The Stages of Dementia: How Dementia Progresses

Dementia refers to a category of diseases that affects your cognitive functions, such as memory and behavior. Symptoms and signs typically worsen over time and may progress in three stages.

There are three common stages of dementia: early, middle, and late. These highlight the progression and severity of symptoms.

Although most people with dementia progress through these stages, each person progresses at different speeds. For example, some people’s symptoms rapidly progress from mild to severe, while others may take years to move from one stage to another.

The average person with Alzheimer’s disease — which accounts for 60–80% of dementia cases — lives 4–8 years after receiving the diagnosis. That said, some people may live as many as 20 years after their diagnosis.

It’s estimated that 7 million people in the United States, ages 65 and older, had dementia in 2020. As life expectancy increases and the older population continues to grow, current trends suggest this number may nearly double by 2040.

The early stage of dementia, also known as mild dementia, is when a person starts to experience symptoms. These early signs may sometimes be hard to notice.

People in this stage may still function independently. But, they might also experience memory lapses that affect daily life, such as forgetting words or where things are.

Other common symptoms of early stage dementia include:

• early memory loss, such as forgetting recent events
• personality changes, such as becoming more subdued or withdrawn
• getting lost or having trouble orientating themselves, even in familiar places
• difficulty with problem-solving and complex tasks such as managing finances
• trouble organizing or expressing thoughts

People in this early stage may also become irritated, anxious, or frustrated with their changing abilities.

It’s important to encourage people with dementia to do the tasks they can still do and help them with those they may be struggling with.

This stage typically lasts 2 years.

People in the middle stage of dementia, also known as moderate dementia, experience more noticeable symptoms. It will likely become harder to perform daily tasks, such as getting dressed, eating, and bathing.

In the middle stage, people might also require daily support from a caregiver at home. Alternatively, some people move to an assisted living home where dementia support is provided.

Common symptoms of middle stage dementia include:

• increased confusion or poor judgment
• increased forgetfulness, such as the names of friends and family members
• increased short-term memory loss which may look like repeating themselves
• increased long-term memory loss, such as forgetting events in the distant past
• signs of delerium, paranoia, or hallucinations

Personality and behavioral changes, sometimes caused by agitation and unfounded suspicions, may also happen more frequently. This might include:

• changes in sleep patterns, such as sleeping during the day and feeling restless at night
• screaming, yelling, or shouting
• confusion, disorientation, or restlessness at sundown (sundowning)
• saying inappropriate things

This is typically the longest stage of dementia. On average, it lasts between 2 and 4 years.

People in the late stage of dementia, also known as severe dementia, may likely require full-time assistance at home or in a nursing home. In this stage, life expectancy is also greatly reduced.

Severe symptoms might include:

• an inability to communicate, such as only being able to speak in their childhood language
• an altered perception of time
• needing full-time assistance with daily tasks, such as eating, dressing, and bathing
• an inability to recognize faces of friends, family, or even themselves in a mirror
• loss of physical abilities, such as walking, sitting, swallowing, or holding one’s head up
• incontinence
• increased susceptibility to infections, such as pneumonia

This is typically the shortest stage of dementia. It may last 1–2 years.

How fast do the stages of dementia progress?

Progressing through the three stages of dementia varies for each person.

According to the Alzheimer’s Society, each stage typically lasts:

• early stage: 2 years
• middle stage: 2–4 years
• late stage: 1–2 years

What is the usual progression of dementia?

The progression of dementia depends on a few factors, such as the age when a person is diagnosed and the type of dementia they have. But dementia often progresses through three stages.

The early stage is when someone experiences mild symptoms, such as confusion and misplacing items. They are still largely independent at this stage.

The middle stage is when someone might need assistance to perform daily tasks, such as eating and bathing. Behavioral and personality changes become more significant, too.

The late stage is when symptoms are most severe. People often require full-time care and might be challenged by daily physical and cognitive tasks, such as walking, swallowing, and speaking.

What are the signs of dementia progressing?

