Treatments for Dementia and Mild Cognitive Impairment

Unfortunately, at the present time, there are no really good treatments for Alzheimer's Disease once it has begun.  However, there are good prevention strategies and there are treatments that can give some modest but worthwhile temporary improvement and slow the rate of decline somewhat.

Currently, the FDA has approved only one type of treatment for Alzheimer's Disease, using one of four different medications, all of which are acetylcholinesterase inhibitors.  There are other treatments that are likely to be of some benefit.  But the reason for just one being approved is that drug companies have to spend millions of dollars to go through the FDA approval process.  So only drugs that are likely to make at least $100 million or so in profits are worth the trouble.  These acetylcholinesterase inhibitor medicines are only modestly beneficial and quite expensive.  Drug companies aren't going to research things they can't patent, like many of the things below.

There are actually quite a large number of reasonably well proven ways to decrease the chance of ever getting Alzheimer's Disease or getting Vascular Dementia, the two most common causes of severe loss of memory and intellectual functioning in old age.  Some of these prevention strategies have also been tested as treatment interventions.

Exercise has been found to both help prevent Alzheimer's and to help treat it after it develops.  It clearly improves the physical and mental condition of Alzheimer's patients and decreases their chances of institutionalization.  Mental exercise, as well, looks to be of some value both as a preventive and as a treatment according to well designed studies.

Fish oil has been found to help in treatment in one double-blind placebo-controlled trial.  Fish consumption has been repeatedly associated with low rates of Alzheimer's, showing a preventive role as well as a treatment role.  It is good for so many diseases that everyone should be taking it.  I have not found any nursing home giving it to patients despite its low cost.

Estrogen, but not estrogen with medroxyprogesterone, has been found to help women prevent Alzheimer's, although more research is needed.  This can be given to women who have had hysterectomies, since there is no fear of increasing endometrial cancer.  Some studies have found that giving the progesterone for just a short period every several months will prevent endometrial cancer in women who have not had hysterectomies.  But the use of this strategy only for Alzheimer's prevention is not reasonable at this time.

Ibuprofen, the least expensive non-steroidal anti-inflammatory drug (NSAID), might be useful for Alzheimer's Disease, but its tendency to cause ulcers, damage the kidneys, and raise blood pressure is probably too common to recommend it.  Also, a recent large double-blind, placebo-controlled study of naprosyn and rofecoxib, two similar NSAID medications, failed to find any benefit.

Multivitamins and the B vitamins folate, B-6, and B-12 may also help prevent Alzheimer's and are probably good for treatment.  Herbals including sage, lemon balm, ginkgo, and vinpocetine may be of benefit in treatment.  Each has at least one double-blind trial each showing benefit, although only ginkgo has enough double-blind trials to get a solid idea.  Ginkgo appears only mildly beneficial, but that may be OK.  I like sage and hope the research holds up since it is cheap and easy to add to your diet.  

For prevention, eating dark berries like blueberries, drinking grape juice, and eating spinach or greens all look promising as does avoiding mammal meat, especially mammal fats and trans fats, as much as possible.  Alcohol drinking at one to six drinks per week and never over one per day appears to reduce Alzheimer's as does coffee and tea.  Be careful: too much alcohol is a common cause of dementia.  Fruits and vegetables in general are probably good. These studies are covered under the Prevention section.  It would appear that these prevention strategies might help treatment as well.  

Avoiding smoking and obesity reduces the risk of developing dementia as does avoiding salt and keeping your blood pressure down.  Avoiding dietary aluminum is also be a good idea.  Of course, don't get knocked unconscious or suffer significant head trauma.  See these studies under Causation.

Citicoline, a natural brain chemical involved in the production of phosphatidylcholine, has been found mild value in multiple double-blind studies.  Since its mechanism of action is very different, its benefit may be additive to other treatments. Whether its worth the $42-$81 per month expense is another question.

