Pharmacological treatments for dementia

Unfortunately, there is currently no cure for dementia, so the main goals of treatment are to maintain quality of life, maximise function in daily activities, enhance recognition, mood and behaviour, foster a safe environment, and promote social engagement.

Consideration of non-pharmacological interventions should be standard practice for anyone with cognitive impairment but, for some, pharmacological interventions may also be beneficial.

Treating healthcare professionals should communicate to patients and their families the expected benefits, potential side-effects and costs associated with any medication.

In Australia, for a patient to be eligible for government subsidised dementia medications, the condition must be confirmed by, or in consultation with, a specialist (neurologist, psycho-geriatrician, geriatrician or psychiatrist).

For summary information on the prescribing and use of dementia-specific medications in Australia, visit Australian Institute of Health and Welfare: Dementia in Australia.

For criteria and updates concerning Pharmaceutical Benefit Scheme (PBS) subsidisation of medication for all forms of dementia, including Alzheimer's disease, please visit the Pharmaceutical Benefits Scheme website.

Pharmacological therapies for dementia

There are a number of classes of drugs that can address some of the symptoms of dementia. These include medications that support:

cognition and function
behavioural and psychological symptoms of dementia (BPSD)
pain management
slowing disease progression.

Medications that treat cognition and function

There are a small number of approved medications that may help alleviate the symptoms of dementia (and in turn, potentially improve quality of life for people living with the disease). Unlike monoclonal antibodies that can slow disease progression (see more below), these medicines do not treat the underlying disease or delay its progression.

Treating healthcare professionals should communicate to patients and their families what the expected modest benefits of these medications are, the possible side effects of the medication, and stress that the process of cognitive decline will continue regardless of whether medication is taken or not.

Cholinesterase inhibitors

Cholinesterase inhibitors are the most commonly prescribed medications for mild to moderate forms of Alzheimer’s disease. These medications aim to help memory, thinking, language and other thought processes by preventing the breakdown of acetylcholine (an important chemical messenger) in the brain.

There are three cholinesterase inhibitors: donepezil, galantamine and rivastigmine, all of which are subsidised through the PBS.

Notes on cholinesterase inhibitors:

There are no significant differences in effectiveness between the three drugs.
Choice depends on availability, cost and side-effects.
Adverse effects may be minimised by increasing the dose gradually and ensuring your patients take their medication with a meal. Side effects usually resolve over time or, if necessary, with dose reduction.
Patients who do not respond to one cholinesterase inhibitor may respond to another.
You should monitor patients who have a history of peptic ulcer or who are taking nonsteroidal anti-inflammatory drugs. Patients who are taking beta-blockers or other rate-slowing medications should also be monitored for bradycardia.

For the most up-to-date PBS information, visit the Pharmaceutical Benefits Scheme website.

Glutamate regulators

Glutamate regulators (memantine) limit the damage caused when there is too much glutamate (another type of chemical messenger) in the brain. Glutamate regulators can be prescribed for patients with moderate to severe Alzheimer’s disease to support memory, attention, language, and the ability to perform simple tasks.

Notes on glutamate regulators:

Memantine is usually well-tolerated, although the dose may need to be reduced in patients with renal impairment.

For the most up-to-date PBS information, visit the Pharmaceutical Benefits Scheme website.

Medications for behavioural and psychological symptoms of dementia (BPSD)

There are different ways of referring to the behavioural changes that can occur with dementia. In some settings it is referred to as behavioural and psychological symptoms of dementia or BPSD. Some people prefer to use the term changed behaviours or responsive behaviours.

The most effective treatment for changes in mood or behaviour is supporting people through non-pharmacological approaches: physical or psychological therapies, and allied health and/or environmental supports.

In some circumstances, where other strategies have not been successful, healthcare practitioners may suggest the use of an antipsychotic medication.

The only PBS-listed medication for dementia-related BPSD is risperidone. It works by blocking specific brain receptors for dopamine and serotonin (chemical messengers in the brain responsible for mood and other functions).

Risperidone is classified as a restrictive practice (specifically, chemical restraint) when it is used to influence, soothe, sedate, or control a person's behaviour. There are requirements under aged care and disability regulations for providers to ensure there is informed consent for the use of restrictive practices and for monitoring and reporting their use.

Notes on BPSD medications:

Evidence demonstrates that antipsychotic medicines are not effective for all people and can cause significant side effects.
Where antipsychotic medicines are prescribed, they should be used at the lowest effective dose, for the shortest appropriate period, regularly reviewed, and deprescribed where possible.
Prescription of antipsychotic medications intended to manage behavioural symptoms should be in the context of person-centred behavioural support assessment and planning which is regularly monitored and reviewed.
Prescription of psychotropic medications requires informed consent by the patient or their appointed medical decision-maker. The patient or their decision-maker should be informed about the reason, intended duration and potential benefits and harms of treatment. If no one is authorised to provide consent, application must be made to the appropriate state or territory authorising body.

Medications for pain management

People with dementia may be less able to communicate to their carers and healthcare providers that they are in pain, resulting in reduced quality of life and increased symptoms of distress, mood or behaviour change. Unrecognised or untreated pain can also contribute to avoidable hospital presentations and may be associated with conditions such as infections, falls, pressure injuries or other underlying health issues.

Look for verbal and non-verbal signs of pain, agitation or distress, such as crying, moaning, facial expressions or changes in behaviour, and provide appropriate assessment and pain treatments.

For more information, visit our Pain and dementia page.

Medications that slow disease progression

In recent years, there have been medication developments for Alzheimer’s disease. These are disease-modifying, monoclonal, antibody therapies that target and clear toxic beta-amyloid proteins in the brain and help to slow cognitive and functional decline. These two medications are lecanemab and donanemab. They are available in Australia but they are not listed on the PBS, which means they are not subsidised.

Medication management and review

After starting any pharmacological treatment, patients should be regularly reassessed. This should include standardised tests of cognition and function to determine the medication's effectiveness and possible side-effects (and drug interactions relating to the use of multiple medications).

Wherever possible, the person with the diagnosis should be involved in decisions about their treatment and informed consent obtained. If the person cannot make decisions on their own, they should be assisted in making decisions from a support person such as a family carer or friend and with adjustments to support decision-making capacity. If the person does not have decision-making ability, a substitute decision-maker may have been appointed, or an application can be made under state and territory laws.

Future treatment breakthroughs

Researchers are looking for new ways to treat Alzheimer's disease and other forms of dementia. To keep abreast of research initiatives, please visit the Dementia Australia Research Foundation website.