As people move through the stages of dementia, their cognitive and physical abilities gradually decline.

Some signs and symptoms to look out for include:

• wandering, getting lost, or being unable to orientate themselves
• trouble communicating
• memory loss and increased forgetfulness
• trouble recognizing familiar landmarks and faces
• increased agitation, aggression, or restlessness
• trouble walking, eating, or controlling bowel movements

People with dementia may progress through these three common stages at different speeds and with differing symptoms. If you suspect you may be experiencing early symptoms of dementia, speak with a doctor.

While no cure is available for Alzheimer’s and other common dementias, early diagnosis can help people and their families plan for the future. Early diagnosis also allows people to participate in clinical trials. This helps researchers develop new treatments and eventually find a cure.

The Stages of Dementia: How Dementia Progresses

Dementia refers to a category of diseases that affects your cognitive functions, such as memory and behavior. Symptoms and signs typically worsen over time and may progress in three stages.

There are three common stages of dementia: early, middle, and late. These highlight the progression and severity of symptoms.

Although most people with dementia progress through these stages, each person progresses at different speeds. For example, some people’s symptoms rapidly progress from mild to severe, while others may take years to move from one stage to another.

The average person with Alzheimer’s disease — which accounts for 60–80% of dementia cases — lives 4–8 years after receiving the diagnosis. That said, some people may live as many as 20 years after their diagnosis.

It’s estimated that 7 million people in the United States, ages 65 and older, had dementia in 2020. As life expectancy increases and the older population continues to grow, current trends suggest this number may nearly double by 2040.

The early stage of dementia, also known as mild dementia, is when a person starts to experience symptoms. These early signs may sometimes be hard to notice.

People in this stage may still function independently. But, they might also experience memory lapses that affect daily life, such as forgetting words or where things are.

Other common symptoms of early stage dementia include:

• early memory loss, such as forgetting recent events
• personality changes, such as becoming more subdued or withdrawn
• getting lost or having trouble orientating themselves, even in familiar places
• difficulty with problem-solving and complex tasks such as managing finances
• trouble organizing or expressing thoughts

People in this early stage may also become irritated, anxious, or frustrated with their changing abilities.

It’s important to encourage people with dementia to do the tasks they can still do and help them with those they may be struggling with.

This stage typically lasts 2 years.

People in the middle stage of dementia, also known as moderate dementia, experience more noticeable symptoms. It will likely become harder to perform daily tasks, such as getting dressed, eating, and bathing.

In the middle stage, people might also require daily support from a caregiver at home. Alternatively, some people move to an assisted living home where dementia support is provided.

Common symptoms of middle stage dementia include:

• increased confusion or poor judgment
• increased forgetfulness, such as the names of friends and family members
• increased short-term memory loss which may look like repeating themselves
• increased long-term memory loss, such as forgetting events in the distant past
• signs of delerium, paranoia, or hallucinations

Personality and behavioral changes, sometimes caused by agitation and unfounded suspicions, may also happen more frequently. This might include:

• changes in sleep patterns, such as sleeping during the day and feeling restless at night
• screaming, yelling, or shouting
• confusion, disorientation, or restlessness at sundown (sundowning)
• saying inappropriate things

This is typically the longest stage of dementia. On average, it lasts between 2 and 4 years.

People in the late stage of dementia, also known as severe dementia, may likely require full-time assistance at home or in a nursing home. In this stage, life expectancy is also greatly reduced.

Severe symptoms might include:

• an inability to communicate, such as only being able to speak in their childhood language
• an altered perception of time
• needing full-time assistance with daily tasks, such as eating, dressing, and bathing
• an inability to recognize faces of friends, family, or even themselves in a mirror
• loss of physical abilities, such as walking, sitting, swallowing, or holding one’s head up
• incontinence
• increased susceptibility to infections, such as pneumonia

This is typically the shortest stage of dementia. It may last 1–2 years.

How fast do the stages of dementia progress?

Progressing through the three stages of dementia varies for each person.

