and patient information leaflet supplied with your medicine, and seek advice from a doctor, pharmacist, nurse prescriber or another appropriately qualified healthcare professional about your own health and medicines. In an emergency call 999; for urgent advice use NHS 111 or the appropriate local service.

Information may change over time. Publication within PillarMeds Pro does not replace professional clinical review.

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