Since many of these strategies have different mechanisms of action, it would appear that some of their benefits might be additive.  If true, it would mean by following many of these at the same time would be a more successful intervention.  Since most of these interventions, with the exception of estrogen, should be being followed by everyone for general health reasons, they should all be used to the greatest extent possible.

CPAP Helped Alzheimer Patients with Obstructive Sleep Apnea: In a 6-week DB study of 40 patients average age 78, the CPAP group decreased from 30 events per hour to 7 after 3 weeks and 5 after 6 weeks. No change was seen with sham treatment after 3 weeks, after which all received CPAP. Neuropsychological scores improved the first 3 weeks with no additional improvement. Sleepiness scores decreased from 9.0 to 6.6 to 5.6 after 3 and 6 weeks. Clinical Psychiatric News 11/05

Large Study Doesn't Find Apnea-Dementia Connection: In a study of 718 men over age 78 from the Honolulu-Asia Aging Study of Sleep Apnea, less than 30% of the men had no sleep-disordered breathing (apnea-hypopnea index < 5) and nearly one-fifth (19%) had severe sleep-disordered breathing (apnea-hypopnea index > or = 30). Severe sleep-disordered breathing was associated with higher body mass index, habitual snoring, and daytime drowsiness. No association was found between sleep-disordered breathing and cognitive functioning, including measures of memory function, concentration, and attention. Because a healthy-participant effect may have contributed to this finding, more extensive cognitive testing may be necessary to reveal more subtle deficits from sleep-disordered breathing. Sleep-disordered breathing and cognitive impairment in elderly Japanese-American men. Foley DJ, et al. National Institute on Aging, Bethesda. . Sleep 2003 Aug 1;26(5):596-9.

Exercise of Alzheimer's at Home Improved Physical and Mental State: Linda Teri, University of Washington, studied a home-based exercise program for patients with Alzheimer's disease combined with teaching caregivers how to manage behavioral problems involving 153 community-dwelling patients randomized to a three-month combined 30 min/d exercise and caregiver training program or routine medical care. Exercise patients were 3 times more likely to exercise and had improved scores for physical role functioning. Two years later, exercise patients continued to have better physical role functioning and a trend toward less institutionalization due to behavioral disturbance. They had improved Cornell Scale for Depression in Dementia scores (P = .02) at three months. Those exercise patients with higher depression scores at baseline, improved significantly more at three months on the Hamilton Depression Rating Scale (P = .04), and they had maintained that improvement two years later (P = .04). JAMA. 2003;290:2015-2022

Exercise Raises MMSE Cognitive Ability in Geriatric Hospital Unit: In a randomized controlled trial of 15 patients with dementia using daily physical exercises supported by music for 30 min/session vs. a group of 10 control patients, who received an equal amount of attention through daily conversation, the exercise group showed a significant improvement in cognition. The Mini-Mental State Examination (MMSE) mean score increased from 12.87 to 15.53. The control group showed no significant improvement. The effects on behavioural changes were not significant. Cognitive and behavioural effects of music-based exercises in patients with dementia. Van de Winckel A, Feys H, De Weerdt W, Dom R. Katholieke Universiteit Leuven, Belgium. Clin Rehabil. 2004 May;18(3):253-60

Cognitive Stimulation Therapy Helped as a Treatment: 201 demented and elderly Brits were randomly assigned to usual care or CST.  At follow-up the intervention group had significantly improved relative to the control group on the Mini-Mental State Examination (P=0.044), the Alzheimer's Disease Assessment Scale - Cognition (ADAS-Cog) (P=0.014) and Quality of Life - Alzheimer's Disease scales (P=0.028).  It was necessary to treat six in order to benefit one, a ratio better than many medical interventions. Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial. Spector A, Thorgrimsen L, Woods B, Royan L, Davies S, Butterworth M, Orrell M. Br J Psychiatry. 2003 Sep;183:248-54