According to the Alzheimer’s Society, each stage typically lasts:

• early stage: 2 years
• middle stage: 2–4 years
• late stage: 1–2 years

What is the usual progression of dementia?

The progression of dementia depends on a few factors, such as the age when a person is diagnosed and the type of dementia they have. But dementia often progresses through three stages.

The early stage is when someone experiences mild symptoms, such as confusion and misplacing items. They are still largely independent at this stage.

The middle stage is when someone might need assistance to perform daily tasks, such as eating and bathing. Behavioral and personality changes become more significant, too.

The late stage is when symptoms are most severe. People often require full-time care and might be challenged by daily physical and cognitive tasks, such as walking, swallowing, and speaking.

What are the signs of dementia progressing?

As people move through the stages of dementia, their cognitive and physical abilities gradually decline.

Some signs and symptoms to look out for include:

• wandering, getting lost, or being unable to orientate themselves
• trouble communicating
• memory loss and increased forgetfulness
• trouble recognizing familiar landmarks and faces
• increased agitation, aggression, or restlessness
• trouble walking, eating, or controlling bowel movements

People with dementia may progress through these three common stages at different speeds and with differing symptoms. If you suspect you may be experiencing early symptoms of dementia, speak with a doctor.

While no cure is available for Alzheimer’s and other common dementias, early diagnosis can help people and their families plan for the future. Early diagnosis also allows people to participate in clinical trials. This helps researchers develop new treatments and eventually find a cure.

What is dementia: signs, stages, prevention

With dementia, the main function of a person – cognitive (mental) deteriorates sharply. Memory worsens, speech is disturbed, it becomes difficult not only to work, but also to do simple household chores. The term “dementia” itself is translated from Latin as “dementia”.

More often dementia develops in older people, but it is wrong to consider its manifestations as the norm and inevitability. This is an acquired pathological condition that can be prevented, delayed or mitigated with timely measures.

It is important to diagnose dementia as early as possible in order to prolong the active life phase and maintain mental clarity. For a doctor’s advice on cognitive impairment and diseases of the nervous system, you can contact the Medical Center on Botanicheskaya.

What is dementia and how it manifests itself

Dementia is not a disease in the usual sense of the word. According to the International Classification of Diseases, this is a syndrome, that is, a complex of symptoms related by a common cause. It is observed in certain diseases of the brain or develops due to other factors.

One of the first signs of dementia is memory impairment. Both long-term and short-term memory are weakened: the patient may forget familiar routes and names, ask again the same information, lose personal belongings, etc. At the same time, the ability to absorb and process information is impaired.

Additionally, in dementia, at least one group of symptoms from the following list (or several at once) is noted:

1. The ability to think logically and solve complex problems is impaired.
2. Critical thinking worsens. This means that a patient with dementia cannot make decisions and manage money on his own, he ceases to see dangers in the environment.
3. Speech function is impaired. A person makes mistakes and forgets the usual words, ceases to understand phrases in a figurative sense, pauses in conversation. With the development of the syndrome, it becomes increasingly difficult for him to express his thoughts and communicate with loved ones.
4. The ability to think in abstract categories is lost.
5. The ability to visually recognize objects in space is deteriorating. A person hardly recognizes people by their faces, he can forget what his house looks like and why the surrounding objects are needed. At the same time, physically vision can remain good – the point is in cognitive function.
6. Man’s behavior changes and personality disintegrates. The range of interests may narrow, apathy, aggression towards others, sudden mood swings and a desire to avoid social contacts may appear.

Types of dementia and causes of its development

Depending on what causes dementia, there are several types of this syndrome:

1. Dementia due to diseases of the nervous system (also called atrophic). It develops due to damage to brain cells in Parkinson’s, Alzheimer’s, Pick’s and other pathologies. This type also includes dementia with Lewy bodies – pathological formations of a protein nature inside nerve cells.
2. Vascular dementia. It can be caused by pathologies of cerebral vessels – from arterial hypertension to stroke.
3. Mixed. This type includes dementia, which arose against the background of a combination of several diseases or risk factors.

Also, the causes of dementia include poisoning with potent drugs and metal salts, metabolic disorders (including diabetes mellitus), brain infections, injuries and tumors, and severe alcohol dependence. These reasons are listed in the medical manual “Dementia” (edited by Academician N.N. Yakhin).

All pathologies and factors have one thing in common: they destroy brain cells. Moreover, the lesion can be focal, because the diseases affect different parts of the main organ of the nervous system – the frontal, temporal, parietal, etc. Depending on the cause and nature of the lesion, the complex of symptoms may also differ when comparing the clinical picture of several patients.

Stages of dementia

An important characteristic of dementia is that this syndrome does not just show intellectual impairment. Dementia is diagnosed only in those cases when, due to serious disorders, the patient loses the ability to lead a social life, work and serve himself at home. Up to this point, they talk about a gradual decline in mental function, which can last several years.

It turns out that dementia itself is the most severe degree of cognitive impairment, when they become maximally pronounced. However, the syndrome also develops in certain steps.

Depending on the severity of manifestations, there are three stages of dementia:

1. Mild . The patient cannot fully work and communicate with other people due to intellectual impairment, his interest in ordinary hobbies and activities is weakening. But at the same time, he remains independent in everyday life and orients himself in his house.
2. Moderate . A person loses the ability to use the simplest household items and appliances without the help of loved ones, constantly needs to be accompanied. However, he can still dress himself, put a spoon to his mouth, or perform other simple actions.
3. Expressed . Such a patient needs almost round-the-clock assistance, as he is completely maladjusted. At this stage, one speaks of the so-called “senile dementia”.

In addition, focal and global dementia are distinguished. Focal disorders affect the memory and intelligence of a person, but his personality and critical thinking are preserved. Global dementia is characterized by a gradual disintegration of the personality, serious changes in behavior, loss of the ability to think critically.

Dementia is a disease of the elderly: how cognitive impairment is related to age

Dementia is a syndrome that affects the elderly in the vast majority of cases. Vascular pathologies, metabolic problems, diseases of the nervous system are more often manifested in adulthood due to natural causes, and in fact they lead to impaired mental function.

Moreover, the risk of developing dementia in the elderly increases with age. According to studies, among people over 55 years old, the percentage of cases is up to 8%, while after 80 years the likelihood of experiencing cognitive impairment increases many times (up to 40-45%).

Russian scientists E.E. Vasenina, O.S. Levin and S.G. Sonin calculated that in Russia in 2017 there were 1.7 million patients with dementia, and worldwide their number approached 50 million (based on a scientific article by the named team of authors).

Along with the increase in life expectancy, the number of patients with cognitive impairment will also grow – such is the forecast of scientists. Therefore, early detection of the disease, prevention and supportive therapy are extremely important.

Diagnosis of dementia

Diagnosis of dementia can be difficult due to the fact that patients can vary significantly in both the set of symptoms and the causes that led to cognitive impairment. As a rule, the diagnosis of dementia takes place in several stages and begins with an initial consultation.

To clarify the clinical picture, it is important for the doctor:

• to talk with the patient or the person caring for him, to collect an anamnesis. The doctor uses a questionnaire specially designed for this purpose and finds out when the first signs of dementia appeared and what exactly the cognitive difficulties are. Next, the specialist asks questions about the lifestyle and health of the patient and finds out which of the risk factors are present;
• assess the physical condition – gait, coordination of movements, fluency of speech;
• conduct a short cognitive test using one of the methods accepted in the medical community;
• determine whether dementia is caused by reversible or irreversible causes. This may require laboratory tests.

If the primary conversation and examination is carried out by a therapist, he has reason to assume the development of dementia, the doctor will refer the patient to a specialized specialist for detailed diagnosis and further treatment.

People often hesitate to see a doctor because they are afraid to hear the diagnosis of dementia and attribute the first signs of the disease to normal age-related changes. But this is a fundamentally wrong tactic, because the earlier the syndrome is detected, the more likely it is to prolong the usual full life and delay the severe manifestations of the disease.

Is dementia incurable?

Indeed, modern medicine is not yet able to completely reverse the process and cure the onset of dementia. But it is wrong to treat dementia as an irreparable condition in which any treatment is meaningless.

Maintenance therapy is indispensable, because it can greatly alleviate symptoms, slow down the progression of the disease and improve the quality of life of people with dementia. In addition, dementia can have a different nature; it is not always caused by incurable neurodegenerative diseases. In some cases, the syndrome is caused by metabolic disorders or infections that can be treated.

Drug treatment of dementia and its features

In some cases, the doctor may prescribe specialized drugs to slow the progress of the disease and improve the patient’s condition. This may be required, for example, with infectious brain lesions, pain syndrome, insomnia and in other situations.

Depending on the type of dementia and its clinical manifestations, the doctor may prescribe anti-dementia, vascular-metabolic drugs, as well as antidepressants, sleeping pills or neuroprotectors. If dementia is accompanied by vascular pathologies or metabolic disorders, medications indicated for these conditions can be prescribed.

At the same time, do not forget that uncontrolled medication is dangerous. After all, drugs that stimulate improvement in one type of dementia are often contraindicated in cognitive impairment of another nature.

What else is important to know about drug treatment of dementia:

1. It is important to take drugs prescribed by a specialist regularly, otherwise their effectiveness will be low. It is important for people caring for patients with dementia to understand that an elderly person with cognitive impairment is not able to control medication on his own – he needs constant help. In this case, medicines should be stored in an inaccessible place and given in a strict dosage.
2. Most medicines do not give immediate results. The first improvements, as a rule, should be expected within a few weeks after the start of therapy.
3. Medicines are prescribed for a short period of time (usually up to 3 months), and then it is important to re-talk with the doctor and adjust the therapy so that it really effectively counters the development of dementia.
4. Be aware of side effects and possible incompatibilities between different drugs. In order for the doctor to choose the right medicines and, if necessary, find a replacement for them, it is important to inform the specialist about all the medicines that a person with dementia takes.

Non-drug therapies

Non-drug supportive therapies for dementia patients can also effectively influence the cognitive sphere. They are used simultaneously with taking medications prescribed by the attending physician.

The advantage of these methods is that they have no contraindications and are used for any type of dementia, except for the most severe stage.

Which methods of restoring cognitive function are indicated for dementia:

1. Cognitive training. During the training, simple fragments of poems are memorized, passages of text are read aloud and other exercises are performed.
2. Cognitive stimulation . It involves the impact on different senses, often carried out in a group. The activity may include a warm-up, simple games, singing, dramatization, solving riddles and other activities.
3. Biographical training . Since long-term memory often suffers in dementia, it is helpful to replay and recall past events.
4. Music therapy, art therapy. The interest of patients with dementia in the outside world fades over time, so it is important, at least during special classes, to maintain contact with the arts, to continue education and development in a simplified form.
5. Diary entries. The practice of keeping a diary is not only useful for maintaining speech function, but also allows patients to record their own emotions and experiences.
6. Walking and light exercise – physical activity in any form is highly desirable.

It is important to practice every day, giving them enough time to get a positive effect.

Prevention of dementia: how to prevent the development of the syndrome

Unfortunately, it is impossible to completely protect yourself from cognitive impairment: often they are provoked by unpredictable and not fully explained by science pathologies (which include, for example, Alzheimer’s disease).

However, several areas of dementia prevention are recognized worldwide. They are effective because about 35% of dementia cases are due to modifiable risk factors. Eliminating these factors in advance can reduce the risk of cognitive impairment in old age.

What are the most effective and important preventive measures:

1. Physical activity. It is physical culture that is now considered the basis of prevention, since it has a complex effect on the body, prevents direct and indirect risk factors. It is important to systematically engage in physical activity throughout life or start it as early as possible before cognitive function begins to decline. Intense training brings special benefits to the brain, but if there are contraindications for them, do it to the best of your ability, adequate to your age. Physical exercise not only affects the psychological state of a healthy person in the present, but also protects nerve cells and can prevent intellectual decline in the future.
2. Weight maintenance . Obesity, and as a result, vascular disease and diabetes are serious risk factors that are best avoided.
3. Treatment of arterial hypertension . If this disease is detected at an early age, it is important not to let it take its course and be registered with a cardiologist. The task of this area of ​​prevention is to restore the health of the cardiovascular system before failures in its work provoke irreversible damage to brain cells.
4. Mental activity and multi-stage education . To ensure that cognitive functions do not suffer in old age, it is important to give the brain a sufficient and constant load. It has been proven that people who completed only primary school and stopped studying at 11-12 years old have a one and a half times higher risk of cognitive impairment. At the same time, complete secondary or higher education significantly reduces the likelihood of developing dementia.
5. Smoking and alcohol cessation . The destruction of brain cells under the influence of ethyl alcohol or nicotine is one of the indirect causes of dementia, which should be excluded in advance.
6. Active social life. Lack of social interaction and early voluntary isolation may also be risk factors. Therefore, it is important to maintain a sufficient number of contacts with colleagues, friends and relatives.
7. Healthy diet , which must include fruits, vegetables and fish, and it is better to reduce the percentage of meat and dairy products. This is the so-called Mediterranean-type diet, which has a beneficial effect on the state of blood vessels and the body as a whole.

Diagnosis and treatment of dementia in Moscow

Senile dementia has a reputation as an incurable disease, but it is important to remember that some of its forms are preventable. In addition, even if the affected brain cells cannot be restored, competent treatment can slow down the degenerative processes and significantly improve the quality of life of a person who is faced with the syndrome. With any type of dementia, the patient should receive the necessary drug and non-drug therapy, as well as full care, household assistance and moral support.

You can contact the specialists of the Botanicheskaya Medical Center for detailed advice on the prevention or treatment of dementia. Remember that it is not the diagnosis that is terrible – ignorance and the lack of qualified help are terrible at a time when a lot depends on it.

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Treatment – Dementia and mild cognitive impairment – Directory of nosologies – List of nosologies

Care and maintenance

It is preferable for the patient to stay in his own home under the supervision of relatives. The constant opportunity to see and use familiar objects keeps the patient busy for a long time. Patients with mild forms of dementia almost always retain the ability to perform simple household activities that require little help from loved ones. Individuals with mild dementia may continue to work if they are not required to regularly adjust to changing conditions and learn new information.

Antidementia preparations

Anticholinesterase drugs

Donepezil (Alzepil)

A drug from the group of anticholinesterase agents (AChE), developed first, which has not lost its relevance to date.

In a Cochrane review (Birks JS, Harvey RJ, 2018), there was moderate-strength evidence of modest improvement in cognition, activities of daily living, and physician assessments of the patient’s general condition when donepezil was administered to asthma patients for 12–24 weeks. There are indications that taking donepezil is neither more expensive nor cheaper than taking a placebo when assessing the costs of the health care system. The benefit of the drug at a dose of 23 mg / day does not exceed the benefit of taking a dose of 10 mg / day, and the benefit of taking a dose of 10 mg / day is slightly greater, 5 mg / day, however, when taking a higher dose, more refusals of treatment or adverse events before the end of the course.

There is no evidence for the efficacy of donepezil in mild cognitive impairment (Birks J, Flicker L 2006).

Available commercially in 5 and 10 mg tablets. Taken once. It is prescribed at a dose of 5 mg during the first 4-6 weeks, with the subsequent transfer of the patient to 10 mg.

The most common (20-30%) observed adverse events from the gastrointestinal tract; cholinergic toxicity of the drug may manifest as bradycardia. According to post-marketing observations, in rare cases, the development of rhabdomyolysis and / or neuroleptic malignant syndrome is noted.

Rivastigmine

The drug is available in oral (solution and capsules) and transdermal forms.

Results from 7 studies indicate that use of rivastigmine (6–12 mg/day orally or 9.5 mg/day patch) for 6 months is superior to placebo. The effects on cognition (ADAS-Cog score 2, with a maximum score of 70) and activities of daily living (standardized mean difference (SMD) of 0.20, considered small) were small. Patients taking rivastigmine were more likely to improve than placebo (odds ratio 1.47.95% confidence interval (CI) 1.25 – 1.72). However, there were no changes in behavior (assessed in three studies) or burden on caregivers (assessed in one study). Patients treated with rivastigmine had twice the risk of developing adverse events, while using the patch, the risk was somewhat less than when taking the capsules. It is possible that certain types of adverse events (nausea, vomiting, weight loss, dizziness) are less likely to occur when using a patch than when taking capsules.

Galantamine

The study included outpatients with mild or moderate impairment in the early stages of AD. The effect of galanthamine in individuals with more severe impairments has not been evaluated. The review shows the positive effect of galanthamine, which persisted for 3-6 months of administration. However, when using doses of more than 8 mg / day, there was no statistically significant effect of the dose on the effect of the drug.

The safety profile of the use of galanthamine in the treatment of AD is similar to that of other AChEs, with cholinergic-mediated gastrointestinal disturbances predominating among adverse events. There is anecdotal evidence of a better tolerability of the 16 mg/day dose in one study with a duration of 4 weeks, the efficacy of this dose was not significantly different from higher doses, and is probably preferred for initial treatment. Controlled studies of longer-term use of galantamine have not been conducted.

The use of galanthamine in MCI is not recommended due to its association with an increased risk of death.

Memantine

Memantine is a non-competitive antagonist (negative allosteric modulator)

magnesium site of the N-methyl-D-aspartate (NMDA) receptor. Thus, memantine, by binding to the region of the receptor intended for binding with magnesium ions (Mg2+), reduces the excessive stimulatory effect of glutamate. The latter is the main excitatory mediator of cortical and hippocampal neurons.

Along with the moderate anti-dementia and insignificant anti-Parkinsonian efficacy of memantine, the drug also has a neuroprotective effect, which is associated with a decrease in the excitotoxicity of excess glutamate. At the same time, no clinically significant effect on the course of dementia has been proven.

The patient has a moderate positive effect on patients with moderate and severe dementia in AD.

Two studies compared memantine 20 mg/day with placebo in patients with mild to moderate vascular dementia. The duration of treatment was 28 weeks. An improvement in cognitive function scores was noted without a significant impact on the daily activities of patients. Memantine was safe and well tolerated.

Long-term use of memantine has not been proven effective to date.

Memantine is widely used in clinical practice due to the lack of drugs with a higher degree of evidence.

Combination of drugs: memantine + donepezil

Long-acting combination drug of memantine and donepezil (not available in Russia as of 2018) provides more convenience due to the reduced frequency of dosing. Both drugs moderately reduce the severity of cognitive impairment; memantine, but not AChE drugs, showed a positive effect on behavioral disorders in patients. (Owen RT, 2016; Matsunaga S, Kishi T, 2018). It is noteworthy that both components have a long half-life – about 70 hours, which makes it possible to ensure a stable concentration in the blood even with minor violations of the treatment regimen, and also significantly reduces the severity of the withdrawal syndrome.

Antioxidants: vitamin E and selegiline

Vitamin E (α-tocopherol) and selegiline (MAO-B inhibitor) in AD patients have been studied for their antioxidant properties. The available data indicate that vitamin E supplementation at a dose of 2000 IU slightly slows down the progression of functional impairment in patients with mild to moderate AD, without significantly affecting cognitive function scores.

Despite the positive data obtained at the beginning of the study, including the possible neuroprotective properties of selegiline, no clinically significant effect of the drug in patients with AD was shown. Neither short-term nor long-term (up to 69 weeks) use of the drug does not improve cognitive function, emotional state, daily activity, or general assessments of patients. Currently, its appointment and additional research is not recommended (Birks J, Flicker L. 2003).

Other drugs

Symptomatic therapy reduces the severity of symptoms, but does not affect the course of dementia.

In the last decade, AD immunotherapy has been actively developed: vaccines and, especially, passive vaccination with monoclonal antibodies that have an affinity for amyloid proteins. The attractiveness of antibodies as drugs is associated with their high selectivity for therapeutic targets, and often with a low incidence of adverse events. The data of the conducted clinical trials give hope for the emergence of a new generation of drugs (Lannfelt L, Möller C, 2014).

Neuropsychiatric disorders in patients with dementia

Brad

Hallucinations

Figure 11

Algorithm of actions for the development of agitation and aggression in patients with dementia

Depression and anxiety

Agitation or aggression may be the main manifestations of depression in patients with dementia, with cognitive impairment being placed in the diagnosis by questioning or testing. It is possible to conduct a trial treatment with antidepressants.

When choosing a drug, preference is given to safer drugs – SSRIs (except paroxetine), trazodone or agomelatine. To reduce the severity of increased anxiety in the first weeks of antidepressant treatment, it is advisable to use low doses of neuroleptics with a sedative effect, for example, quetiapine 12.5–25 (50) mg. They are prescribed simultaneously with an antidepressant and are canceled after 2-3 weeks. More information about antidepressants is available here.

Aggression and irritability

The main role in the elimination of aggression is played by the creation of an environment convenient for the patient: familiar people, a room, a calm environment, timely detection and treatment of somatic diseases. With the ineffectiveness of non-drug remedies and the patient’s danger to himself and others, antipsychotics with a sedative effect are used – quetiapine, olanzapine, clozapine – as short as possible. Hospitalization of a patient in a hospital, as a rule, increases behavioral disorders, including aggression.

Sleep disorders

Given the high risk of developing adverse events when prescribing hypnotics and sedatives, sleep hygiene of patients (mode, calm environment, elimination of sources of discomfort, walking and other types of activity that does not cause arousal before bedtime) is of great importance. As sleeping pills, melatonin 3-12 mg at night, trazodone 25-100 (150) mg at night are used; in extreme cases, antipsychotics with a sedative effect – quetiapine and clozapine.

The use of modern sleeping pills (zopiclone, zolpidem) and benzodiazepines in patients with dementia is unacceptable, the appointment of antihistamines (hydroxyzine, doxylamine) is highly undesirable.

A more detailed review of non-pharmacological treatments for behavioral disorders in patients with dementia is provided in a separate review.

Pain in patients with dementia

Elderly patients with advanced dementia cannot report pain. At the same time, according to research estimates, from half to two-thirds of patients suffer from pain. To assess pain, indirect signs are used: for example, changes in the behavior of patients, their reactions to habitual stimuli. The following is the PAINAD scale designed to measure pain in patients with dementia in a hospital/nursing department setting. The use of the scale by relatives of patients has not been studied.

It must be remembered that pain behavior is individual. Each patient responds to pain differently, and there are behavioral changes that are not included in this scale. Despite this, the scale remains a valuable tool to draw attention to those who experience discomfort but cannot communicate it.

Table 6

Pain Rating Scale for Patients with Severe Dementia (PAIN-AD)

0 points – no pain, 10 points – severe pain.

In patients with dementia, the use of opioid analgesics is limited due to an increased risk of confusion.

Restrictions in the treatment of patients with dementia

Patients with dementia are contraindicated in drugs with a sedative effect, especially drugs with a long half-life (benzodiazepine tranquilizers, barbiturates, antihistamines).

The choice of antipsychotics should take into account the risk of worsening extrapyramidal symptoms in patients. Due to the technical difficulties with regular follow-up of complete blood count, which is required when taking clozapine, quetiapine is the drug of choice for the relief of psychosis (the evidence for prescribing the drug is inconclusive).

With the exclusion of Parkinson’s disease and Alzheimer’s disease (vascular, post-traumatic dementia), Olanzapine may be used. For patients with Alzheimer’s disease, the use of risperidone is preferable, due to the least pronounced anticholinergic effect of this drug.